Social determinants of health

Cyberdrugs will only take off if there is a significant price advantage over that on the black market The Wild West is a prominent metaphor for the new challenges and opportunities the Internet brings. The adventurous welcome the challenge, the cautious fear the hazards. The Internet has opened up a whole new area of information exchange and free trade. The information exchange makes it difficult for totalitarian regimes to easily control their citizens’ access to information, and Internet share trading makes governments more cautious about their fiscal policies. Free traders welcome the level playing field, for they see restricted markets opening up, and efficiencies based on market forces.1 The Internet cuts out the “middle man”. However, there are downsides, as anyone harassed by SPAM mail will know. Multinationals can more easily extend their sphere of influence, the pornography trade flourishes, as does the trade in music and illicit CDs, which boldly flouts copyright laws. Internet trading of pharmaceuticals challenges the tradition that pharmaceutical drugs should only be prescribed by health professionals and dispensed by pharmacists who have seen the person face-to-face. In June 1999, the American Medical Association formally adopted the position that appropriate medical care can only result from face-to-face consultations.2 Likewise, members of the US Food and Drug Administration are expressing a caveat emptor (“let the buyer beware”) about e-pharmaceuticals,3 because of problems with the quality of cyberpharmacies and the qualifications of cyberpharmacists.4 To what extent does society get involved in individuals’ free choice, especially in the context of drug use? Is free trade better than social control? Social safeguards are set both to protect the ignorant and to restrain the wilful, although critics will argue that the medical and pharmacy professions are simply protecting their eroding turf. With drugs of dependence, those involved in misuse would prefer to cut out the “middle man”, and make their own deals. In addition, they are quite prepared to use substances of poor quality and uncertain potency. Should the profession try to stop this? And, if so, how? Social controls of the supply of drugs of dependence vary for different drugs. Thus, society is tightening its control over tobacco advertising and distribution, relaxing controls over alcohol, and clamping down on illicit drugs. Decisions for each drug class are decided somewhat arbitrarily — partly they relate to the severity of the perceived problems arising from use of the drug and partly to the feasibility of control measures. The underlying assumption is that society should exercise some control over drug dealers who seek to exploit those vulnerable to drug addiction, but, in each case — whether tobacco, alcohol or illicit drugs — some uneasy compromises are necessary. These compromises change over time, depending in part on ideological and political forces, as well as on the science of drug-related harm. What is the size of the cyberpharmacy problem in relation to addictive drugs? Is the single case of online purchasing of drugs for misuse described by St George and colleagues in this issue of the Journal (page 118)5 an exception, or the start of a new and dangerous trend? We need more data, but we can make some observations. Licit drugs present a far greater problem than illicit drugs. Most drug-related deaths in our society are a result of diseases caused by tobacco. Tobacco accounts for over 80% of drug-related deaths and 79% of years of life lost. 6 When the cardioprotective effects of alcohol are factored into the equation, the impact of alcohol is on a par with those of the illicit drugs. Yet, alcohol as a licit drug is freely available in our local supermarkets. Are not tobacco and alcohol a higher priority? The illicit use of licit drugs — prescription opioids and benzodiazepines — is more difficult to study. In particular, the impact of sedatives, including benzodiazepines, is difficult to quantify, as their main impact is their contribution to opiate deaths in polydrug overdoses. How big a problem, compared with other sources, is the cybersourcing of licit drugs for illicit use? As general practitioners have become more aware of the need to restrict benzodiazepine prescribing, a black market has developed. There is also a growing market in black-market prescription opiates, like MS Contin (Mundipharma) and Kapenol (GlaxoSmithKline). Thus, there is a ready market for people keen to buy these drugs. Cyberdrugs will only take off if there is a significant price advantage over that on the black market. Data are hard to obtain, but we suspect that, until it becomes harder for users to obtain benzodiazepines from lax prescribers or on the black market, the purchase of cyberdrugs will be regarded as too slow and too expensive. What should we now do? We need more data, and cases like that described by St George et al help to alert health professionals in the field to this new drug source. The suggestions put forward by St George and colleagues have merit, but, without more data, their alarm may be premature. In the past, drug control on the supply side, especially of illicit drugs, has produced disappointing results.7 In the meantime, we believe more effort is needed to control the damage caused by tobacco, alcohol and opiates.

Alan J Gijsbers FRACP, FAChAM · Gregory Whelan MD, FRACP, FAFPHM, FAChAM

Overseas-based online pharmacies dispense prescription medications without a prescription, thus creating an alternative source of pharmaceuticals for people using illicit drugs. Health professionals need to be aware of this new drug source, which may change the rates and patterns of illicit drug use in Australia. Because of the nature of the Internet, this issue needs to be dealt with at both an international and a national level. The provision of health-related services through the Internet is fast becoming a reality. Online pharmacies are an extension of this service.1 There have been reservations about privacy as well as the quality of the information available from these health sites, but we have recently become aware of a more disconcerting issue: obtaining potentially addictive prescription medication through the Internet. Online pharmacies, such as those based in Mexico and Asia, will dispense prescription medications without a prescription, including commonly misused pharmaceutical drugs (eg, diazepam, oxycodone, temazepam and anabolic steroids). In 1998, results of the National Drug Strategy Household Survey indicated that 46% of Australians have used an illicit drug at some time. Analgesics were identified as second only to marijuana as the most widely used illicit drugs.2 When compared with the total Australian population, the group with the highest proportion of current users of any illicit drug was young people aged 14–29 years, and in the period 1995–1998 recent illicit drug use by teenagers rose.3 Although illicit drug use is not exclusively a youth issue, young people are competent users of the Internet, with 75% of 18–24 year olds accessing the Internet in 2000, compared with only 9% of those over 65 years.4 Example of drug misuse via the InternetA 20-year-old patient was referred for management of anxiety and polydrug misuse. The patient related that anyone could be a misuser and pusher of drugs without relying on illicit suppliers of such drugs or “doctor shopping”. A click of a mouse could supply whatever drug a patient wanted from online pharmacy services available 24 hours a day. These sites are easy to use and often require little more than a credit card number to gain access to a wide range of prescription drugs, such as diazepam, alprazolam, temazepam, methylphenidate, morphine and codeine. The patient had a 2-year history of using large amounts of zolpidem, temazepam, alprazolam and diazepam with alcohol, as well as regular use of marijuana. These medications were originally obtained by doctor shopping for prescriptions. However, while researching these medications on the Internet, our patient discovered the online pharmacies that dispensed prescription medication without a script. Zolpidem, oxycodone and methylphenidate were all ordered by the patient from online pharmacies based in Mexico and Thailand. He “surfed” the Internet for the site with the cheapest drugs and found one that sold 100 zolpidem, his drug of choice, for US$70.00, with a delivery charge of US$5.50. He was able to order quantities of 100, 200 or 500 tablets. It took 2 weeks for the discreetly packaged drugs to arrive at the patient’s door. The patient volunteered this information during therapy for drug addiction and was quick to see the negative implications. After a period of counselling about the causes of medication misuse, he was motivated to cease further ordering and willing to undergo drug detoxification. Further investigationsWe accessed many of the sites used by the patient to obtain medications. Online pharmacies are subject to the laws of the country in which they are based. Those in Australia require a valid Australian prescription before prescription medication will be dispensed (Peter Waterman, Media Spokesperson, Pharmacy Guild of Australia, personal communication). However, in some countries, such as Mexico, many prescription medications can be purchased over the counter, and they can be sold over the Internet without prescription. Of 33 surveyed pharmacy websites in the United States most (88%) require a prescription before medication will be dispensed,5 and the remaining sites either dispense prescription medication without a prescription, or accept scripts by fax or email. This may mean that one script could be recycled through many of these online pharmacies. Other overseas sites offered to provide consumers with a prescription after an online or phone consultation. Some sites charge a membership fee before medications like morphine and oxycodone can be obtained. There are also sites that provide, for a fee, a directory of online and land-based pharmacies that dispense prescription medications without prescription. Many sites boast of proven methods for getting packages past customs, and some offer to re-ship medication if a seizure notification from customs can be produced. The Therapeutic Goods Administration (TGA) in Australia, the government organisation responsible for controlling and regulating importation and manufacture of medications, prohibits the importation of prescription medications without a permit or prescription. The medications must be for personal use only and cannot be on-sold, but this is difficult to police. Importers can bring up to 3 months’ supply of medications into the country per importation.6 These regulations can only be enforced if the contents of packages are discovered, and it seems that some packages do slip through. We have written to and discussed these issues with the following people: Managing Director of Australia Post; Chief Executive Officer of the Australian Customs Service; Drug Intelligence Network (Australian Federal Police); Crime Stoppers (New South Wales Police); and Local police. We could not determine what actions these authorities were pursuing in regard to this issue. Australia Post does not have the authority to open postal articles because of privacy issues (Sal Perna, Group Manager, Australia Post, personal communication). Customs informed us that their surveillance capacity has been increased over the past 2 years to meet the challenges posed by Internet purchases of medications and other restricted goods. Customs also regularly prosecutes those who attempt to import prohibited goods without permits. At present all international mail and 70% of air cargo arriving in Australia is examined either physically or by x-ray (J H Jeffery, Acting Chief Executive Officer, Australian Customs Service, personal communication). DiscussionThe use of the Internet as an alternative source of supply of prescription medications for people using illicit drugs is unlikely to overtake the street market or doctor shopping for scripts as a means of obtaining illicit drugs; in 1999–2000 the Health Insurance Commission identified over 9000 “doctor shoppers” (defined as people who had attended 15 or more different general practitioners in 1 year).7 However, the extent of the current use of the Internet as a source of drug supply is unclear. Although medications can be ordered from home, without contacting medical practitioners or pharmacists, ordering drugs over the Internet is still expensive and entails a 2-week wait for the medications. However, it may have the potential to encourage people who would not purchase drugs on the street or “doctor shop” to purchase drugs over the Internet. The purchase of medication from offshore pharmacies also raises the issue of the quality of the medication. Drugs manufactured in Mexico are not as closely regulated as they are in Australia or the US, and are not subject to the same quality standards. This increases the potential for increased rates of addiction and accidental overdose. Although the Internet may not be the major source of supply for illicit drug users, restricting access to Schedule 4 and 8 drugs through this channel can do no harm. This is where Customs plays an important role. The decrease in the availability of heroin in Australia caused by the 2001 “heroin drought” led to a marked fall in the number of heroin-related deaths, but did not necessarily lead to a decrease in rates of illicit drug use.8 Many heroin users simply substituted pharmaceutical drugs for heroin. Thus, restricting supply is not the answer to the complex problems posed by drug misuse. Prescription medications are still widely available on the Australian black market and through doctor shopping. However, restricting Internet access to these drugs may help to prevent the creation of new users. Another factor to take into account is that, if drug users are no longer presenting to GPs to acquire scripts, it may be difficult to determine their past drug use histories, as the use of online pharmacies to acquire prescription medication is unrecorded. Because of the nature of the Internet, problems with online pharmacies need to be dealt with at an international and national level. Customs plays a vital role at a national level and has informed us that they and the Australian Government are aware of and are addressing the issue (J H Jeffery, personal communication). We also suggest that the Australian Government could initiate discussions with the countries where these pharmacies are based, perhaps encouraging them to tighten controls. At a local level, doctors and other professionals working with people who misuse drugs, and especially with young people, should be educated about drug availability on the Internet. All those working with these people should be made aware that the avenues for acquiring drugs are changing, and they should continue to provide support through education and harm-minimisation strategies. We realise that it will be impossible to completely stamp out Internet availability of illicit drugs. However, a concerted and concentrated campaign by all involved parties will ensure the vast majority are denied access to such drugs through the Internet.

Bernard N St George MB BS, FRANZCP · Joseph R Emmanuel MRCGP, DRCOG · Kate L Middleton

Balakrishnan R Nair,* Brendan Flynn† * Director, † Medical Registrar, Division of Geriatric Medicine, John Hunter Hospital, New Lambton, NSW 2291. knairATmail.newcastle.edu.au To the Editor: We refer to the recent article by Parslow and Jorm1 and the editorial by Headey2 on the link between pet ownership and health outcomes. There is no evidence that pet ownership per se confers cardiovascular benefits. Indeed, the findings of the study were that pet owners were more likely to smoke, had a higher diastolic blood pressure and a higher body mass index than the non-pet owners. The editorial points out that, based on sociological studies, it is likely that pet ownership does have a positive effect on health, but the medical data demonstrating how this is achieved are lacking.2 Might there be other negative effects of pet ownership on health outcomes? A patient under our care recently demonstrated the potential risks involved in pet companionship for elderly people. An 81-year-old woman who was living independently was admitted after a fall caused by tripping over her delightful Himalayan Persian cat. Her presenting symptom was severe back pain exacerbated by weight bearing. However, no bony abnormality was identified. She had difficulty mobilising initially, and the outcome of her fall was significant morbidity with some loss of her previous mobility, even on discharge. She stayed in hospital for 12 days. A follow-up phone call revealed that the patient was still experiencing difficulty mobilising some 2 weeks after discharge. This case raises the possibility that the risks may outweigh the benefits of pet ownership in elderly people who are already at risk of falls. A MEDLINE search, using the terms elderly, trauma, cat, pet and fall (and combinations of these), did not reveal any relevant literature. A recent case report highlighted other cardiovascular issues relating to cat ownership.3 It described a patient who had recurrent episodes of syncope whenever her cat slept on the right side of her neck. The underlying mechanism was carotid sinus hypersensitivity. She required a single-lead ventricular pacemaker and for the cat to lie on her left side. Anecdotal evidence from colleagues highlighted the danger of “dogs taking elderly patients for walks”, resulting in rotator cuff injuries. Additionally, older patients with peripheral vascular disease and fragile skin have presented with non-healing ulcers from dog scratches. Pet ownership for the purpose of modifying cardiovascular risk factors would seem to be unwise in this population. However, the benefits of companionship and the pleasure derived from pets may outweigh the risk of falls for many elderly patients. Should we be doing more “cat scans” or “pet scans” in older patients?

