- Email: [email protected]
CT SCANS IN PSYCHIATRY
1080
Cigarette smoking and pre-existing respiratory disease were risk factors but duration of the operation, wound infection, and obesity were not. In 1981 Craig2 looked at other factors and found that the type of surgical incision was important. For example, in oesophageal resection separate abdominal and thoracic incisions affected pulmonary function less than a single thoraco-abdominal incision, perhaps because the diaphragm was not divided. For cholecystectomy, a subcostal incision produced less hypoxia than a mid-line incision. The type of pain relief was also important, narcotics being inferior to epidural analgesia or unilateral intercostal blockade. Now Ford and Guenter3draw attention to postoperative reduction of diaphragmatic activity. This does not seem to be influenced by site of incision or degree of pain but could be due to afferent nervous input from the viscera, particularly in the upper abdomen. In some patients this reflex inhibition of the diaphragm can be overridden voluntarily, and reversion towards normal can be expected within 24-48 hours. (These observations support the practice of elective positivepressure respiration for 24-48 hours postoperatively in highrisk patients.) At present it seems that about 40% of the decrease in respiratory function is due to unknown factors, possibly diaphragmatic, and a further element (up to another 40%) to pain. Effective pain relief without respiratory depression is the aim. Laszlo and colleagues4 studied preventive measures in 88 non-bronchitic and 52 bronchitic patients. They found in a controlled trial that twice-daily physiotherapy for nonbronchitic patients had no effect, so physiotherapists’ valuable time should not be wasted in this way. Surprisingly, preoperative ampicillin did nothing for the bronchitic patients, although all of them had physiotherapy as well. Lately, Celli and colleaguess have done a controlled trial of three methods of improving respiratory function in 172 patients having abdominal operations. Intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises were randomly compared with no treatment.
(Incentive spirometry requires a small, portable apparatus by which patients can measure their own respiratory achievement.) All three treatment groups did significantly better than the controls and incentive spirometry was selected as the treatment of choice because it gave no complications and seemed to shorten the hospital stay; but length of stay depends on many factors other than pulmonary complications. One anomaly in the study was the lack of correlation between radiographic changes and clinical assessment of pulmonary disorders (this highlights the need when comparing different trials to note how "pulmonary complications" are defined). The cost of treatment must also be considered, and physiotherapists are not so abundant that all surgical patients can have supervised deep breathing exercises four times a day. The way forward is clear-reduction of smoking in the population, improved postoperative analgesia, and further research on the reflexes inhibiting the diaphragm and on how these can be overridden. Meanwhile, cheap, simple apparatuses for incentive spirometry are a good investment. 2.
DB 46-52.
Craig
Postoperative
recovery
3. Ford GT, Guenter CA. Toward
Am Rev
Respir Dis 1984;
of pulmonary
function. Anesth
Analg 1981;
60:
prevention of postoperative pulmonary complications.
130: 4-5.
4. Laszlo
G, Archer GG, Darrell JH, Dawson JM, Fletcher CM. The diagnosis and prophylaxis of pulmonary complications of surgical operation. Br J Surg 1973; 60:
129-34. 5. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984; 130: 12-15.
