Signed—The Lancet

24

activities that take place within the NHS. By the spring, the appointment of regional directors should be complete and this network will underpin the health service research and development structure. Peckham has no doubts about the value of research, his target being to ensure that 1-5% of the NHS budget is spent in this way (mostly meta). He has begun by determining priorities within broad areas of medical activity-mental health, cardiovascular disease, cancer, and so forth-while simultaneously, from the Cochrane Centre3based in Oxford, establishing a means of coordinating projects via a database to ensure that existing knowledge can be put to best use and that researchers know exactly what information is already available. Yes, we should foster clinical research. The orthoresearchers need all the encouragement we can give them and the meta-researchers need to know that they, too, can contribute to the enterprise. Clinical research needs to be responsibly done, and good training programmes will ensure that responsibility. Ultimately, however, Richard Feynman’s4 views on the value of science apply to clinical science every bit as much as to basic scientific endeavour: "If we suppress all discussion, all criticism ... we will doom humanity for a long time to the chains of authority, confined to the limits of our present imagination. It has been done many times before. It is our responsibility as scientists, knowing the great progress which comes from a satisfactory philosophy of ignorance, the great progress which is the fruit of freedom of thought, to proclaim the value of this freedom... and to demand this freedom as our duty to all coming generations". The Lancet present, uncertain future. Lancet

1. Editorial. Clinical research: disturbing 1991; 337: 19-20. 2. Steiner R. The philosophy of freedom. London: Rudolf Steiner Press, 1970. 3. Editorial. Cochrane’s legacy. Lancet 1992; 340: 1131-32. 4. Feynman R. What do you care what other people think? London: Unwin Hyman, 1989.

Signed—The Lancet On certain matters, the editorial staff of The Lancet are of one mind. When we write of the great threats to public health, or of the fundamental importance of science in medical practice (see above), or of the need for reform in medical education-these are issues close to the Lancet heart; and, if a journal can have a voice, this is what you are hearing. But on matters such as botulinum toxin, bioelectrical impedance, or even atherectomy (all discussed last week), the notion of an editorial policy or consensus hardly rings true. Clearly, editorials can be divided into type X and type Y. Looking at the half-dozen pages we have devoted each week to editorials, we now conclude that many of the type Ys would be better published as signed Commentaries, written in a more personal style and

with no pretence to represent the views of The Lancet. (Not "signed editorials".) The first contributions of this sort appear below, and in due course we shall ask a sample of readers how they feel about the change. What about type X? These will be reserved for special occasions-and, to avoid the least possibility of confusion, they will henceforth bear the signature of

The Lancet

COMMENTARY HUMAN RIGHTS

Consensus

on

non-discrimination in HIV

policy

The primacy of non-discrimination and the importance human rights in the prevention of human immunodeficiency virus (HIV) transmission and the management of AIDS are reaffirmed uncompromisingly in AIDS in the World,! whose principal editor, Dr Jonathan Mann, still believes firmly in the policies that he and the former Director General of the World Health Organization, Dr Halfdan Mahler, courageously espoused in the early years of the global programme on AIDS. The chapter on human rights contains fifty-two declarations, statements, resolutions, and recommendations underpinning the human rights approach to HIV/AIDS policy from international organisations at global or regional levels. Seldom has such consensus been achieved on public health policy. Nevertheless, there are disturbing signs that many forms of discrimination are growing. Thus more countries have enacted legislation requiring compulsory screening for immigrants, prisoners, military personnel, and others and insidious forms of discrimination in insurance and

of

employment are widespread. Compulsory isolation and detention

of HIV-infected persons is one of the most extreme forms of the coercive approach. The Swedish Communicable Diseases Act of 1988 requires not only declaration of HIV infection to the health authorities but also notification of non-compliance with "practical instructions"—ie, doctors and nurses must declare cases and also risk behaviours. Compulsory isolation can then be ordered by a medical officer of health subject to approval by a county administrative court. The European Committee for the Prevention of Torture and Inhuman or Degrading treatment (CPT)during a visit to Sweden in 1991, spent some time at the unit in Beckomberga Hospital to which persons subject to compulsory isolation orders are sent. Their confidential report3 to the Swedish authority has now been made public, together with the government’s response.4 The unit was found to be spacious and well equipped. Persons detained seemed "reasonably satisfied with the way they were being treated". One person, detained for several years, refused to speak to the delegation, and a woman detainee said that she had been deprived of the right to leave the unit, for short periods accompanied by staff, for 28 days after testing positive for marihuana. The CPT commented that the rights and privileges of detained HIV-infected persons were not set out clearly but did not question the basis of such detention. In its response, the Swedish government reaffirms that mandatory solitary