Balakrishnan R Nair · Brendan Flynn

Michael McDonnell General Practitioner, and owner (with his wife) of Daisy and Cashew, 1/4 Mylne Street, Toowoomba, QLD 4350. To the Editor: Having read the article by Parslow and Jorm,1 I dashed to my surgery — praise the Lord, my diastolic blood pressure was 70 mmHg. So, I raced home again and reassured our labradors that they would not have to be shot. Let’s leave elderly pet owners and their blood pressures alone. Pet ownership is all about companionship, friendship, trust, care for your friend — the really important things in life — not your diastolic blood pressure!

Michael McDonnell

On a per capita basis, Australia spent more than seven times as much on its Sydney Olympic team as did Canada, to win four times as many medals. Compared with Australia, Canada spent an additional amount per capita (standardised to the purchasing power parity rate at year 2000) of US$1605 per life-year gained on healthcare in 2000. Neither country is “right” or “wrong” in making these funding choices, but they highlight the need for more explicit discussion about what is being spent, what is obtained for the given expenditure and what society actually values.

Craig R Mitton PhD · H Dele Davies MD, MSc · Cam R Donaldson PhD

Rich countries must lead the fight against climate change affecting rich and poor in our global village It is nearly a tautology to say that poor people and poor nations generally act with short time horizons or, in the jargon of economics, high discount rates. Anecdote and analysis confirm it. Those who realistically fear potentially severe consequences tomorrow are less concerned about next year. At the family level, these attitudes can be understood as the consequence of natural selection acting on the propagation of genes. High discount rates are necessary to ensure one’s genes survive under short-term stress; when the ground is treacherous and the tiger is following, raising one’s eyes to the horizon is risky to survival, let alone procreation. Although even poor societies and nations generally act with longer time perspectives than their individual members, they too must acknowledge the demands of short-term survival.1 However, many human reactions honed through natural selection no longer serve us well. We crave dietary fat for the nutritional security it once brought, but in modern excess it kills rather than saves us. Equally, the scale of our impact on the environment now has effects on time scales much longer than those of typical human time horizons. The archetypal example is perhaps global pollution leading to global climate change. We are now well into a planetary experiment on the effect of injecting a bolus of warming pollutants, three to four times natural levels, during an instant of geological time. Nothing much happens at first, but analysts say that much more is set to happen unless we mend our ways soon.2 Still, it may be decades before the really bad things happen. Should we care? How much? And should how much we care depend on how poor we are? This issue is illustrated starkly by a graph developed from calculations by Hughes at the University of Edinburgh3 (Box). It shows the ratio of the cost of health and economic damage from local energy-derived air pollution (household indoor pollution from use of poor quality fuels and urban outdoor air pollution) to the cost of damage from climate change.4 A standard low discount rate is applied (3% per year) to convert future costs into the equivalent cost today. The graph shows that, in poor countries, short-term local pollution typically causes three to four times more health and economic damage than climate change. This occurs even though poor countries are expected to experience much more health damage from climate change than rich countries. In contrast, in rich countries, long-term damage caused by climate change is greater, even after discounting, because short-term pollution has been greatly controlled. Many in the climate-change debate argue that, because of the huge stakes involved, developed countries should use lower-than-standard discount rates and act today to reduce the long-term damage. This could even be at the cost of spending less on today’s problems. After all, developed countries can afford longer time horizons and produce most of the climate-changing emissions through their use of fossil fuels. However, it is difficult to put this argument to poor countries, which have many other pressing problems and have benefited little from the burning of fossil fuels that has produced most climate-changing emissions to date.5 However, the graph also reveals potential solutions. It shows the attractiveness of rich countries investing in poor countries to simultaneously reduce both local and global pollution. These “win–win” activities could benefit both countries because of their different discount rates and local impacts. An example is investing in clean household fuels that simultaneously halve the local health impact of air pollution and reduce climate-changing emissions.6 Recognising these “win–win” opportunities helps us set current priorities.7 Unfortunately, the climate-change debate no longer encompasses the option of total prevention. It is nearly certain that, no matter what we do, we are already committed to significant change and, indeed, are already experiencing the first stages. We must start planning how to live with this change. The principal health impacts are expected to include an increase in environmentally related infectious and vector-borne diseases in poor countries.8 However, climate change enhances rather than creates these diseases,9 offering another means of prioritising competing public-health needs. For instance, if climate change will increase malaria, we would benefit from spending more now on reducing the baseline malaria rate before serious climate change begins. This is a practical way to consider the long term, while addressing today’s serious problems.10 Perhaps the most important long-term benefit of the climate-change debate is that it illustrates, more than any other issue, that we live in a global village. Although one can argue, on humanitarian and other grounds, that an easily preventable child death in India impoverishes everyone, everywhere, such arguments do not go far in most policy forums. However, it is incontrovertible that greenhouse gases released anywhere affect us all, everywhere. In addition, no matter how much greenhouse gas we ourselves release, we are all subject to the same global climate and its changes. Thus, we are hostage to each other and will have to find ways to make the necessary decisions together to protect us all, rich and poor. Health and economic damage to nations from energy use * Ratio of cost of damage to nations from local energy-derived air pollution over cost of damage to nations from global climate change.3 † Poor = South Asia and Sub-Saharan Africa. ‡ Middle-income = East Asia, Middle East and Latin America; § Rich = nations belonging to the OECD (Organisation for Economic Co-operation and Development), eastern Europe/former USSR.

Kirk R Smith

What it means to be Australian is harder to define than ever in these complex, shifting times I’ve been looking into what it means to be an Australian all my life. As one of a group of young playwrights who came to prominence in the early 1970s, our group mission, in so far as we articulated it, was to investigate the “Australian identity”. In an interview I gave in London in 1973, I was quoted as saying: “There is an awful Australian uniqueness, and for the first time the Australian theatre is getting down to the business of finding out what it is.” A bit of an overstatement, perhaps, but we did see ourselves as exploring the darker side of Australian life, albeit in a satirical way. Australia’s chauvinism, materialism, conservatism and suburban conformity were put under the microscope, but even as I was savaging such tendencies in my plays, I found my country endearing as well as horrific. In those days there was a sense that the whole population shared common characteristics — our black, sardonic humour, our energy, our directness and our hatred of pretentiousness — that could be thought of as typically Australian. Then, at a literary dinner at the start of the 1980s, the articulate, scathingly witty, but sternly moral journalist, David Marr, scolded us all for our preoccupation with “Australian identity”. He said there was no such thing. What we had been calling the “Australian identity” was nothing more than the Anglo-Celtic identity and a male, middle-class, heterosexual version of it, to boot. We were, in fact, a country of many identities: Aboriginal, gay, ethnic, feminist, working class, rural and dozens of others. There was no overall “Australian-ness”, and to claim we were trying to find it was naïvety at best, and arrogance at worst. I slunk away and tried to find reasons to include feminist lesbian Greeks and rural Aboriginals in my plays, but quickly decided that it was probably better that they wrote their own plays, which they promptly did, and Australian theatre has been all the richer for it. The lesson I learned is that when one tries to make sense of a topic like “what it means to be Australian”, one has to tread warily. If you’re one of the 700 000 Australian children being raised in poverty, you’re obviously going to have a very different view of what it means to be Australian than if you’re a futures trader making $500 000 plus at the age of 26. If I were writing about this issue at the start of the 1960s, I could truthfully say that being an Australian meant living in the country with the smallest gap between rich and poor in the world. In 2003, we have one of the largest income disparities of all the industrialised nations. Although the top 30% of income earners in Australia are much better off, in absolute terms, than they were 40 years ago, surveys show they are no happier, and this baffles the science of economics. Writers and artists have been suggesting for thousands of years that happiness is never simply a question of consumption. It also has a lot to do with feeling loved, fulfilled and creative. Some part of human happiness may be bound up with wealth, but the more enlightened economists are now dicovering that it’s relative rather than absolute wealth that counts. Humans as a species are very sensitive to their relative status in a community. We don’t just want to be loved, but also respected and noticed. So part of what it means to be an Australian these days is working longer hours, experiencing more stress and suffering increasing rates of depression in order to purchase the symbols of success which will make one feel respected. Forty years ago, a 120 m2 house was considered quite acceptable for a family. Now it has to be double that size before one feels adequate. The single most important measure in the political governance of most countries remains the rate of growth of gross national product (GNP), implicitly maintaining the fiction that increased consumption equals increased happiness; this despite the fact that galloping GNPs also mean a galloping increase in resource consumption and a galloping rate of increase in pollution and environmental degradation. What it means to be an Australian varies widely. Being a rural Australian last year meant experiencing the worst drought on record, living with more uncertainty and hardship than city Australians, thanks to El Niño. Being an Australian in many areas meant facing major bushfires. If you’re a Muslim Australian, it means being under suspicion; if you’re a female executive, it means not being as well paid as your male counterpart. If you’re second-generation Greek Australian, it means being able to send up your Greek-ness and love it at the same time. If you’re a young Australian, it means working harder and longer and having a more uncertain future than your parents had; and if you’re an Australian over 60 and in good health, it apparently means that you’re happier (as a group) than anyone else. So was the magisterial David Marr right after all? Is the “Australian identity” a fantasy? When I find myself laughing at the truly appalling Kath and Kim, I can’t help feeling that, for all our preening and pretensions on the world stage, there’s still a bit of that awful Australian uniqueness around. And any country that can laugh at its own awfulness can’t be all that bad. One of the really good things about this country is that we remain, by and large, the world’s most successful experiment in multiculturalism. With our Muslims and Aboriginals, we have a long way to go, but there is more intermarriage between ethnic minorities and Anglo-Celts here than in any other comparable country, indicating that the long-lived racial ghettos of America are not going to happen here. I don’t think it’s a matter of the Anglo-Celts absorbing and dominating minority groups, but a genuine interaction in which the social centre of gravity will shift to a new and original position. The personal perspectives by doctors from migrant backgrounds, Yu (page 598), Houssami (page 595) and Santoro (page 600), reflect these changing dynamics. If the world manages to avoid travelling down its present road to long-term disaster, we might well have one of the most interesting countries in the world here, in time. I’m alarmed at the way the world is heading — greed and envy pushing us towards what could be an eventual terrible reckoning. And I’m alarmed that we’re such an enthusiastic little helper in the whole process. But when I look around the world at the other options, I’m still rather glad I’m here and hold an Australian passport.

David Williamson

Do the media promote, for the sake of entertainment, unrealistic hopes and exaggerated fears of doctors? modern ambivalence towards the medical profession is strongly promoted by the lay press. In Britain, at least, and I suspect in most countries, press interest in medical matters has never been greater. Whether the press has merely responded to a demand, or has actually created the demand, is a question that I cannot answer; I think that there is probably a dialectical relationship. The supply created the demand, and the demand created the supply. No one will now ever be able to say which came first. But that there has been an increase in interest is undoubted. If you compare the newspapers of the 1950s with those of today, you will immediately notice the difference. I once calculated that an assiduous reader of the Daily Telegraph alone would read more than 2000 articles per year relating to health, surely more than anyone could assimilate into a sensible intellectual framework. And although I myself have benefited personally from the great increase in interest in health matters in newspapers, in that my career as a journalist was founded on it, I nevertheless lament it as a cultural phenomenon; for at a time when newspapers maintain fewer and fewer foreign correspondents, and report on foreign news ever more scantily, it seems to me to represent a response, or possibly an invitation, to an involution of people’s interests in the world beyond themselves, and to an unhealthy (I use the word metaphorically) self-absorption. Be that as it may, interest in medical affairs is here to stay, at least until we suffer a real social cataclysm, if we ever do. And because newspapers thrive on the sensational, they give a very skewed idea of what medical practice is actually like. You never see an article telling you that little Miss Jones had her appendix out yesterday and is recovering without complications, or that Mr Smith has taken his antibiotics, and his infection is now waning. While these facts are important to Miss Jones and to Mr Smith, they are definitely not news, however representative of the world they may be. Having written for several newspapers for a number of years, I think I can discern a pattern in their reporting. It has two fundamental poles: the miracle cure and the murderously incompetent, or just plain murderous, doctor — a dialectic enlivened by occasional reports of medical threats to the survival of the whole of humanity. This reporting is essentially frivolous. Perhaps it is futile to complain of it, but our newspapers have become a branch of the entertainment industry. Modern technology has, more-over, heightened the tendency to frivolity; speed of information is far more important than its veracity or wider significance (in any case, it will all be forgotten tomorrow). Editors often seem more interested in whether authors can turn out an article of reasonable coherence by 4 pm than in whether the article has any other value. In vain do authors plead for more time to research a subject so that what they write will be more authoritative. Access to the internet enables almost everyone to appear as if they know something about almost any subject; and in the kingdom of the ignorant, the man with one fact to hand is king. The twin poles of medical reporting — miracle cure and murderous doctor — promote undesirable emotions in the population. On the one hand, unrealistic hopes are aroused, such that death itself comes to seem an anomaly, and the fundamentally democratic nature of human life — “one man, one death” — is forgotten. On the other hand, unreasonable fears are likewise aroused; the fact that it is not surprising that there should be incompetent or wicked members of a profession that contains many thousands of men and women (because that is what human nature decrees) is lost sight of. A report of incompetence or wickedness is soon generalised, so that the most blameless practitioners find themselves tarred with the same brush. Officialdom reacts similarly, although with a slightly different motive, namely to exert power and control over the independent corporation of doctors. When it was revealed in Britain that a Liverpool pathologist had taken organs from deceased babies for research without asking the parents’ permission, there was an outcry, obviously promoted by newspapers, and the administrators of some hospitals decreed that every drawer and every cupboard in every room should be searched for hidden body parts. A friend of mine had his outpatient clinic interrupted by three men in suits searching for babies’ organs in his desk drawers (they did not find any). Unrealistic hopes are just as harmful as exaggerated fears. They actually increase human misery by disguising the inevitable limitations of existence, which have to be accepted if they are not to be psychologically debilitating and deforming. This, surely, was the fundamental point made by the social philosopher, Ivan Illich. His books Medical nemesis1 and Limits to medicine2 were published about a quarter of a century ago, just as I was qualifying, and rather irritated me at the time. Had I joined the medical establishment only to become, in Illich’s famous words, “a major threat to health”? I was annoyed, but since then have calmed down and now see the wisdom in what he was saying, even if he over-egged his pudding. An exaggerated belief in the technological powers of medicine can deprive people not only of the ability, but even of an awareness of the need, to cope with the inevitable ups and downs of human existence. They come to view the problems inherent in life — all existential fluctuations — as matters susceptible to medical management. Books such as Listening to Prozac3 encourage them to believe that our understanding of neurobiology is now so great that we can switch moods on and off like taps, to produce any temperature we like, at the touch of a prescription. The supposition is that it is normal to be happy all the time, and that any deviation from constant bliss is a pathological condition. Doctors may be flattered to be considered so powerful and important, but in any case, will find themselves constrained to prescribe medication that they know in their hearts to be perfectly useless and in some cases harmful. How else will they get patients who believe that there is a pill for every ill out of their consultation rooms? Macbeth’s physician was right: we can’t pluck out a rooted sorrow with some sweet oblivious antidote. Rooted sorrows are an inevitable part of human existence, we are not made for constant bliss. Medicine is a noble endeavour, but a limited one. Its advances are taken for granted the moment they are made, and new sorrows rush in where old ones have departed. That is why medicine will always be able to relieve sufferings, but will never be able to abolish suffering itself.