CT SCANS IN PSYCHIATRY HEAD more
scanning by computerised tomography is generally
informative, more comfortable, and less hazardous than
previous investigative procedures,’ but is too expensive to be done lightly. Usually a radiologist will want the patient to have been seen by a neurologist or neurosurgeon. This is understandable; neurologists remain the most important diagnosticians of brain disease and have a much better grasp of the abnormalities diagnosable by scanning than do other clinicians. There is increasing evidence, however, of the value of CT scanning in psychiatric disorders that the neurologist seldom sees. For example, although dementia can usually be diagnosed unequivocally by the experienced psychiatrist, difficulties arise in patients with depressive symptoms.2 Elderly patients with clearcut evidence of depressive illness usually have a normal CT scan but a substantial minority have cerebral atrophy in the absence of any signs of dementia.3 The outlook in this subgroup of depressed patients seems unusually poor. Another instance is Alzheimer’s disease, the most common form of senile dementia: this seems to have two forms, one slow and insidious, the other rapidly progressive,4 and preliminary the aid analysis suggests that these can be differentiated with ofa CT scan, although the differences are subtle.5 Striking findings have also been reported in chronic abusers of alcohol. Often before any serious cognitive impairment is evident, CT scans reveal generalised cerebral and cerebellar atrophy,6,7 and in one study it was claimed that 77% of the patients could be diagnosed as alcoholic on the basis of the CT scan findings.6 Some patients dependent on benzodiazepines likewise have abnormal CT scans,8 associated with cognitive impairment,9 but the meaning of these observations is uncertain. Computerised tomography has produced intriguing results - in schizophrenia. Since the first paper suggesting that schizophrenic patients had more cerebral atrophy than agematched normal controls,’° other groups have offered confirmatory findings ;11,12 It seems that Kraepelin’s term dementia praecox, for the conditions later to be known as schizophrenia, was not inaccurate after all. Most of the studies have been in chronic schizophrenic patients, but Weinberger et all3 found that 20% of acute schizophrenic 1. Knaus WA, Davis DO. Utilisation and
cost
effectiveness of cranial computed
tomography at a university hospital. J Comput Assist Tomogr 1978; 2: 209-14. 2. Arie T. Pseudodementia. Br Med J 1983; 286: 1301-02. 3. Jacoby RJ, Levy R, Bird JM. Computed tomography and the outcome of affective disorders: a follow-up study of elderly patients. Br J Psychiatry 1981; 139: 288-92 4. Naguit M, Levy R. CT scanning in senile dementia; a follow-up of survivors. Br J Psychiatry 1982; 141: 618-20. 5. Colgan J. Regional density and survival in senile dementia-an interim report on a prospective computerised tomographic study. Br J Psychiatry (in press). 6. Bergman H, Borg S, Hindmarsh T, Iderström GM, Mützell S. Computed tomography of the brain and neuropsychological assessment of male alcoholic patients and a random sample from the general male population. Acta Psychiatr Scand 1979; 286 (suppl): 47-56. 7. Ron MA. The alcoholic brain. CT scan and psychological findings. Psychol Med 1983: mongr suppl 3. 8. Lader MH, Ron M, Petursson H.
Computed axial brain tomography in long-term benzodiazepine users. Psychol Med 1984; 14: 203-06. 9. Petursson H, Gudjonsson GH, Lader MH. Psychometric performance during chronic benzodiazepine treatment and withdrawal. Psychopharmacology (in press). 10. Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet 1976; ii: 924-26. 11. Weinberger DR, Torrey EF, Neophytides AN, Wyatt RJ. Structural abnormalities in the cerebral cortex of chronic schizophrenic patients. Arch Gen Psychiatry 1979; 36: 935-39. 12. Nasrallah HA,
Jacoby CG, McCalley-Whitters M, Kuperman S. Cerebral ventricular enlargement in subtypes of chronic schizophrenia. Arch Gen Psychiatry 1982, 39: 774-77.
13.
Weinberger DR, Delisi LE, Perman GP, Targum S, Wyatt RJ. Computed tomography in schizophreniform disorder and other acute psychiatric disorders. Arch Gen Psychiatry 1982, 39: 778-84.
1081
patients under the age of 40 had cerebral atrophy. If, as some workers suggest, the cerebral atrophy can predate onset of schizophrenic symptoms, CT scans might have both diagnostic and predictive value-but only if satisfactory discrimination could be made between appearances in different conditions. In conditions that involve the temporal lobe-and these are likely to include schizophrenia’—CT scans are not very revealing and magnetic resonance imaging superior. findings are all from research studies that do not yet day-to-day clinical relevance. A review of the patients at one psychiatric hospital, the Maudsley Hospital,
may prove
These have seen
during the first year in which a CT head scanner was available showed that 50% of 201 patients referred for clinical reasons had abnormal scans. However, many of these abnormalities were predictable from clinical information and in only 11 % was diagnosis, management, or prognosis affected by the scan findings. One advantage of the scan results was that in the second six months of referral psychiatrists were more able to predict scan findings correctly than during the first six months. It is unfortunate that, in general, the cost of investigation at present precludes serial scans to monitor the course of illness. KIDNEY BROKERAGE: A GLIMPSE OF THE FUTURE? RENAL transplantation now offers the recipient an excellent chance of an unfettered existence. Despite its drawbacks there can be few renal-failure patients who would not prefer a transplant to a life on dialysis. It is therefore particularly regrettable that there are not enough cadaveric nor does it seem likely that there will be enough in the near future. As a result, a suitable kidney bears a high value because of its potential for conferring health. It is perhaps characteristic ofour times that value in the context of health should become value in monetary terms, and on p 1102 this week David Bach of Harvard Medical School urges serious discussion of the purchase of kidneys from unrelated living donors. The immediate response from most doctors will be one of total repugnance. Indeed the Transplantation Society has decreed that any member participating in such a transaction will be expelled. Nevertheless, the issue of buying tissues and organs is likely to re-emerge over the next decade although perhaps in less emotive forms. It is as well, therefore, that the arguments are assessed dispassionately if we are not to find that unacceptable precedents have been set in the absence of open discussion. The case that Dr Bach asks us to examine is a simple one. Individuals in poor circumstances-and we do not necessarily have to look to the Third World to find poverty although this is usually assumed to be a potential source of donor kidneys-will be offered the opportunity to sell a kidney for transplantation to recipients who have the wherewithal to pay substantially for the privilege. Thus a renal-failure patient is restored to health and a family is provided with funds to protect its members from privation. Considered in isolation, such a transaction between individuals raises no serious ethical objections. Live donor transplantation in which a kidney is given to a near relative has been accepted since the earliest days of renal transplantation: indeed it could be seen as a prime example of Christian values in operation, since a
kidneys,
14 Roberts GW, et al. Peptides, the limbic lobe and schizophrenia. Brain Res 1983; 288: 199-211. 15 Roberts JKA, Lishman WA. The use of the CAT head scanner in clinical psychiatry. Br J Psychiatry 1984; 145: 152-58. 1. Morris I.J. Presidential address, Transplantation Society, 1984.
sacrifice is being made for the wellbeing of others. In this case a relative can benefit directly from transplantation: in kidney brokerage the donor’s family benefits as a result of the financial transaction. The risk to the donor, the argument goes, has proved acceptable in one situation, why not therefore in the other? It does indeed seem likely that the risks to a donor’s health are small, although by no means negligible, and largely confined to those of the surgical procedure: follow-up of kidney donors for at least ten years has shown no important deterioration in glomerular filtration rate although there is a slightly higher incidence of hypertension and proteinuria.2 Yet there are the gravest objections to the acceptance of kidney brokerage or any other arrangement that employs financial pressures to induce individuals to undergo medical procedures which they would not otherwise countenance. These objections derive from the fact that the practice of medicine is not simply a transaction between individuals but carries implications for the society in which that transaction is carried out. Some practices are unacceptable because of the repercussions on the wellbeing of society, which suffers as a consequence of these actions. The bribing ofa policeman, for instance, in order to escape prosecution may not result in harm to any individual; indeed, both parties could be viewed as benefiting at least in the short-term. The practice is ethically unacceptable even on utilitarian grounds because a society based upon corruption is unable to discharge its responsibility to its members with equity and justice. By the same token, if the good health of one privileged group is achieved at the expense of the certain discomfort and possible ill-health and death of a less privileged group, then society is not fulfilling its duties. The fact that social policies may drive individuals, through the threat of starvation, to participate in such transactions hardly makes them acceptable; and when givers and beneficiaries belong to geographically distant societies, widely disparate in wealth and development, the equation becomes still more distasteful. Such disparities either within or between societies carry duties and responsibilities towards the less privileged rather than the right to exploit them. In his final work, the