Anthony Daniels

To the Editor: Mental health literacy of the general public is suboptimal, and knowledge and attitudes about some mental illnesses, such as schizophrenia and substance use disorders, are particularly poor.1 The media have been implicated in contributing to overall low levels of mental health literacy, with studies showing that mental illness is commonly portrayed negatively and linked with crime.2,3 However, few studies have considered whether particular mental illnesses are especially likely to be “framed” in the context of crime. In 2000, we undertook a survey of media reporting of mental illness and crime. We retrieved 13 389 Australian media items on mental health or illness from 515 sources during the year 2000 (all national metropolitan daily and Victorian suburban and regional newspapers and all national radio and television networks). We extracted detailed information from a random sample of 1126 items, identifying the mental illness that was the item’s predominant focus (co-morbidity is not typically reflected in reporting) and whether this was mentioned in the context of crime.4 Overall, only 71 of the 1126 items (6.3%) referred to mental illness in the context of crime. However, a substantial proportion of items on schizophrenia (9 of 57, 16%) and substance use disorders (13 of 117, 11%) did so, as did 33 of 311 items (11%) about mental illness in general. By contrast, only a small proportion of items on depression (7 of 218, 3%) and other disorders (9 of 146, 6%) referred to crime, while none of the items on eating disorders (29), dementia (133), or stress (115), did so. Examples of media references to mental illness in the context of crime included: A teenager accused of a fatal stabbing was described as “psychotic, mentally retarded, displaying signs of schizophrenia [and] hearing voices” (The Australian 2000; 15 Nov: 4). A man was referred to as a “paranoid schizophrenic” and “lunatic” in association with attempted murder (ABC Television World at Noon 2000; 16 Nov: 12:19 h). A woman charged with “a spate of armed robberies” was described as “fighting a drug addiction” (Radio 3AW News 2001; 8 Jan: 13:02 h). It was encouraging to find that relatively few items referred to mental illness in the context of crime, but confronting that those that did were disproportionately about schizophrenia and substance use. Studies that have considered the extent to which people with these disorders contribute to crime statistics suggest that public perceptions of them as criminally dangerous are exaggerated,5 and the media may have a role here.

Catherine Francis PhD · Jane E Pirkis PhD · David R Dunt PhD · R Warwick Blood PhD · Philip M Burgess PhD

Why do some “frequent flyers” of the ED gain a permanent place in our hearts? Recently, the death of a homeless man who had lived in a bus shelter next to our inner-city emergency department (ED) for a quarter of a century made national and international headlines.1,2 Here, I present the story of this man’s relationship with the ED and also describe our involvement with two other homeless men. Then, I ponder why it is that patients like these can make such an impact on the healthcare workers who come in contact with them. Karl, the bus-stop manAlthough Karl did not present as a patient every day, we saw him in the ED every day, as he used our waiting-room toilet as his own. We found him to be a very quiet, private, polite, kind and gentle man. The nuns and hospital staff (especially the nurses and social workers) would give him tea, biscuits and sandwiches when he visited, but rarely did he accept other offers, such as assistance in securing alternative accommodation. He lived in a corner of a nearby bus shelter, and neither he nor the shelter could be considered pleasing to the discerning nose. We repeatedly tried to coax him into the ED for a clean-up and a new set of clothes. On the odd occasion he did accept the offer of a clean-up — notably on Christmas Eve in 1993, when the hospital notes document that the nurses handwashed his clothes when he wouldn’t part with them. He even allowed us to trim his beard a little, and we did think he looked rather like a Santa Claus. Perhaps it was because of his Christian background that Christmas was the only time he ever seemed to truly relax and enjoy being in the presence of the ED staff. Perusal of Karl’s medical record reveals only seven official attendances, including three overnight admissions under my name. In spite of a past history of alcohol misuse, his health problems had been limited to chronic venous insufficiency, swollen legs, cellulitis and scabies infestation. During one admission, an ED registrar had asked jokingly, “Is it Karl’s birthday?” (in fact, we didn’t know his date of birth, and never did find out). On another occasion, during winter, I had admitted him overnight simply because the outside conditions were harsh and he was fearfully cold. In September 2002, Karl was found dead, of natural causes, in his bus shelter. The outpouring of sympathy for this unassuming man, who had become such a “fixture” in the life of the ED, was amazing. Even in death, his life was an enigma. From what could be pieced together from the locals — people whose children he had helped to catch the bus, shop owners and waitresses from whom he had bought or had received gifts of coffee and food (including bacon sandwiches — his favourite), nuns who crossed the road near his bus shelter on the way to and from their convent (whom he uniquely acknowledged by accepting their gifts and offering a smile and ever-so-rare words), and the nurses whom he had looked out for in the dark as they returned home after working a late shift — it became apparent that he had had a daily routine, a circuit. But he had never let us get to know him and never revealed anything about his history. We felt he was a loner by choice and we respected that choice. Unlike other homeless people we saw in the ED, he was never seen to be intoxicated, rude or aggressive. Karl was a man who spoke with his eyes rather than with words. When he died, many of us truly grieved for this kindly, silent, bearded figure. Harry, the newspaper manAnother younger, homeless man evoked a similar feeling of loss upon his demise — this time, the death actually occurred in our ED. I have written of his case previously,3 partly because of its general medical relevance but also because I found myself, like many others in the ED, emotionally affected by it. Harry was a scrawny, wiry man of 40-something who looked a great deal older than he actually was. We frequently saw him in the streets around the hospital. Any greeting of “Hullo” or “Good morning” that we gave him was returned with gusto. We knew him as the man who sold newspapers. We thought this was his way of earning a little more money, as we knew that he drank. He never talked about himself and never asked for a handout. I remember clearly the morning he was brought into the ED by ambulance, having had a witnessed collapse. Quickly it became evident that he was critically ill — he had septic shock secondary to cavitating pneumonia (Box). However, once we had reversed his profound hypoglycaemia (0.7 mmol/L) and commenced to warm him up from his hypothermia (33.5°C), he just kept apologising to us for being a trouble. Over the subsequent hours, we tried to save his life, and did successfully bring him through a broad complex tachycardia. All the ED staff, including non-healthcare staff, were focused in their concern for him, with everyone requesting frequent updates. Unfortunately, we lost him following an arrest. Although he put up an amazing fight, advanced resuscitation, including defibrillation, could not save him. The ED staff went quiet in their grief. Many, including myself, shed a tear. We knew this patient and he had expressed his appreciation of our efforts — even as he was dying. It turned out that he, like Karl, had been a loner. Before he died, he asked us to contact his only friend — the newsagent who supplied him with papers, basic accommodation and the sincere care that only a friend can provide. There were no relatives and there was no past we could piece together. His absence from the neighbourhood haunted us long after his death. “John”, the “scratchie” man“John”, a street person with drug use issues, is one of our most frequent attendees currently. He is highly intelligent, very manipulative, and almost totally non-compliant with antibiotic therapy for a septic knee and sundry other complaints. Even when coaxed to stay in the ED for treatment once difficult intravenous access has been established, he manages to escape several times a day on crutches or on one of our wheelchairs (generally by using the ruse that he is going out for a “smoke”). On one such outing, he bought a lottery “scratchie”, and on his return asked a nurse to check whether he had won anything. For a while there, we all thought he had scratched himself $50 000; he was festively congratulated and we were all very happy for him. When it turned out that an unfortunate minor technicality meant that he just missed out on his prize, the ED staff immediately passed the hat among themselves so they could buy him another couple of scratchies. DiscussionMany homeless and disadvantaged people use the ED as their main point of access to healthcare and social care.4-6 Outside normal working hours, calling in at an ED may be the only practical option available to them. The three cases described here illustrate the bond that can develop between ED staff and the homeless people who visit at irregular times. ED staff will know which of their regular visitors are living “rough”, either by their address (“no fixed address”, multiple changing addresses, or homeless shelter address cited in the medical record), or by talking to other staff or the patients themselves. Maybe it is because EDs are always available and the staff will, with each presentation, listen to the homeless person’s issues, talk to them and try to work out something for them, that there develops a caring bond between the homeless and ED staff. Why do we care? I have mused often about this question and have asked my staff for their thoughts on the matter. The demanding work of an ED tends to attract staff with certain qualities in common. One is our need for gratification — we want to do things and see results, despite the difficulties. This is not necessarily an easy task — many (but not all) homeless patients are “hard work”. They may present to the ED in a confused or demented state; they may be anxious or plain scared. Some fight to reject any care offered to them; others, because of their personalities, mental-health and/or substance-use disorders,7,8 may be overtly rude, aggressive, and verbally and/or physically abusive to all around them. At times we get frustrated and upset, but over time we get to know each of their names and their individual needs. We are persistent, trying over and over again to help them. With each new presentation, both “sides” may begin their “games” anew. Whether the homeless to us, or we to them, become familiar or even “family”, I think all ED staff, on the whole, feel privileged to be in a position to offer not only core healthcare but also comfort and help to homeless people. This is, I believe, why we are so sad and reflective when we lose one of them. Chest x-ray of Harry, showing cavitating pneumonia

Gordian W O Fulde FRACS FRCS FACEM

Objective: To review the results of opinion polls on community attitudes to in-vitro fertilisation (IVF) and other aspects of assisted reproductive technology over a 20-year period.Design, setting and participants: Fourteen Australia-wide interview surveys that included questions relating to IVF were carried out between July 1981 and November 2001 as part of regular Morgan polls of community attitudes on various topics. Each survey involved about 1000 respondents drawn from randomly selected “cluster points” in urban and rural locations.Main outcome measures: The proportion of people who approved or disapproved of various aspects of IVF treatment.Results: Support for IVF to help infertile married couples increased from 77% in 1981 to 86% in 2001. Approval for IVF procedures being supported by Medicare funding rose from 70% in 1981 to 79% in 2000.Conclusions: Community approval of the use of IVF to treat infertility has risen significantly in Australia over the past 20 years.

Gabor T Kovacs MD, FRACOG, FRCOG · Gary Morgan BComm · E Carl Wood AC, CBE, FRCS, FRACOG · Donna Howlett BSc, MBA · Catherine Forbes BSc, MSc, PhD

Treating substance misuse might not significantly reduce the number of offenders According to recent estimates, crime costs the community $32 billion annually. Of this, $1960 million is directly attributable to drugs, and, if indirect costs were included, the proportion attributable to drugs would be higher.1 Clearly, interventions that target potential risk factors for crime, such as drugs and mental health problems, will have significant payoffs for individuals and the wider community. However, the relationship between drugs and crime is complex. Policy development in this regard needs to take into account the multifaceted nature of the problem. In this issue of the Journal (page 408), Heffernan et al present the first Australian publication that seeks to clinically assess the level of substance-use disorders and psychological distress among police arrestees.2 This article makes a constructive contribution to the evidence base. The study highlights that the overwhelming majority of arrestees suffer from clinical substance-use disorders and psychological distress, and that they are a population who may be in need of treatment. Replication of these findings is important to furthering our understanding of the need for treatment among this group. In Australia, evidence is emerging (building on overseas research) that criminal behaviours among arrestee and prison populations vary widely, from minor disorderly conduct through to homicide, with different factors contributing to these behaviours. Illegal drug use is just one of many risk factors, but there is no doubt that it is significant in the behaviour of a subset of offenders. Recent analyses of police detainees and the incarcerated adult male population estimate that this is the case for between 34% and 52% of offenders.3,4 This clearly suggests that effective treatment interventions could significantly reduce crime rates. Criminological studies that track when people start, persist with and desist from drug use and offending demonstrate that most offenders become involved in minor crime before experimenting with and using illegal drugs.5,6 For example, the onset of crime preceded regular heroin use in 69% of one sample of offenders.5 Illegal drug use seems to compound a pre-existing problem, and so produces higher levels of offending.7 Thus, treating substance misuse among offenders, although an essential public health measure, might not necessarily result in significant reductions in the number of offenders. This is because crime and drug use may be caused more by factors external to the individual, such as early-childhood experiences and development, access to labour markets, access to local drug markets and their supply routes, the social and cultural environment, lifestyle choices, and other determinants that are not easily amenable to treatment.8 The links between drug use and crime and the policy implications that flow from this will be affected by the nature of the local drug market. The Australian Institute of Criminology’s Drug Use Monitoring in Australia project has conclusively shown that police detainees’ drug use patterns vary across the country. Higher rates of amphetamine use have been detected in Queensland, Western Australia and South Australian sites; while higher rates of heroin use have been detected in New South Wales sites.9 Furthermore, breakdowns by offence type indicate that users of amphetamines are arrested for a range of offences, not just violence, and similarly heroin users are arrested for a range of offences, not just property. The links between drugs and offending types appear more variable than is often thought. Changing human behaviour is difficult. Some people take drugs because they like the effects, some because they are risk takers, and some to self-medicate for past and current painful situations and events; others take them because they are addicted and simply cannot stop. Not everybody who is defined as dependent will want or seek treatment. In this complex environment, public policy responses, such as drug courts and court diversion systems, need to be cognizant of what drives behaviours and develop appropriate responsive systems (of which levels of dependency will be only one factor). Recent evaluations of the south-east Queensland and NSW drug courts10,11 have shown that, even with a 12-month, structured, supervised program, some people continue to be criminally active and use illegal drugs. Estimates from the early stages of the Queensland study suggest about a third of graduates reoffended within the follow-up period after graduating from the court. Similarly, police diversion schemes need careful targeting, as good longitudinal research shows that, after a “first” contact with the criminal justice system, many young offenders (upwards of 60%) do not come back into contact with the juvenile system again.12-15 Because of the intersection between illegal drug use and crime, the criminal justice systems in Australia have developed a range of policy innovations to divert offenders into treatment and other programs. These include early police diversion programs, court-based initiatives to divert offenders into treatment, and formal drug courts for serious offenders. There have also been attempts to provide treatment programs within prisons. However, opportunities for diversion could be strengthened in other areas. The first area is at the “end” of the criminal justice system, by providing postrelease support programs for prisoners leaving custody. Given that some 58% of prisoners have been imprisoned previously and 22% of police detainees have been imprisoned in the past 12 months, interventions to break the cycle of reoffending would have a significant beneficial effect on both the individual and the wider community — drug treatment is clearly one of those interventions. The second opportunity to improve diversion to treatment is in the gap between police diversion and the drug court: targeting people who are arrested and processed but whose offence is not sufficiently serious to meet the criteria for a formal drug court program. The study by Heffernan et al includes a significant number of these people, providing support for “arrest drug referral” schemes, as undertaken in the United Kingdom.16 However, there could be very large numbers of people suitable for such schemes. Policymakers first need to know how many of those people would avail themselves of treatment. In addition, treatment options must exist — at present, there is a range of effective treatments for heroin, but options for other illegal drugs are extremely limited. Reducing crime requires a multipronged approach that goes beyond criminal justice and treatment responses, to include a whole-of-government approach. Building the evidence base with valuable contributions such as that by Heffernan et al is vital to ensuring our interventions are successful.

Toni Makkai PhD

Objectives: To determine the 12-month prevalence of substance-use disorders and psychological morbidity in an Australian arrestee population.Design: Cross-sectional descriptive study.Participants and setting: 288 police arrestees at the Brisbane City Police Watch House in February and March 2001.Outcome measures: Prevalence of drug and alcohol disorders; psychological “caseness” according to the 28-item General Health Questionnaire; demographics and index offences.Results: 86% of the arrestees had at least one substance-use disorder; most had multiple disorders. More than 80% were substance dependent. The predominant substances used were amphetamines, marijuana, opioids and alcohol. 82% of the men and 94% of the women were suffering significant psychological distress.Conclusions: Development of services for detoxification and treatment of this population is a pressing need. The findings provide crucial information for the planning and implementation of drug courts and court diversion systems.

Edward B Heffernan BSc(Hons), FRANZCP · John B Saunders FRACP, FAFPHM, FRCP · Gerard Byrne PhD, FRANZCP · Joe Finn BN

A 6-year-old child, held in detention with his parents pending the outcome of their application for refugee status, manifested psychological distress by repeated episodes of refusing to eat or drink. This case presented clinical and ethical dilemmas for health professionals who were constrained from acting in the child’s best interests by government policy of mandatory detention. It is Australian government policy to detain asylum seekers who do not have a valid entry visa in one of six privately operated immigration detention centres while their refugee status is determined (Box 1). The detention environment has been implicated as a direct contributor to psychological distress, either de novo or as a “retraumatising influence”.1 This is reflected in the suicide rate in detention centres, which is conservatively estimated at 3–17 times that in the Australian community.2 Justice P N Bhagwati, Regional Advisor, United Nations High Commission for Human Rights, identified key human rights issues pertaining to immigration detention in Australia.3 These included the lack of independent monitoring mechanisms, restricted access by healthcare workers and lawyers, lack of protection of the family unit (exemplified in the Woomera Housing Project, whereby women and children were allowed to live in the community while their husbands remained in detention), the policy of detaining unaccompanied minors, and the prison-like conditions, which are not conducive to healthy childhood growth and development. In August 2001, Australasian paediatricians and psychiatrists issued a joint position statement calling for children and their families to be released from Australian detention centres, and highlighting concern for children’s “subsequent emotional development and for the effects of detention on the functioning of their families”. In June 2003, there were 315 children held in detention in Australia and Australia’s “excised offshore places” (such as Ashmore and Christmas islands),4 as well as on Manus Island (Papua New Guinea) and Nauru.5 The clinical and ethical dilemmas that arise when government policy restricts clinicians’ decision-making are illustrated by the clinical record of a 6-year-old boy in detention with his family, who had repeated episodes of refusal to eat or drink (Box 2). This case highlights issues applicable to many children in detention in Australia. DiscussionThis boy was in a state of distress, and preoccupied by imprisonment and the violence he had witnessed, as depicted in his drawings (Box 4). The form of his response may have been influenced by the behaviour of distressed adults (as role models) in Woomera and Villawood detention centres who staged hunger strikes. His improvement when away from the detention centre, and rapid deterioration on returning, communicated the impact of an aversive environment. Several authors have described high levels of depression, anxiety and post-traumatic stress disorder (PTSD) in adult asylum seekers detained in Australia. They have also observed that detention may profoundly undermine the parental role, leaving children with little protection or comfort.1,7,8 Considerable evidence exists that refugee children themselves are at significant risk of developing psychological disturbance (PTSD, depression, anxiety and sleep disorders),9 but they frequently present with mixed symptoms, not necessarily fulfilling a single diagnostic category.10 The likelihood of psychological disturbance increases with the synergistic impact of multiple risk factors, including observing parental helplessness, separation from parents, witnessing or experiencing traumatic events, and the time taken for immigration status to be determined.11 Psychological distress in the early years may have implications for long-term functioning12,13 and competence in adult life.14,15 Protective factors for children exposed to trauma include being with their parents,16 having a safe and predictable environment,17 and achieving a sense of mastery over the environment by becoming part of a school community.18,19 In May 2001, when this child first presented, public and professional criticism of the conditions in detention centres was beginning to be voiced. The treating team studiously avoided media attention, on the assumption that maintaining confidentiality and advocacy at the individual level was likely to produce the most favourable mental health outcome. The team was challenged by differing views on the extent to which healthcare workers should confront the systems issues contributing to this child’s distress. This child’s presentation highlighted both a hiatus in the evidence base for effective treatment options for such children, and the frustrations of health professionals at being unable to provide best-practice care. Although we offered play and art therapy, family and individual sessions, “therapy” made little sense, given the boy’s awareness of the constant threat of discharge back to the “camp” and the uncertain outcome of the family’s refugee claim. Clinical recommendations, such as maintaining family integrity or school attendance, could not be accommodated by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) and the agency managing the detention centre (Australasian Correctional Management). Child protection, legal and ethical issues were extensively discussed in managing this case. The overarching constraint was the clash between the principle of acting in the child’s best interests and government policy on mandatory detention — often prolonged mandatory detention. t Under the Children and Young Persons (Care and Protection) Act 1998 (NSW), healthcare workers in New South Wales are mandated to report children at risk of harm to the NSW Department of Community Services, so that appropriate protective measures can be instituted.20 This child fulfilled the criteria for reporting, and various attempts to report him were made. Child protection is governed by state legislation and could not be activated, as detention centres are a federal responsibility. Furthermore, the Minister for Immigration has certain guardianship rights with respect to asylum-seeker children, creating difficulties for state welfare authorities. The ethical dilemma of returning a child to an aversive environment is not unusual for health professionals. When the environment is known to be abusive, healthcare workers can call on nominated child-centred agencies to assist in maintaining children’s wellbeing. However, this was not possible in this case, as detainee children are not subject to Australian child protection legislation, and their welfare is not systematically monitored. In 1990, Australia signed the United Nations Convention on the Rights of the Child. This convention embodies the principles of provision (of education, health and other services), protection (from torture, abuse and arbitrary detention) and participation by children in decisions affecting their lives. Article 22 proposes that refugee children should have the same rights as citizen children.21 In May 2002, an alliance of health professionals launched a submission to the Human Rights and Equal Opportunity Commission (HREOC) Inquiry into Children in Immigration Detention, and recommended that children should not be held in anything other than minimal detention for processing purposes only, and that all children and their parents should be released immediately.22 The child presented in this article was the subject of a complaint to the HREOC, which “recommended” that the Australian government pay $70 000 compensation to the child for harm suffered. The government rejected the Commission’s findings and recommendations.23 Under present government policy, children seeking protection in Australia are unlikely to receive services that fulfil their complex needs, and we remain concerned that their prolonged detention will impair their psychological well-being and their capacity to become integrated members of the community.1 1: Schematic representation of the process for asylum seekers without a valid entry visa for obtaining a Temporary Protection Visa* * Information from Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) website (www.immi.gov.au/facts/index.htm). †A Temporary Protection Visa entitles the holder to: temporary residence for 3 years; limited Welfare and resettlement assistance; access to Medicare benefits; no access to government English lessons; no family reunion; cannot leave and re-enter Australia (www.immi.gov.au/facts/64protection.htm). 2: Clinical record — a 6-year-old boy with recurrent refusal to eat or drink A 6-year-old boy presented to the Emergency Department of the Children’s Hospital at Westmead in May 2001. He was accompanied by his mother, infant sister and a uniformed officer from the Villawood Detention Centre. His mother reported, via an interpreter, that he had refused to talk or eat for the last 4 days, but that she had managed to coerce him to take small amounts of liquid. This episode began after the boy observed a man cutting his wrists (in the boy’s words “killing himself”) at the detention centre. The family was of Middle Eastern origin and belonged to a small religious group regarded as heretics in their country of origin. They had arrived in Australia by boat in March 2000, and then spent 11 months at Woomera Detention Centre and almost 3 months at Villawood Detention Centre. The younger child was born in detention. The family had been refused refugee status at all the initial stages of processing (Box 1), and were making a final-resort appeal to the Minister for Immigration and Multicultural and Indigenous Affairs for humanitarian consideration, a process seldom successful. The chronology of events is shown in Box 3. For 6 months before presentation, the boy had withdrawn from play with other children, and had been drawing similar repetitive images (Box 4). He became startled when he heard two-way radios used by detention centre officers. His mother described a chronic history of bedwetting and nightmares, which began after he witnessed riots and people setting themselves alight at the Woomera Detention Centre. Before this, he had been healthy, with normal development, although he had refused to eat and talk for half a day after one incident at Woomera. On examination, the boy was pale, listless and had clinical signs of mild dehydration. His height and weight were on the 75th and 50th percentiles, respectively. He was admitted to hospital for 6 days during which he gradually resumed talking and eating, although his bedwetting and nightmares persisted. Mental-state examination revealed a dull affect with slow, quiet speech and an anxious penetrating stare. He was unable to verbalise any wishes for the future, and said there was no point in making friends, because they all left while he remained in the “camp”. He described bad dreams about officers taking his father to gaol, and people cutting children with glass. The only drawing he produced in which the figures were not covered with bars was one of “the man who cut himself” (Box 5). He displayed extreme separation anxiety when his father departed after visits. He was assessed by the child psychiatry team as having acute on chronic post-traumatic stress disorder, fulfilling the Diagnostic and statistical manual of mental disorders (DSM-IV) criteria6 in that: (i) he was exposed to traumatic events; (ii) his response involved intense fear and helplessness; (iii) he had persistent re-experiencing of his trauma (through nightmares and with various triggers); (iv) he had a numbing of general responsiveness (with social withdrawal and refusal to speak or eat); and (v) he had symptoms of increased arousal (resulting in disturbed sleep). The differential diagnosis included depression, but this was considered less likely when many of his symptoms resolved within his short admission. He was discharged back to the detention centre after 6 days in hospital, with follow-up arranged with the centre psychologist and hospital team. The discharge summary, copied to the Centre Manager of Villawood Detention Centre, stated that he was at high risk of recurrence unless a more normal environment could be provided, that he should remain together with his family, and that access to a school with stable peer relationships would be important. In addition, it was asserted that the uncertainty about his family’s future was likely to be perpetuating his symptoms. Six days later, the boy re-presented to the hospital with refusal to eat or drink and mild dehydration. His readmission necessitated a series of complex interagency negotiations in an attempt to provide a reasonable standard of care. The negotiations involved Australasian Correctional Management (the agency managing the detention centres), Villawood Detention Centre management and health services teams, and various case managers assigned by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA), and covered coordinating parental visits and family counselling sessions, interpreters, visitors, culturally appropriate food, and possible discharge arrangements. Other difficulties included the lack of a structured daily program (as an asylum seeker, he was not eligible to attend the hospital [Department of Education] school), the social alienation of the child and family within the ward, the emotional distress experienced by the interpreters encountering the family situation, and dealing with the dilemma of whether the hospital should be acting as a place of safety for the child. Since protection from trauma was the most important part of treatment, discharge to the detention centre was likely to re-traumatise him. During the 8-week hospital stay, the boy became increasingly frustrated and difficult to contain because of his limited access to recreational, educational and other stimulating activities. He resented that detention centre officers were in close proximity at all times. His separation anxiety was fuelled by unpredictable parental visits, and the alternating arrangement of one parent staying with him. Multiple case planning meetings involving Villawood and DIMIA representatives failed to produce a resolution to the dilemma of a discharge placement for the child. The municipal office of the Department of Community Services was unable to intervene. There was no alternative except to discharge him back to the detention centre. The child now entered a phase of repeated presentations to the emergency department every few days over a period of 4 weeks, with a pattern of food refusal and dehydration. On each occasion, he required nasogastric rehydration and stayed for 1–2 days. His mother described how he would become pale, quiet and sweaty when he saw the fences that featured in his drawings. After six such presentations, he was readmitted for nutritional review as he had lost 3 kg. Two weeks later, his parents agreed to DIMIA’s offer of discharge to foster carers, and DIMIA arranged Department of Community Services approval of the nominated carer. DIMIA declared the boy’s new home and school a “place of detention”, and engaged a private psychotherapist. He was reported to have frequent emotional outbursts, disrupted sleep and difficulty coping with separations from his family after weekend access. The foster carers were ill-prepared for dealing with his distress, and the placement was continuously under threat. With no placement alternative, DIMIA granted permission for the boy to live with his mother and sister in the community. Seven months later, his father joined them when the Federal Court allowed re-application to the Refugee Review Tribunal and Temporary Protection Visas were granted. Of interest is that no new evidence was presented, compared with the family’s original application. These visas are valid for 3 years, and the future thereafter is uncertain for the family. Although an eager learner at school, the boy currently has regular nightmares and is fearful that his family may be returned to the “camp”. At the time of publication, the family are being seen by therapists at a state-funded trauma counselling service. 3: Chronology of events related to the child March 2000 Arrived in Australia (age 5 years) March 2000 – February 2001 Woomera Detention Centre. Infant sister born March – May 2001 Villawood Detention Centre May 2001 Initial hospital presentation and admission (age 6 years) May 2001 Re-presented 6 days after discharge May 2001 First letter and fax to the Minister for Immigration from treating team at Children’s Hospital at Westmead May – July 2001 8-week hospital admission June 2001 Subsequent letter to the Minister for Immigration from treating team at Children’s Hospital at Westmead July – August 2001 Six emergency department presentations August 2001 Received reply from the Minister for Immigration September 2001 2-week hospital admission September 2001 Granted Bridging Visa.* Discharged into foster care January 2002 Mother and sister granted Bridging Visas, and child returned to mother’s care in the community (aged 7 years) August 2002 Family granted Temporary Protection Visas, allowing family to live together in the community *Used to allow an applicant for a substantive visa to remain in the country out of detention while their visa application is being processed. 4: The child’s drawings were dominated by the fence “They’re crying. They’re all scared. Scared of officers — all of them” (the child’s description of the people in the foreground). “It’s a stick. They bash up children with that wood” (the child’s description of the person in the background). 5: The child’s drawing after seeing a detainee cut his wrists “The man who cut himself”