political scientist Richard Titmuss described the voluntary donation of blood in the United Kingdom as a model of the "gift relationship" that lies at the root of the welfare state.3 It is difficult to imagine anything more removed from this ideal than the selling of kidneys for transplantation to those who can afford the privilege. Titmuss argued that commercialisation of the gift relationship represses the expression of altruism, erodes the sense of community, lowers scientific standards, sanctions the making of profits in hospital and clinical laboratories, subjects critical areas of medicine to the laws of the marketplace, places immense social costs on those least able to bear them-the poor, the sick, and the inept-and increases the danger of unethical behaviour in various sectors of medical science and practice. The fact that kidney brokerage can be seriously discussed in Britain and the USA illustrates not only how far the mores of the market economy have invaded the health sector but also what the consequences of such economic philosophies are when applied to medicine. Recognition of the path we are being urged to follow may be by far the healthiest outcome to the debate that Dr Bach has initiated. RM, Goldszer RC, Brenner BM. Hypertension and proteinuria: long-term sequelae of uni-nephrectomy in humans Kidney Int 1984, 25: 930-36. 3. Titmuss RM. The gift relationship: from human blood to social policy London: Allen and Unwin, 1970
2. Hakim
Cigarette smoking and pre-existing respiratory disease were risk factors but duration of the operation, wound infection, and obesity were not. In 1981 Craig2 looked at other factors and found that the type of surgical incision was important. For example, in oesophageal resection separate abdominal and thoracic incisions affected pulmonary function less than a single thoraco-abdominal incision, perhaps because the diaphragm was not divided. For cholecystectomy, a subcostal incision produced less hypoxia than a mid-line incision. The type of pain relief was also important, narcotics being inferior to epidural analgesia or unilateral intercostal blockade. Now Ford and Guenter3draw attention to postoperative reduction of diaphragmatic activity. This does not seem to be influenced by site of incision or degree of pain but could be due to afferent nervous input from the viscera, particularly in the upper abdomen. In some patients this reflex inhibition of the diaphragm can be overridden voluntarily, and reversion towards normal can be expected within 24-48 hours. (These observations support the practice of elective positivepressure respiration for 24-48 hours postoperatively in highrisk patients.) At present it seems that about 40% of the decrease in respiratory function is due to unknown factors, possibly diaphragmatic, and a further element (up to another 40%) to pain. Effective pain relief without respiratory depression is the aim. Laszlo and colleagues4 studied preventive measures in 88 non-bronchitic and 52 bronchitic patients. They found in a controlled trial that twice-daily physiotherapy for nonbronchitic patients had no effect, so physiotherapists’ valuable time should not be wasted in this way. Surprisingly, preoperative ampicillin did nothing for the bronchitic patients, although all of them had physiotherapy as well. Lately, Celli and colleaguess have done a controlled trial of three methods of improving respiratory function in 172 patients having abdominal operations. Intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises were randomly compared with no treatment.
(Incentive spirometry requires a small, portable apparatus by which patients can measure their own respiratory achievement.) All three treatment groups did significantly better than the controls and incentive spirometry was selected as the treatment of choice because it gave no complications and seemed to shorten the hospital stay; but length of stay depends on many factors other than pulmonary complications. One anomaly in the study was the lack of correlation between radiographic changes and clinical assessment of pulmonary disorders (this highlights the need when comparing different trials to note how "pulmonary complications" are defined). The cost of treatment must also be considered, and physiotherapists are not so abundant that all surgical patients can have supervised deep breathing exercises four times a day. The way forward is clear-reduction of smoking in the population, improved postoperative analgesia, and further research on the reflexes inhibiting the diaphragm and on how these can be overridden. Meanwhile, cheap, simple apparatuses for incentive spirometry are a good investment. 2.
DB 46-52.
Craig
Postoperative
recovery
3. Ford GT, Guenter CA. Toward
Am Rev
Respir Dis 1984;
of pulmonary
function. Anesth
Analg 1981;
60:
prevention of postoperative pulmonary complications.
130: 4-5.
4. Laszlo
G, Archer GG, Darrell JH, Dawson JM, Fletcher CM. The diagnosis and prophylaxis of pulmonary complications of surgical operation. Br J Surg 1973; 60:
129-34. 5. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984; 130: 12-15.
CT SCANS IN PSYCHIATRY HEAD more
scanning by computerised tomography is generally
informative, more comfortable, and less hazardous than
previous investigative procedures,’ but is too expensive to be done lightly. Usually a radiologist will want the patient to have been seen by a neurologist or neurosurgeon. This is understandable; neurologists remain the most important diagnosticians of brain disease and have a much better grasp of the abnormalities diagnosable by scanning than do other clinicians. There is increasing evidence, however, of the value of CT scanning in psychiatric disorders that the neurologist seldom sees. For example, although dementia can usually be diagnosed unequivocally by the experienced psychiatrist, difficulties arise in patients with depressive symptoms.2 Elderly patients with clearcut evidence of depressive illness usually have a normal CT scan but a substantial minority have cerebral atrophy in the absence of any signs of dementia.3 The outlook in this subgroup of depressed patients seems unusually poor. Another instance is Alzheimer’s disease, the most common form of senile dementia: this seems to have two forms, one slow and insidious, the other rapidly progressive,4 and preliminary the aid analysis suggests that these can be differentiated with ofa CT scan, although the differences are subtle.5 Striking findings have also been reported in chronic abusers of alcohol. Often before any serious cognitive impairment is evident, CT scans reveal generalised cerebral and cerebellar atrophy,6,7 and in one study it was claimed that 77% of the patients could be diagnosed as alcoholic on the basis of the CT scan findings.6 Some patients dependent on benzodiazepines likewise have abnormal CT scans,8 associated with cognitive impairment,9 but the meaning of these observations is uncertain. Computerised tomography has produced intriguing results - in schizophrenia. Since the first paper suggesting that schizophrenic patients had more cerebral atrophy than agematched normal controls,’° other groups have offered confirmatory findings ;11,12 It seems that Kraepelin’s term dementia praecox, for the conditions later to be known as schizophrenia, was not inaccurate after all. Most of the studies have been in chronic schizophrenic patients, but Weinberger et all3 found that 20% of acute schizophrenic 1. Knaus WA, Davis DO. Utilisation and
cost
effectiveness of cranial computed
tomography at a university hospital. J Comput Assist Tomogr 1978; 2: 209-14. 2. Arie T. Pseudodementia. Br Med J 1983; 286: 1301-02. 3. Jacoby RJ, Levy R, Bird JM. Computed tomography and the outcome of affective disorders: a follow-up study of elderly patients. Br J Psychiatry 1981; 139: 288-92 4. Naguit M, Levy R. CT scanning in senile dementia; a follow-up of survivors. Br J Psychiatry 1982; 141: 618-20. 5. Colgan J. Regional density and survival in senile dementia-an interim report on a prospective computerised tomographic study. Br J Psychiatry (in press). 6. Bergman H, Borg S, Hindmarsh T, Iderström GM, Mützell S. Computed tomography of the brain and neuropsychological assessment of male alcoholic patients and a random sample from the general male population. Acta Psychiatr Scand 1979; 286 (suppl): 47-56. 7. Ron MA. The alcoholic brain. CT scan and psychological findings. Psychol Med 1983: mongr suppl 3. 8. Lader MH, Ron M, Petursson H.
Computed axial brain tomography in long-term benzodiazepine users. Psychol Med 1984; 14: 203-06. 9. Petursson H, Gudjonsson GH, Lader MH. Psychometric performance during chronic benzodiazepine treatment and withdrawal. Psychopharmacology (in press). 10. Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet 1976; ii: 924-26. 11. Weinberger DR, Torrey EF, Neophytides AN, Wyatt RJ. Structural abnormalities in the cerebral cortex of chronic schizophrenic patients. Arch Gen Psychiatry 1979; 36: 935-39. 12. Nasrallah HA,
Jacoby CG, McCalley-Whitters M, Kuperman S. Cerebral ventricular enlargement in subtypes of chronic schizophrenia. Arch Gen Psychiatry 1982, 39: 774-77.
13.
Weinberger DR, Delisi LE, Perman GP, Targum S, Wyatt RJ. Computed tomography in schizophreniform disorder and other acute psychiatric disorders. Arch Gen Psychiatry 1982, 39: 778-84.
1081
patients under the age of 40 had cerebral atrophy. If, as some workers suggest, the cerebral atrophy can predate onset of schizophrenic symptoms, CT scans might have both diagnostic and predictive value-but only if satisfactory discrimination could be made between appearances in different conditions. In conditions that involve the temporal lobe-and these are likely to include schizophrenia’—CT scans are not very revealing and magnetic resonance imaging superior. findings are all from research studies that do not yet day-to-day clinical relevance. A review of the patients at one psychiatric hospital, the Maudsley Hospital,
may prove
These have seen
during the first year in which a CT head scanner was available showed that 50% of 201 patients referred for clinical reasons had abnormal scans. However, many of these abnormalities were predictable from clinical information and in only 11 % was diagnosis, management, or prognosis affected by the scan findings. One advantage of the scan results was that in the second six months of referral psychiatrists were more able to predict scan findings correctly than during the first six months. It is unfortunate that, in general, the cost of investigation at present precludes serial scans to monitor the course of illness. KIDNEY BROKERAGE: A GLIMPSE OF THE FUTURE? RENAL transplantation now offers the recipient an excellent chance of an unfettered existence. Despite its drawbacks there can be few renal-failure patients who would not prefer a transplant to a life on dialysis. It is therefore particularly regrettable that there are not enough cadaveric nor does it