Karen J Zwi FRACP · Brenda Herzberg FRANZCP · David Dossetor FRCPsych · Jyotsna Field MPsych

Carers cannot care without backup, nor be everything from nurse and banker to best friend Six years ago my daughter Isabella, now aged 31, was diagnosed with schizophrenia after a prolonged period of bizarre behaviour. She had many difficulties during her childhood. She was never able to relate to her peer group, to play with them or to be included in their activities. She depended on her parents and other adults for mental stimulus. An embarrassing obsession with another student led to the first of several changes of school. She received a great deal of psychotherapy from psychiatrists. Professor Allan Fels, his wife Isabel Cid de Fels, and their daughters Isabella (left) and Teresa (right). Photo courtesy Vicki Jones Photography, VIC. Isabella now lives at home, receives treatment from a psychiatrist, and takes medication which generally relieves her psychotic symptoms. Isabella is a loveable, charming, sensitive, articulate and intelligent young woman, but even with medication her illness can cause serious difficulty in comprehending reality, frequent obsessional behaviour, sometimes socially inappropriate behaviour, lack of motivation and bouts of irritability. Like others with schizophrenia, she may need help in making “reality checks” — distorted and confused perceptions may be kept in check by talking to people with a better grasp of what is happening. Families, friends, volunteer helpers and professionals may be of great help here. One effect of deinstitutionalising those with mental illness since the 1980s has been the greater burden on families. An attempt by Isabella to live away from home with others, in a house with mental health workers present from 9 am to 5 pm on weekdays, did not work. She has underdeveloped living skills, and her illness is such that she could not live by herself — she basically depends upon family care. The challenge for the family is well summed up by E Fuller Torrey in Surviving schizophrenia: “Family members, especially mothers, are often asked to simultaneously be the person’s case manager, psychotherapist, nurse, landlord, banker, janitor, cook, disciplinarian and best friend”.1 Families cannot be all these things, and especially they cannot be psychiatric hospitals. The physical and emotional impact on the family is very great, mostly all consuming, especially for my wife. Without intellectual stimulus and some pressure to engage in activity, Isabella lapses into prolonged inactivity, passiveness and depression. She needs company to relieve her of anxiety about changing obsessions. Occasional respite care provides some relief, but is underresourced, like many other services. Consequently, a significant number of people who are seriously affected by the illness may not cope at all, and leave home, sometimes turning to drugs, alcohol and even to prostitution and crime. Families that try to care need substantial backups, but these are often lacking. While it was recognised that deinstitutionalisation could work only with adequate social support, the quality and range of the necessary community-based psychosocial services were seriously underestimated. Isabella has been unable to receive adequate attention from services and, like many others, has suffered from a lack of rehabilitation and recovery programs. More programs of organised recreation and activity are needed (in Isabella’s case these would include, besides occupational therapy, activities such as reading together, writing together, general education on current affairs and general knowledge), as well as vocational training, counselling, help with developing living skills, structuring the day, managing diet and physical exercise, and in obtaining part-time work. A greater range of services is also needed to manage crises which occur in the course of the illness — yet even in hospital services are limited. Some support for families does exist through social and mental health workers. Our experience has been mixed. In some instances, we experienced problems that seemed to stem partly from a failure to adequately include the family — the long-term primary carers with the best understanding of the person and their illness — in management. At other times, we experienced demeaning and dispassionate attitudes from some mental health workers. We encountered some social workers with an attachment to inappropriate or ill judged notions of independence and personal freedom for the person with schizophrenia. This has sometimes been based on a superficial understanding of that person’s circumstances, reinforced by short-term involvement caused by high rates of staff turnover. A consequence in our case has been a tendency to try to lead our daughter in a quite different direction from the one we believe she should follow. For example, she was encouraged, without consultation with us, to leave home (which she did for a time) without any understanding of the likely problems. Similarly, she was encouraged to enter personal relationships which we knew would cause her distress after a short time. There is growing evidence that early treatment may assist in alleviating the illness, and, in view of this, it would be useful if general practitioners could ensure its early diagnosis. However, inadequate attention is often paid to the early signs and symptoms, and to the concerns of relatives, which leaves families feeling let down. Yet, there are already many other demands on our hard-pressed GPs. It will require higher prioritisation of schizophrenia by the public, by governments and by the medical profession if the illness is to secure more attention. An even harder ask is that school teachers and counsellors watch for early signs of schizophrenia. Often, they are the first to notice that something is seriously amiss, but are not trained to recognise what it is. While satisfied with Isabella’s current psychiatric care, we are disappointed that previous specialists resisted our suggestions that Isabella might have schizophrenia (given a family history of the illness) and that continuous psychotherapy from age 13 to 25 years was unproductive. It would be interesting to gather hard evidence on the outcomes of such therapy. Schizophrenia has been stigmatised in society, a situation which we should all try to overcome. This is why we agreed to airing the issue on ABC TV’s Australian story (www.abc.net.au/austory/transcripts/s659714.htm). Occasionally, the term schizophrenia is avoided and replaced with euphemisms such as “developmental arrest mental illness”. I do not agree; the condition should not be disguised, and the stigma associated with it should be addressed directly. It should be named in the same way that we name diabetes or asthma. Schizophrenia does not seem to receive the priority it needs from our public health system. Australia spends less of its health budget on this illness, proportionally, than other countries, according to a recent study by the economic consulting firm, Access Economics.2 This is partly historical, partly because of its low priority politically, and partly because of a failure to recognise the large social payoffs from preventing the drug-related illnesses and crime for those at the serious end of the spectrum. As an illness which extends over an entire lifetime, it has enormous personal, family, social and economic ramifications.

Allan Fels AO

With release of the ALRC/AHEC inquiry report, we are now in a position to develop sound policies The report Essentially yours: the protection of human genetic information in Australia,1 launched in May this year, represents the first comprehensive exploration in this country of the ethical, legal and social implications of the emerging revolution in genetic science and technology. The report is the outcome of a major, two-year, public inquiry conducted by the Australian Law Reform Commission and the Australian Health Ethics Committee of the National Health and Medical Research Council (NHMRC). Although the central themes of the inquiry were ethical standards, privacy protection and protection against unlawful discrimination, the final report examines the impact of the “new genetics” across a very wide range of social and professional contexts — accounting for the “super-sized” 1200-page document, presented in two volumes and containing 144 recommendations for reform. The inquiry covered obvious issues such as the ethical oversight of genetic research and the increasing use of DNA collection and testing by law enforcement authorities. Other questions considered by the inquiry included: the regulation of genetic testing in the workplace; the collection and use of genetic information by the insurance industry; genetic testing by immigration authorities; DNA parentage testing; the use of genetic testing as an element in the construction of kinship and identity; and the use of genetic testing to identify potential sporting champions. This may sound like the stuff of science fiction, but the report documents contemporary cases and controversies in all these areas. In the course of its extensive community consultation effort, the inquiry found significant optimism in Australia about the promised benefits of genetic science for improved diagnostics and therapies. However, there is also an underlying anxiety about the rapid pace of change and the capacity of our institutions to regulate science effectively in the public interest. Thus, the centrepiece of the recommendations is the establishment of a standing Human Genetics Commission of Australia (HGCA). The role of the HGCA would be to provide independent, high-level, technical and strategic advice to Australian governments, industry and the community generally about current and emerging issues in human genetics, and to provide a consultative mechanism for the development of policy statements and national guidelines in this area. One of the threshold questions for the inquiry was whether to accept arguments in favour of “genetic exceptionalism”. This is the idea that genetic information is so fundamentally different from, and more powerful than, all other forms of personal health information that it requires different or higher levels of legal protection. In contrast, genetic “inclusivists” argue that genetic information is neither distinctive nor unique in its ability to predict an individual’s health, but indicates only a rough range of probabilities. The inquiry concluded that an exceptionalist approach would be unhelpful to the extent that it would divorce genetic information from the principles, processes and institutions that have been developed over time to provide ethical oversight of research and ensure best practice in clinical medicine. However, the inquiry accepted that genetic information has some special features and issues that necessitate a thorough inspection of existing principles, practices and safeguards, and of the legal, ethical and regulatory landscape, to ensure these are all adequate to the task. The inquiry concluded that “big law” — an omnibus genetic regulation act — is inappropriate at this time. Nevertheless, the report makes a large number of recommendations for careful fine-tuning of existing legislation in the areas of privacy, discrimination, industrial law, and occupational health and safety, to meet the challenges of the new genetics. For example, it recommends that the federal Disability Discrimination Act 1992 be amended “to clearly prohibit unlawful discrimination based on a person’s real or perceived genetic status”, and that the federal Privacy Act 1988 be amended to cover genetic samples as well as data. The report also strongly emphasises that we need not only adequate protection against the unlawful use of genetic information, but also measures to ensure that, where genetic information may be used lawfully, it will be used fairly and intelligently. As a consequence, the inquiry’s recommendations go beyond simply changing laws — they involve a broad mix of strategies and approaches, including the promulgation of ethical codes, codes of practice and official standards (eg, by the NMHRC and the Federal Privacy Commissioner); industry codes and best practice standards; community and professional education; and better coordination of governmental and intergovernmental programs. Medical practitioners are well aware of how difficult it is to keep abreast of all the implications of the genetic information explosion. The report calls for all the parties involved in medical education (initial and continuing) to work collaboratively to greatly enhance genetics education for all doctors. The report also makes plain the increasingly important role that genetic counselling will play in everyday clinical practice. For some genetic tests, counselling will be adequately provided by medical practitioners; nevertheless, the report recommends that Australian healthcare authorities give urgent priority to assessing and responding to the need for increased, adequately resourced, genetic counselling services. The inquiry recognised the powerful “familial dimension” of genetic information — that is, the extent to which an individual’s genetic information can also reveal information about, and therefore have implications for, that person’s relatives, including those in preceding and succeeding generations. This leads to a recommendation that, despite the traditional importance of confidentiality to the doctor–patient relationship, there may be exceptional circumstances in which doctors (and familial cancer registries) should be permitted to disclose confidential information to genetic relatives without the patient’s consent, if such a disclosure is necessary to lessen or prevent a serious threat to an individual’s life, health or safety. In this sensitive area, the inquiry asks that guidelines be developed to assist healthcare professionals in this task. Some other recommendations of particular interest to the scientific and medical communities are summarised in the Box. The inquiry’s findings and recommendations have been presented to the two relevant federal Ministers — the Attorney-General and the Minister for Health and Ageing — and the government is expected to respond and outline its plans for implementation soon. However, the pervasive influence of genetic science means that recommendations for change have been addressed to more than 30 bodies across the public and private sectors — many of these organisations do not need to wait for the federal government before they can take action. We have an excellent opportunity in Australia now to develop policy based on sound principle, rather than managing emerging problems on the run. The area of genetic testing and information is so personal and so sensitive that it is critical we get this right — and do so now — to avoid the crisis of confidence and the public backlash that would inevitably follow from the revelation of poor or unethical practices. Some specific recommendations of the Australian Law Reform Commission/Australian Health Ethics Committee inquiry National ethical and privacy guidelines should be developed specifically to cover the use of genetic information held in tissue banks, research databases and genetic registers (including “inchoate” databases, such as Guthrie card collections). The support and guidance given to human research ethics committees when reviewing proposals dealing with genetic issues should be significantly strengthened. Laboratories that conduct genetic tests for medical, diagnostic or treatment purposes (rather than for research purposes) should be accredited by the National Association of Testing Authorities, and accreditation requirements should be strengthened to deal more broadly with ethical standards in genetic testing, such as proof of consent. The Therapeutic Goods Administration should be empowered to more effectively regulate medical devices used in genetic testing, as well as DNA test kits provided directly to the public, whether such kits are marketed for health purposes or for identification (such as for parentage testing). Nationally consistent standards should be developed in relation to population genetic screening programs, covering such matters as informed consent, testing standards, quality assurance, cost–benefit considerations, and reporting and data collection. Employers should not be permitted to collect or use genetic information in relation to job applicants and employees, except in rare and compelling circumstances. Such circumstances might be when this is necessary to protect the health and safety of workers or third parties, and the action complies with stringent standards developed for this purpose by the HGCA and occupational health and safety authorities.

David Weisbrot BA, JD · Kerry J Breen MD, FRACP

It is time for general practice to move into the 21st century Medicine in Australia seems to lurch from crisis to crisis. General practice workforce issues, Medicare and medical indemnity currently occupy centre stage,1 but as long as the need for reform remains high on the healthcare agenda, other crises are sure to follow. Current catalysts for change include the ongoing increase in health expenditure, the impending impact of chronic illness and ageing on healthcare, the need to address the community's demands for access to new drugs and technology, and medicine's abiding focus on cure rather than prevention. General practice in the 21st century will only prosper if its collective focus is on adapting and enhancing its unique characteristics — first contact, comprehensiveness, continuity and coordination of care . . . An important ingredient in this cauldron of crises is general practice. Healthcare systems in which primary care has a central role have higher patient satisfaction, lower overall health expenditure, better population health indicators, and lower per capita rates of drugs prescribed. In short, general practice, with its key elements of first contact, comprehensiveness, continuity and coordination of patient care, is central to the health of any healthcare system.2 However, all is not well with general practice. Australian GPs, along with their international colleagues, protest that they are undervalued, overworked and no longer in control.3 "They feel like hamsters on a treadmill. They must run faster just to stay still . . . The result of the wheel going faster is not only a reduction in quality of care, but also a reduction in professional satisfaction and an increase in burnout amongst doctors."4 Assemble any group of Australian GPs and talk will soon turn to how recent Federal Government policies regulating general practice have reduced their fiscal autonomy, increased red tape, eroded their professional time, and diminished the quality of their clinical care.5 This discontent and frustration is responsible, in part, for the current free fall of the Medicare bulk-billing rate.6 However, a more ominous threat to the future of general practice is its increasing unattractiveness as a vocation. Junior doctors in Australia7 and North America8,9 are increasingly dissatisfied with general practice, and are voting with their feet. Anecdotal reasons advanced for this discontent include the low remuneration and lack of prestige of general practice, the demands of practice that may preclude a life beyond medicine, and the advent of competing players in the delivery of primary care, such as nurse or alternative medicine practitioners.8-10 One determinant of a specialty's standing in the medical community is its performance in research. Australian general practice has some catching up to do in this area.11 Indeed, general practice research appears to be in the throes of an identity crisis. In March this year an international conference of WONCA (the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, or the World Organization of Family Doctors, for short) was convened in Kingston, Canada, to draft a statement on the importance and future prospects of primary care research.12 It is surprising that such a conference was needed at all. But as noted in the Lancet, ". . . discussion at the conference also revealed the loss of direction — and confidence — that primary care research is presently experiencing. Very few examples of good family practice research were presented . . . The emphasis on reflection at the expense of action was telling — and disappointing."12 With all this doom and gloom, what to do? Our special issue on general practice attempts to address this question. Kamien (page 10) explores the collective wisdom of Australia's inaugural professors of "community medicine".13 Their achievements have been prodigious, but implicit in their reminiscences and counsel is the hope that deans of medical schools might support general practice more fully, and pursue more vigorously teaching environments beyond those found in esoteric tertiary-care and quarternary-care institutions.13 That this can happen with leadership and vision is illustrated by the continuing advances of general practice academia in the United Kingdom, wherein a third of all UK general practices are involved in community-based undergraduate education.14 Del Mar and his international colleagues (page 26) argue that part of the solution to the woes of general practice is to strengthen its "intellectual aspects" by encouraging "critical thinking" and the pursuit of clinically relevant research.7 The commentators on the contrived bleak scenario of general practice in 2020 — The destiny of general practice: blind faith or 20/20 vision — featured in this issue (page 47) argue that the antidotes to the 2020 poisoning of professionalism include structural reforms and independence of clinical agendas. Kidd (page 16) further stresses that involvement of the Federal Government in general practice vocational training needs to be long-sighted, flexible, and not merely an opportunity for implementing political solutions to current problems.15 If the guardians of this multitiered vocational training program were to get it wrong, they would risk fatally wounding general practice. General practice in the 21st century will only prosper if its collective focus is on adapting and enhancing its unique characteristics — first contact, comprehensiveness, continuity and coordination of care — so that these are in tune with patient and community expectations and the needs of the community's changing health challenges. General practice needs to change so that despondency, stress, loss of control and the perceived professional unattractiveness are things of the past. New GPs will need to embrace rather than suffer preventive medicine, exploit the power implicit in patient self-management, have responsive and flexible schedules of single or group visits, and be closely involved as members of interdisciplinary teams in care delivery within the community. They must also use the rich resources of information technology to reduce rather than increase work loads. Finally, general practice needs to accommodate the life-style aspirations of future doctors. Such developments can only restore the individual morale and professional pride of GPs. Donald Berwick (President and Chief Executive Officer, Institute for Health Care Improvement, Boston, USA) recently observed that "We are carrying the nineteenth-century clinical office into the twenty-first-century world. It's time to retire it."16 To effect such seismic changes in how general practice is provided and remunerated will, no doubt, produce upheaval, but the key to the management of any crisis is control — control of professional purpose, places of practice and pride. It is time for general practice to move into the 21st century.

Martin B Van Der Weyden MD, FRACP, FRCPA

Dr Zen's experience of life as a doctor seems much closer than 2020.* Many of her tribulations are already sapping the morale of clinicians in 2003. It is significant that Dr Zen is a woman. We continue to live in a sexist world, and as the medical workforce, particularly the general practice workforce, becomes more and more female, it is likely to become increasingly subject to exploitative working conditions. Those responsible for recruitment into medical school must ensure that all sectors of society are represented proportionately and that men and women are equally represented. It will then be important to try and ensure that women are given equal opportunities within every branch of medicine and that general practice remains equally rewarding and challenging for men and women. The working conditions within Corporation Enterprise seem unlikely to attract the brightest and best medical graduates of either sex. The clinical encounter between Dr Zen and her unfortunate patient is an emaciated shadow of a genuine, general practice consultation. The doctor is constrained by her management and financial context and by the technology that she is obliged to use. As medical science develops, clinical practice necessarily becomes more difficult.1 In the future, doctors will need to be more skilful, not less so. As people live longer, more will suffer multiple illnesses, both physical and mental, and will suffer them simultaneously and inseparably. The patient who is overweight, depressed and hypertensive does not have these conditions in separate compartments of his life. He has all three inseparably and he may also be lonely and frightened — all of this is a single condition. The permutations of comorbidity are complex and individual outcomes are always unpredictable.1 Practice based on algorithms pretends that none of this is true and that healthcare is simple. The reductive use of information technology ossifies the processes of care, stifles innovation and fails to realise the potential of computers to model complexity. Dr Zen works in a context within which the agendas of the pharmaceutical industry and of government leave no room for the needs of the patient or the professional aspirations of the doctor. The result, clearly seen in Dr Zen, is a loss of enthusiasm for education and the disappearance of original research that is inspired and directed by clinicians. Governments, dependent on systems of democratic voting, are driven by the utilitarian imperative of the greatest good for the greatest number. Within healthcare, we are seeing the rise of a new utilitarianism underpinned by modern epidemiology and imposed through systems of healthcare that are supported by information technology and sponsored by pharmaceutical companies. This new utilitarianism treats both doctors and patients as standardised and replaceable units, and would have us believe that a smoker is not an autonomous adult who has chosen to smoke but a patient who has been inadequately treated by their general practitioner. The waning of professional power has been regarded as promoting patient autonomy, but its replacement by corporate power compounded by centralised political control seems likely to be much more destructive of individual patient autonomy, dignity and, ultimately, health. Current health policy is driven by a view of health defined as the absence of disease and measured by the prolongation of life. This view works to the advantage of the pharmaceutical industry. The interests of corporate profit underpin the trends which are already shifting attention and investment within healthcare from the sick to the well and from the old to the young, and replacing care mediated by touch with a system driven by paper and computers. Only a minority of most populations is acutely ill at any one time, whereas the majority are healthy and can be persuaded of a need to take action to remain so by undergoing screening or taking preventive medication. There is more money to be made from selling healthcare interventions for the healthier, richer majority than for the sicker, poorer minority, both globally and nationally.2 Similar forces drive the widening of health inequalities seen by Dr Zen in a nurse-led service for the poor and a doctor-led service, however attenuated, for the more affluent. The events of 2025: people powerReturning to the not so distant future and confronted by the fear that is enduringly implicit in the human experience of illness, we find that the need for a trusting relationship between doctor and patient is so strong that, by 2025, Australia has witnessed the so-called Taxicab Revolt. More and more people realised that doctors like Dr Zen were being forced to supplement their incomes by driving taxis. Frustrated by the minimal and standardised healthcare offered by commercially sponsored organisations like Corporation Enterprise, worried patients began to seek out GP taxi drivers who gave them time to talk about the real extent of their fears and anxieties, and advice about how to begin to sort them out. An alliance was formed which eventually led to widespread civil unrest and demands for a health service free of commercial interference and offering personal and continuing care of named patients by named doctors.3 The alliance bridged social divides and produced a renewed social solidarity based on the recognition that the need for healthcare is fundamental to human thriving.4 Different services for rich and poor were no longer acceptable. The rest is history. Tyranny will always bring forth its opponents as the rain does grass.5

Iona Heath

The women who can most afford motherhood are the least likely to have babies Young women today think long and hard about when, and even whether, to become mothers. They observe the changes that occur in their sisters' or friends' lives when they have babies; changes that are for the most part dramatic and, of course, irreversible, and it gives them serious pause for thought. It is not something most of them are going to do until they are really, really sure that it is the right thing — and the right time — for them. Most young women want to wait until they have experienced the world, then acquired a financial base and made sure they are with the right man before embarking on the long journey of parenthood. Sometimes, after waiting until their early 30s to get everything in place, they find they can't bring themselves to change. They are not sure they can cope with the dislocation and chaos a baby will bring into their lives. There is a big decision to be made and, for the first time in history, women are in control of that decision. Exercising it gives them a great sense of power — and a freedom previous generations of women could not even have dreamed of. Australian women today are the first generation to effectively have total control of their fertility and this has dramatically changed everything for them. One hundred and fifty years ago, nearly half of all Australian women could expect to have around nine confinements.1 Early in the 20th century, it was not uncommon for a woman to have "a toddler at her skirt, another at her breast and a third in her womb".2 Less than 50 years ago, in 1961, women were having on average 3.6 children each. Today, around 28% of women will not have children at all and those who do have them are having fewer than any previous generation. In 1993, the fertility rate in Australia (the number of babies a woman will bear over her lifetime) was 1.9, down from 2.1 in 1976. The 1970s rate was the same as the previous lowest level — in 1934, during the Great Depression. Rural women still have more babies — an average of 2.27 in 2001, and the rate for Indigenous women was 2.21, whereas in the same year the national average birth rate had fallen further to 1.7. In some areas it is even lower, for instance in metropolitan Melbourne, which has a birth rate of just over 1.5. A birth rate of 2.1 is required for a country to reproduce itself, so Australia now has to rely on immigration just to maintain its population. This phenomenon of a dramatically declining birth rate is sometimes called the "baby bust" — in contrast to the post-World War II "baby boom", from 1946 to 1963, during which Australia's birth rate soared. Demographers, politicians, editorialists and others are constantly fulminating against this decline. What can they do (they bluster with increasing frustration) to make women have more babies? Why are women having fewer and fewer babies? The reasons are complicated, but the answer in some ways is surprisingly simple. As a society, we ask women to give up too much when they have children and we give them far too little in return. The pleasures of children are, in the pragmatic calculus now undertaken by most young Australian women, not compensated for by what they have to forgo. They are expected to give up their jobs or at least cut back on them, often after having been given a hard time while they were pregnant. They can expect to suffer a significant loss in earnings, from which over a lifetime they will never recover, as they will rarely be able to return to do the same level of work as before. Even the government admits that stopping work to have a child means "the family cash income will drop sharply". According to Fact Sheets on Work and Family issued in 2002 by Senator Amanda Vanstone, the federal Minister for Family and Community Services, when a double-income family, both on average weekly earnings, moves to a single income, they suffer a 38% fall in income that government payments do not come close to redressing. Economist Dr Bruce Chapman from the Australian National University and others have calculated that a woman who has completed secondary education will forgo lifetime earnings, after tax, of around $160 000 for a first child, and about $12 000–$15 000 for each additional child.3 Unlike a similarly industrialised country such as the United States, where mothers are far more likely to return to full-time work even when their children are quite small, Australia seldom makes this a feasible option for new mothers who wish to retain an attachment to the full-time workforce. As a consequence, it will be difficult for mothers to hang on to their skills, let alone to upgrade them so they can keep up with their former colleagues. There are now clear trends showing that the more educated a woman is, and the higher her income, the fewer children she will have. Women aged 30 years and over with a university or higher degree have the lowest birth rate. Women in this group have slightly less than half the number of children of other, less qualified women of the same age. Since the rate of women's participation in university education is continuing to increase (from 8.4% in 1986–87 to 20.2% in 2000–01),4 it seems likely that the fertility rate will also continue to decline. Professional women are almost twice as likely to be childless as women in clerical and sales occupations, and when fertility is correlated with the socioeconomic status of where women live, those in the highest status areas have less than half the number of children than those in the poorest areas.5 In other words, the women who can most afford motherhood are the least likely to have babies. They know how much they would be giving up in a society that pays lip service to maternity, but which in fact treats mothers very badly. Is it any wonder there is a "baby bust"? As a society we do almost nothing to make it easier for women to combine a satisfying and productive life with having a family. Instead, we place all sorts of obstacles in her way, and we cruelly force her into choices that are unfair and discriminatory. Men expect to be able to have families and still enjoy their jobs or careers and, increasingly, so do women. Women are no longer prepared to sacrifice themselves on the altar of maternity, or to be doormats for their families. They want a life — and they are entitled to have one. If we refuse to let them have it, something has to give and, as we have already had amply demonstrated to us over the past 10 years, that something will be having children. Finally, women — younger women especially — are starting to put themselves first.