seem likely that there will be enough in the near future. As a result, a suitable kidney bears a high value because of its potential for conferring health. It is perhaps characteristic ofour times that value in the context of health should become value in monetary terms, and on p 1102 this week David Bach of Harvard Medical School urges serious discussion of the purchase of kidneys from unrelated living donors. The immediate response from most doctors will be one of total repugnance. Indeed the Transplantation Society has decreed that any member participating in such a transaction will be expelled. Nevertheless, the issue of buying tissues and organs is likely to re-emerge over the next decade although perhaps in less emotive forms. It is as well, therefore, that the arguments are assessed dispassionately if we are not to find that unacceptable precedents have been set in the absence of open discussion. The case that Dr Bach asks us to examine is a simple one. Individuals in poor circumstances-and we do not necessarily have to look to the Third World to find poverty although this is usually assumed to be a potential source of donor kidneys-will be offered the opportunity to sell a kidney for transplantation to recipients who have the wherewithal to pay substantially for the privilege. Thus a renal-failure patient is restored to health and a family is provided with funds to protect its members from privation. Considered in isolation, such a transaction between individuals raises no serious ethical objections. Live donor transplantation in which a kidney is given to a near relative has been accepted since the earliest days of renal transplantation: indeed it could be seen as a prime example of Christian values in operation, since a
kidneys,
14 Roberts GW, et al. Peptides, the limbic lobe and schizophrenia. Brain Res 1983; 288: 199-211. 15 Roberts JKA, Lishman WA. The use of the CAT head scanner in clinical psychiatry. Br J Psychiatry 1984; 145: 152-58. 1. Morris I.J. Presidential address, Transplantation Society, 1984.
sacrifice is being made for the wellbeing of others. In this case a relative can benefit directly from transplantation: in kidney brokerage the donor’s family benefits as a result of the financial transaction. The risk to the donor, the argument goes, has proved acceptable in one situation, why not therefore in the other? It does indeed seem likely that the risks to a donor’s health are small, although by no means negligible, and largely confined to those of the surgical procedure: follow-up of kidney donors for at least ten years has shown no important deterioration in glomerular filtration rate although there is a slightly higher incidence of hypertension and proteinuria.2 Yet there are the gravest objections to the acceptance of kidney brokerage or any other arrangement that employs financial pressures to induce individuals to undergo medical procedures which they would not otherwise countenance. These objections derive from the fact that the practice of medicine is not simply a transaction between individuals but carries implications for the society in which that transaction is carried out. Some practices are unacceptable because of the repercussions on the wellbeing of society, which suffers as a consequence of these actions. The bribing ofa policeman, for instance, in order to escape prosecution may not result in harm to any individual; indeed, both parties could be viewed as benefiting at least in the short-term. The practice is ethically unacceptable even on utilitarian grounds because a society based upon corruption is unable to discharge its responsibility to its members with equity and justice. By the same token, if the good health of one privileged group is achieved at the expense of the certain discomfort and possible ill-health and death of a less privileged group, then society is not fulfilling its duties. The fact that social policies may drive individuals, through the threat of starvation, to participate in such transactions hardly makes them acceptable; and when givers and beneficiaries belong to geographically distant societies, widely disparate in wealth and development, the equation becomes still more distasteful. Such disparities either within or between societies carry duties and responsibilities towards the less privileged rather than the right to exploit them. In his final work, the political scientist Richard Titmuss described the voluntary donation of blood in the United Kingdom as a model of the "gift relationship" that lies at the root of the welfare state.3 It is difficult to imagine anything more removed from this ideal than the selling of kidneys for transplantation to those who can afford the privilege. Titmuss argued that commercialisation of the gift relationship represses the expression of altruism, erodes the sense of community, lowers scientific standards, sanctions the making of profits in hospital and clinical laboratories, subjects critical areas of medicine to the laws of the marketplace, places immense social costs on those least able to bear them-the poor, the sick, and the inept-and increases the danger of unethical behaviour in various sectors of medical science and practice. The fact that kidney brokerage can be seriously discussed in Britain and the USA illustrates not only how far the mores of the market economy have invaded the health sector but also what the consequences of such economic philosophies are when applied to medicine. Recognition of the path we are being urged to follow may be by far the healthiest outcome to the debate that Dr Bach has initiated. RM, Goldszer RC, Brenner BM. Hypertension and proteinuria: long-term sequelae of uni-nephrectomy in humans Kidney Int 1984, 25: 930-36. 3. Titmuss RM. The gift relationship: from human blood to social policy London: Allen and Unwin, 1970
2. Hakim