Anne Summers AO PhD

How to heal the festering sore of Indigenous health? In Australia, Indigenous health remains a blot on the nation's collective consciousness. There has been little, if any, improvement in the last quarter of a century.1 Although an association between health and socioeconomic status has been described in many different societies, in Australia we seem to avoid taking this connection into account when considering Indigenous health. The First Nation's people of Australia still do not have the same access to housing, education and employment as those who are relative newcomers; thus, it should not be surprising that their health status is worse. Senator Aden Ridgeway, in his address to the United Nations Human Rights Commission,2 summarised the root of this problem as: Non-Indigenous Australians are keen to embrace the rhetoric of reconciliation, so long as it doesn't require them to take effective action to share the country's abundant resources and political power. Most are not prepared to make any significant adjustments in how they live their lives or how they see their future. Few are prepared to really look within themselves to challenge their beliefs and values, for fear of what they might find and for fear of what they think they might lose. So, what might it be that non-Indigenous Australians are so fearful of finding? Possibly, that the entire basis of land ownership in Australia, and therefore our economy, is based on the lie of Terra Nullius — that is, that no one owned the land claimed by others.3 And, what might non-Indigenous Australians be so fearful of losing? All their benefits, including health benefits, that they may have derived from this lie. At a recent National Health Summit in Sydney (held at Merchant Court Hotel, Sydney, 18–19 February 2003; hosted by Terrapinn), speakers outlined Australia's achievements in health, most notably that we can boast the second highest longevity among OECD countries. But little of what was said had any bearing on Indigenous health — it was almost as though Indigenous health had to be annexed so that the mood could remain positive. However, it is neither moral nor ethical for Australia to continue to ignore the deplorable state of Indigenous health. For too long, too many of the issues have been relegated to the too-hard basket. The festering sore of Indigenous health will not go away by ignoring it, but rather needs direct action — the active promotion of opportunities for Indigenous Australians in mainstream professions and services, health or otherwise. The medical profession has long recognised its social contract to Indigenous Australians, and we can easily start to fulfil this contract by attending to our own backyard. For proportionate racial representation in the medical profession in Australia, we should have about 1260 Indigenous doctors; however, there are no more than 55. All have graduated since 1983 and more than half from the one medical school. Had the other nine medical schools made the same effort to recruit and train Indigenous doctors, we would now be much closer to the racial equity goal of 1260 doctors. The presence of Indigenous Australians within the student body of our medical schools does more than just help to meet a target. It enriches the profession and enables other medical students to access something of the Indigenous experience — many Indigenous medical students and doctors have been the first Indigenous Australians that our non-Indigenous colleagues have met. The presence of Indigenous Australians in our medical schools also keeps the focus on Indigenous health active and honest. And it can provide a shining example and model for other professions who should recruit, support and graduate Indigenous students. In fact, it is important for our Indigenous students in primary and secondary school to see that all professions are accessible and supportive, so they can confidently consider tertiary education as a reality rather than a fanciful dream. Many of our medical postgraduate clinical colleges are already seeking to actively recruit Indigenous doctors into their training programs; we will also need to see the introduction of compulsory Indigenous health curricula into each of the postgraduate training programs. Beyond incorporating Indigenous health and health workers into our ranks, we need to actively encourage appropriate access to health services. For example, as a profession we need to call for the introduction of a Medicare safety net that will make a discernible improvement to the health status of Indigenous Australians. Real gains in Indigenous health are attainable by incorporating Indigenous health provision (albeit with additional benefit or consideration) into our mainstream delivery of health services, rather than, or at least in addition to, setting up more and more services specifically for Indigenous Australians. Beyond healthcare delivery, more of our profession should consider taking leadership in issues related to sovereignty and treaty, and ensure that satisfactory access to housing, education and employment is pursued. What benefit can Australia expect to receive from such a radical change in approach? As Senator Ridgeway said, much of Australia may avoid self-examination for fear of what will be found and what will be lost. This apparent milieu of fear is a poor legacy to leave to future generations of Australians. In confronting these issues, we can offer a better future for our nation and bring healing to the festering sore that is Australia's Black history (and health). The medical fraternity can play a leading role in this process — after all, healing is the prime concern of our profession.

Louis G Peachey BMed, FACRRM

The overarching cause is energy imbalance The health and wellbeing of Australia's children and adolescents, now and in the future, is under threat. In 2002–2003, the most prevalent child health issues affecting children are preventable: obesity, dental disease, emotional and behavioural problems, bullying and learning delays. These problems often present as comorbidities. Overweight and obesity affect about 23% of Australian children and adolescents, with 6% being obese.1 These are conservative estimates, as there has been no systematic monitoring of the prevalence of overweight and obesity in Australian children and adolescents since 1995. However, over the previous decade, the prevalence of overweight children almost doubled, and the prevalence of obese children more than tripled.1,2 There is no reason to believe that the rapid rise in prevalence rates has not continued. Studies of historical datasets have also revealed that the prevalence of overweight and obesity in children and adolescents doubled over the period 1985–1997, a far greater rate of increase than in the preceding 16 years.3 Health inequalities related to overweight and obesity are evident. There is a higher incidence of overweight and obesity in children of parents of particular backgrounds,3 and maternal education is the strongest social determinant of overweight and obesity in childhood.4 Although there are limited national data, and combined New South Wales, Victorian and National Nutrition datasets1 failed to find a rural/urban difference, Victorian epidemiological data show a statistically significant, higher proportion of overweight and obese boys in metropolitan areas, but this difference was not found for girls (Ms K Hesketh, NHMRC PhD Scholar, Centre for Community Child Health, Melbourne, VIC, personal communication). The health consequences of overweight and obesity are substantial, although Australian data remain unclear in certain areas.5 At least in the United States, obesity carries more stigma in children than any physical disability, and this is evident across all socioeconomic and ethnic groups.6 Issues of social acceptance, athletic competence and physical appearance are well known to obese children and affect their sense of social and psychological wellbeing. Obese children with decreasing self-esteem are more likely to smoke and drink alcohol compared with those whose self-esteem increases or remains the same.7 Obese children and adolescents may also have a range of medical conditions including hypertension, dyslipidaemia, and even type 2 diabetes. Other problems, such as musculoskeletal discomfort, obstructive sleep apnoea, heat intolerance, asthma and shortness of breath, greatly affect their lifestyle.8 Implications for the future can be gathered from longitudinal studies. Combined cohort studies indicate that relative body weight is sustained from childhood to adulthood, and, once children or adolescents are overweight or obese, their weight is unlikely to track backwards.5 If this is not sufficient reason for concern, reflect that these studies (of the long-term consequences of child and adolescent obesity) were all performed before the worldwide obesity epidemic developed. What, then, will be the outcome, in 10 or 20 years' time, of large numbers of children and adolescents entering adulthood, already with abdominal obesity and well established risk factors for cardiovascular disease and type 2 diabetes? Focusing on children highlights their contribution to contemporary society and future populations. Addressing the determinants of health and wellbeing for children and adolescents will improve population health and wellbeing overall. The overarching cause of the obesity epidemic is energy imbalance — a relative increase in energy intake (food intake) together with a decrease in energy expenditure (decreased physical activity and increased sedentary behaviour). Identifying the most important predictive determin-ants of each of these behaviours, as well as the most effective and sustainable remedial strategies, is complex and involves parental education and employment; housing environments; play, recreation and physical activity; food and nutrition; accessible active transport; and child-friendly physical and social environments.9 Some simple trends suggest relatively amenable remedies. Children's fruit and vegetable consumption has decreased over the past 20 years. Their physically active time has also decreased, while time spent in sedentary activities such as television watching and computer games has increased. Finally, consumption of energy-dense foods (including sweet soft-drinks and snack bars with a high sugar content) has increased. Possible remedies include: parental education strategies regarding healthy food choices, activity options, obesity trends, as well as supportive behavioural change strategies; supportive policies and environments in the places children and families spend their time (child care, school, workplaces, home, local neighbourhoods); and prioritisation of free time for physical activities. Evidence from controlled trials (although these trials are heterogeneous as regards the age groups and settings studied) highlights the potential for school-based programs that promote physical activity, modify dietary intake and reduce sedentary behaviours. However, recent qualitative research indicates that differences in outcomes will only be achieved if sustainable changes involve all generations, tackle the widely held beliefs regarding eating and activity,10 involve population-wide health promotion messages, and dispel myths such as children's overweight being just "puppy fat". Further, there are environmental aspects that are well beyond an individual family's ability to modify, including: regulation of marketing of unhealthy food choices for children; provision of safe, cheap and accessible public transport; and urban planning initiatives that give priority to child-friendly and pedestrian-friendly environments. The latter options are more controversial, and vested interests may seek to cloud the community's perceptions of factors driving the overweight epidemic. We need to actively involve industry in partnerships for environmental change. Health practitioners working in the community, child and family nurses and general practitioners are crucial in any comprehensive strategies, as they provide a widely available service to families and can tailor specific strategies for individual families.11,12

Elizabeth B Waters MPH, DPhil · Louise A Baur PhD, FRACP

To the Editor: Koenig's rebuttal of some of the conclusions I drew in my recent article was perhaps more vigorous than can be justified given recent changes in Australian culture and the paucity of practice-oriented research.1,2 I accept that religious patients may be healthier in many respects, and being religious may help some patients cope with illness. However, it does not follow that having doctors in Australia enquire into their patients' religious beliefs almost as a matter of routine would be a cost-effective use of their time. In hospitals, doctors are part of a team, and do not themselves have to identify religious concerns and mobilise spiritual resources. Nurses commonly ascertain whether patients are religious, identify concerns, and liaise with chaplains and pastoral workers. Chaplains themselves are highly regarded by all members of the healthcare team; they counsel and help patients cope with illness as part of their role, and are effective.3 For most Australians, religious affiliation is largely nominal. Consequently, only a minority of patients presenting to general practitioners are likely to have religious beliefs affecting their care. Rather than take a religious history routinely, it might be better if GPs were to enquire into religious beliefs when a patient or the family is known to be particularly religious or if the clinical situation warrants it. Urging doctors to take a religious history ignores those patients who are not religious but who might have a spirituality that helps them cope with illness and their particular needs.4 It also ignores changes which have occurred in Australian culture since the mid-1970s.5 Organised religion has declined, while spirituality has surged.5 Moreover, whereas Christians understand spirituality in terms of their relationship with God, in the wider community, spirituality needs no God association. It is often seen as a previously ignored aspect of being human, alongside physical, emotional and social aspects.5 It is increasingly regarded as the integrating holistic factor in life, associated with healing, therapy and well-being. The healthcare system as a whole will need to consider the relevance of these cultural shifts and how it is going to respond. Medical professionals should keep this in mind when discussing the relevance for medical practice and how they will respond. Spirituality has already assumed greater prominence in the practice and education of nurses, psychologists and social workers, and medical professionals should take account of the skills and experience of these groups.

Hedley G Peach

In reply: Despite recent changes in Australian culture, Peach underestimates the importance of religious beliefs to older Australians likely to see physicians today.1-3 As people age and experience negative life events, such as medical illness, longitudinal studies show that they become more and more religious.4 Given the potential impact that spiritual issues have on treatment decisions, the physician–patient relationship and medical outcomes, physicians cannot simply defer these issues to nurses or chaplains, nor do many physicians wish to do so.5 Deferring such issues could, in fact, be more costly than the few additional minutes necessary to take a spiritual history, particularly in patients with serious or chronic medical illness. For patients who are not religious, the doctor should enquire about secular beliefs that could influence medical decisions or that give the patient's life meaning and purpose in the context of their illness. I do agree with Peach that physicians should always phrase enquiries in terms of "spirituality", allowing patients to determine for themselves what this involves — whether it be God, church, or the random forces of nature. Keeping the spiritual history "patient-centred" in this way ensures that no one is excluded and provides many additional safeguards.

Harold G Koenig

To the Editor: The recent articles about spirituality and health1,2 provide a welcome discussion about the very soul of medicine as well as the soul of the individual healthcare practitioner. If spirituality is "whatever is left over when the doctor, social worker, psychologist, community education officer or psychiatrist have had a go",3 then indeed spiritual questions should be left to the particular expert on that fragment of the person. However, if spirituality is the integration of every aspect of the person, the plumbing of depth, the search and discovery of meaning and purpose, the exercise of compassion and love often in relation to the divine,4 then our whole practice of medicine needs to be spiritually conceived and executed, both for our patients and for ourselves. We need to pause and reflect on the quality of our care of ourselves as well as of our patients.5 We need to rescue healthcare delivery from the reductionism of a mere science of "fixing bits" according to economic criteria. We need to deliver healthcare with humanity, compassion and wisdom. Some would include godliness. This is not an optional extra, but the core of true healthcare, in which each of us will need to freely contribute, without imperialism, from the depths of our own spiritual journey.

Alan J Gijsbers

Imprecise language and deliberate confusion of important ethical and legal concepts are clouding our understanding of controversial end-of-life issues. This could affect our decision about whether or not to legalise euthanasia. In postmodern societies, the euthanasia and physician-assisted suicide debate is an important forum for the "death talk" through which we accommodate — with as much comfort as possible — the reality of death into the living of our lives.1 Recently, I debated Dr Philip Nitschke, at the Australian Medical Association's Annual General Meeting in Canberra, 24–26 May 2002, on whether euthanasia and physician-assisted suicide should be legalised. Dr Nitschke advocates such legalisation; I oppose it. In this article, I discuss my impressions of the discussion of euthanasia that took place at that AMA meeting and respond to it. Euthanasia is "a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person, in order to relieve that person's suffering."1 Throughout, I use the word "euthanasia" to include also physician-assisted suicide (although I recognise that in some situations, not discussed here, they must be differentiated). Language mattersLanguage is not neutral, especially in the euthanasia debate. We must choose and use our words carefully and precisely if we are to avoid inadvertently opening the way for the legalisation of euthanasia. For instance, saying that patients must be offered all treatment necessary to relieve their pain, even if that treatment could or would shorten life, or they must be offered all treatment necessary to relieve their suffering, may seem the same. But, properly interpreted, the former statement does not open up the possibility of legitimating euthanasia; the latter could do so and could affect the law accordingly. The language used in some of the resolutions passed by AMA delegates at the meeting can be interpreted several ways, thus creating confusion as to whether delegates had moved from opposing euthanasia absolutely towards approving it. Consequently, the media produced front-page headlines stating that the AMA had switched its policy on euthanasia and had "cleared [doctors] to 'hasten death'."2 Resolution 3Take, for instance, Resolution 3, which stated: National Conference recommends . . . that AMA policy be amended to read "that the AMA support doctors whose primary intent is to relieve the suffering and distress of terminally ill patients in accordance with patients' wishes and interests, even though a foreseen secondary consequence is the hastening of death." Most doctors to whom I spoke at the meeting said they saw this resolution as nothing more than a reaffirmation of the AMA's current position, which, consistent with current ethics and law, rejects euthanasia and supports offering patients all necessary pain-relief treatment, even if it could or would shorten life. However, this resolution might inadvertently go well beyond that. First, the resolution is not limited to pain relief: it refers to relief of "the suffering and distress of terminally ill patients" — a much broader category of symptoms and situations than just pain. Language to better reflect the present AMA position would be "the relief of pain and other symptoms of serious physical distress of terminally ill patients." Secondly, Resolution 3 implies that "the patient's wishes and interests" justify the life-shortening treatment — a key argument of the pro-euthanasia lobby. They argue that competent individuals' informed consent to euthanasia justifies giving them lethal injections. Opponents of euthanasia believe that a person's consent to having death inflicted does not justify another person inflicting death. This latter belief is enshrined in contemporary criminal law, except in countries such as the Netherlands and Belgium, which allow an exception for euthanasia. Further, Resolution 3 could be taken as legitimating the pursuit of death as a secondary consequence, not simply tolerating it as an unavoidable, unwanted consequence. In ethics and law, the difference between these two situations is reflected in the very significant distinction drawn between justifying an unwanted consequence (here, death) and excusing it. "Double-effect" doctrineThe legal doctrine of "double effect" justifies giving pain-relief treatment, provided it is given with the primary intention to relieve pain, and excuses any unavoidable, but unwanted, life-shortening effect of doing so. In short, the act of pain relief is justified — it is a right act; its unwanted consequence of shortening life is excused (ie, tolerated) in the circumstances. Let me explain why the distinction between a justification and an excuse is important in this context: an excuse carries the message that shortening life is wrong, but the person who does so will not be prosecuted (ie, he or she will have legal immunity). The message of a justification — as implied by the wording used in Resolution 3 — is that the conduct of shortening life is right. When considered as a justification, Resolution 3 can also support another pro-euthanasia line of argument: given that doctors have now accepted that hastening death is acceptable and justifiable as a secondary effect, it should not be unacceptable and unjustifiable as a primary intention. In contrast, interpreting the doctrine of "double effect", as suggested above, would not be open to such reasoning. It says that the secondary effect of hastening the death of the patient in providing necessary pain-relief treatment is unwanted and must never be a desired consequence, but, to the strict extent necessary to relieve pain, it is excused in law. That approach also reflects many people's moral intuitions that we must relieve pain, but it is wrong to kill. The doctrine of "double effect" requires, first, that the act resulting in a bad consequence (such as the shortening of life) is morally neutral. Providing pain-relief treatment would qualify as at least a morally neutral act. Second, the pain relief must not be achieved by shortening life (ie, through a bad consequence). Third, the bad consequence, the shortening of life, must not be primarily intended as either an end or a means; rather, the primary intent must be the legitimate aim of relieving pain. Fourth, there must be no other reasonable way of achieving the pain relief without involving the undesired effect of shortening life. Lastly, the proportionality of good and bad consequences required to justify the bad ones must be present. Providing necessary pain relief, even if it shortens life, fulfils all of these conditions; euthanasia fulfils none of them. ConfusionThat the delegates might themselves have been confused about the possible meaning of Resolution 3, which they passed (65 to 48 votes), could be indicated by their rejection (34 to 79 votes) of Resolution 4. That resolution proposed . . . that the AMA "work towards . . . adopt[ing] a neutral position on the issue of voluntary euthanasia." The 31 doctors who voted for Resolution 3, but against Resolution 4 (assuming the same 113 doctors voted in each case), obviously had no idea that Resolution 3 could be interpreted as moving towards acceptance of euthanasia, because they opposed even a neutral stance on it. A neutral stance would be, in fact, not only a move away from opposing euthanasia, but a move towards euthanasia. Its message is that, in principle, there are no moral, ethical or legal reasons to oppose euthanasia; rather, its acceptability is a matter of personal conscience and whether any associated potential abuse can be prevented. Yet another indication that the doctors might not have understood the ambiguity of the language of Resolution 3 and the inconsistency between voting for it and against Resolution 4 is that Resolution 1 was passed with only four against votes. It expressly rejects euthanasia: "[T]he AMA . . . absolutely reject[s] any intervention whose primary intent is to bring about the death of a patient . . ." This resolution distinguishes acting with such an intent — euthanasia — from the justified withdrawal of life-support treatment that results in death, and advocates educating the community about palliative care and ensuring that its provision is given high priority. In short, the resolution outlines a comprehensive anti-euthanasia approach to caring for terminally ill people. Confusion compoundedAfter the AMA conference, a well-known euthanasia advocate posted an email on the Deliverance (Voluntary Euthanasia Australia) chat line commenting on its outcome (List Member, Friday, June 21, 2002). The email stated that one of the participants at the meeting: ". . . got it absolutely right when he said that the principle of double effect allows doctors and others to hide behind it [to carry out euthanasia]. In light of the AMA's plan to (re-)educate doctors on the difference between "ethical care" and "euthanasia" this has particular significance : what the AMA "education" campaign is likely to amount to is to tell doctors to keep their minds off the foreseen consequences of what they do — to aim at pain-relief, not death." This email reflects an important modus operandi of euthanasia advocates — to work for the acceptance and legalisation of euthanasia by intentionally creating multiple confusions between it and other conduct that is ethically and legally acceptable in treating terminally ill patients. I call it "euthanasia by confusion".1 Disputed distinctionsPain-relief treatment versus euthanasiaA key target in creating this confusion is the doctrine of "double effect". It is attacked through allegations that the doctor's goal — his or her intent — and the cause of the patient's death — the causation — are the same in giving pain-relief treatment that could shorten life and in euthanasia. In other words, euthanasia advocates claim that the doctrine of "double effect" is just legal sophistry and that pain-relief treatment that could shorten life is really euthanasia. Those who oppose euthanasia argue that provision of pain-relief treatment is different in kind, not just degree, from euthanasia, because the intent is different. Necessary pain-relief treatment, even that which could shorten life, does not involve a primary intention to kill the patient; euthanasia does. Profound ethical and legal differences hinge on whether such an intent is present. As the Deliverance email demonstrates, euthanasia advocates also claim that doctors are hypocritically hiding behind the permissibility of giving pain relief under the doctrine of "double effect" — in fact, to carry out euthanasia. That is, they claim that, in practice, in giving pain-relief treatment, many doctors are acting with a primary intention of killing patients, not of relieving their pain. Often these claims are made on the basis of the large amount of pain-relief treatment given. But provided the dose (even if it is very large) is necessary to relieve the patient's pain and given with the primary intention of doing so, that is not euthanasia. Where it is clear that these conditions are not fulfilled, it would be euthanasia. There are serious harms in arguing that giving necessary pain relief is euthanasia: it could make doctors frightened to provide it. They must be reassured that they will not be legally liable; indeed, as the law is now developing, they are more likely to be liable for not doing so. Withdrawal of life support versus euthanasiaEuthanasia advocates also deliberately confuse withdrawal of life-support treatment with euthanasia. They argue there is no difference in either intention or causation between withdrawing life-support treatment when it results in the person's death and giving that person a lethal injection. They say that in both cases the doctor kills the patient (ie, causes the patient's death). This commonality of causation means they argue that, if we agree to respect refusals of life-support treatment, we must also agree with euthanasia. Moreover, they claim that, if there is no moral or ethical difference between refusals of treatment that result in death and euthanasia, there ought to be no legal difference. Those who oppose euthanasia disagree. They argue that refusals of treatment are morally and ethically different from euthanasia and ought to remain legally different. There are long-established, well understood, profound and important differences between allowing people to die, when it is ethically and legally justified, and making them die (ie, putting them to death). Respecting people's refusals of life-saving treatment belongs in the former category, euthanasia in the latter. The right to refuse treatment flows from a right to inviolability — a right not to be touched, including by continuing treatment, without one's consent — not from a right to die. There is therefore a right to have treatment withdrawn, which means that death will result from (ie, be caused by) the patient's underlying illness, but there is no right to be killed. Causing a patient's death through administering a lethal injection is different in kind from death resulting from refusal of treatment. The same line of pro-euthanasia argument is also constructed through a confusion of means and ends. This argument is that when death is the inevitable outcome, the means used to achieve that — whether withdrawing life support or a lethal injection — are morally irrelevant and ought to be legally irrelevant. But the means through which we die matter morally and should continue to matter legally. The issue is not if we die — we all die; it is how we die. Deep moral intuitions have long informed us that there are important distinctions between "letting nature take its course", including by refusal of life-support treatment, and killing a dying person. Death: purely private or societal impact?Advocates of euthanasia also argue that that how we die is just a private matter. Opponents of legalising euthanasia reject that argument. They believe each person's death necessarily involves others, including healthcare professionals, and societal values and symbols. Moreover, if euthanasia is involved, how we die cannot be just a private matter of self-determination and personal beliefs, because euthanasia "is an act that requires two people to make it possible and a complicit society to make it acceptable."3 Impact of legalising euthanasiaChanging the norm that we must not kill each other would cause profound damage to society. There would also be serious damage to institutions — in particular, medicine and the law — that maintain respect for human life, especially in a secular, pluralistic society that no longer has a shared religion to carry such values. Fundamental valuesAmong the fundamental elements of the case against euthanasia is its contravention of the principle that to act with a primary intention of killing another person is inherently wrong (except in justified self-defence or defence of others). To legalise euthanasia would damage important, foundational societal values and symbols that uphold respect for human life. In fact, the prohibition on intentionally killing is the cornerstone of law and human relationships, emphasising our basic equality.4 To legalise euthanasia would be to change the way we understand ourselves, human life and its meaning. And a more pragmatic, but nevertheless very important, objection is that abuse of legalised euthanasia cannot be prevented, as recent reports on euthanasia in the Netherlands have documented.5,6 In response, euthanasia advocates argue, in support of legalising it, that doctors are secretly carrying it out anyway. They claim to have found a high incidence of secret euthanasia by healthcare professionals, for example in Australia.7 However, that study has recently been severely criticised on the grounds that the respondents replied to questions that did not distinguish between actions intended to shorten life — euthanasia — and other acts or omissions in which no such intention was present — pain-relief treatment or refusals of treatment — that are not euthanasia. Consequently, the researchers' estimates of the number of cases of hidden euthanasia may be grossly exaggerated.8 But, even if accurate, the fact that doctors are secretly carrying out euthanasia does not mean that it is right. (Further, if doctors were presently ignoring the law against murder, why would they obey guidelines for voluntary euthanasia?) Lethal impactWhat impact might legalising euthanasia have on society? In answering questions of impact we must not look at euthanasia just in relation to individuals or in isolation from the context in which it would operate: at a societal level, the combination of an ageing population, scarce healthcare resources and euthanasia would be a lethal one. And what impact might the consequent message — that suicide is an appropriate response to suffering — have on people who are suicidal? What impact would legalising euthanasia have on the profession of medicine? Euthanasia "places the very soul of medicine on trial".9 Doctors' absolute repugnance to killing people is necessary to maintaining people's and society's trust in them. This is true, in part, because doctors have opportunities to kill not open to other people, as the horrific story of Dr Harold Shipman, the UK physician-serial killer, shows. It would be very difficult to communicate to doctors a repugnance to killing in a context of legalised euthanasia. Harm to medicine also harms society. We need to protect the institution of medicine not just for its own sake, but also because it is a very important value-creating, value-carrying and values-consensus-forming institution, especially in a secular society. How would legalising euthanasia affect medical education? What impact would physician role models carrying out euthanasia have on medical students and young physicians? Would we devote time to teaching students how to administer death through lethal injection? Would they be brutalised or ethically desensitised? (Do we adequately teach pain-relief treatment at present?) Last wordsPhysician-assisted suicide and euthanasia are simplistic, wrong and dangerous responses to the complex reality of human death. For physicians to give lethal injections to their patients or to assist them to commit suicide is inherently wrong from the perspective of principle-based or deontological ethics. But even on a utilitarian or situational ethics analysis, it is ethically wrong — the risks and harms outweigh the benefits. Physician-assisted suicide and euthanasia involves taking people who are at their weakest and most vulnerable, who fear loss of control or isolation and abandonment — in a state of intense "pre-mortem loneliness"10 — and placing them in a situation where they believe their only alternative is to kill themselves. Nancy Crick, a 69-year-old Australian grandmother, was Dr Nitschke's patient. Mrs Crick committed suicide in the presence of over 20 people, eight of whom were members of the Australian Voluntary Euthanasia Society. She explained: "I don't want to die alone." Another option for Mrs Crick should have been to die naturally with people who cared for her present. Was she offered that option? Of people who requested assisted suicide under Oregon's Death with Dignity Act, which allows physicians to prescribe lethal medication, 46% changed their minds after significant palliative-care interventions (relief of pain and other symptoms), but only 15% of those who did not receive such interventions did so.11 How a society treats its weakest, most in need, most vulnerable members best tests its moral and ethical tone. Thus, what doctors decide about euthanasia will play a very large part in determining Australia's moral and ethical tone — far into the future.

Margaret A Somerville AM, FRSC, LLB, LLD (Hon)