MEDICAL CARE AND MILITARY OCCUPATION

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notes that criticism clinical experimentation has been such that it may be hampering the progress of scientific medicine. He complains that by emphasising a "deontological model of the autonomous patient" as the rockbed upon which subject/researcher relationships must be based medicine finds itself in a peculiar situation where unreliably controlled treatment is ethically acceptable while formal, reliably controlled trials of treatments are not. I share many of the concerns that Baum raises about the need to ensure more rather than fewer prospective and retrospective controlled assessments of medical interventions. In an age in which cost-containment concerns are much in evidence physicians must be armed with as much information as can reasonably be acquired about the efficacy of their interventions. Such information provides patients with the strongest assurance that the quality of the care they receive will not be compromised by attention to matters of cost. I wonder, however, whether Baum has identified the right culprit in pointing the finger of blame at informed consent as the obstacle to progress in the assessment of efficacy. A strong case can be made that an emphasis on informed consent and patient autonomy has only prevailed since the late 1960s. Yet there is no evidence that the health care professions were any more willing to subject their interventions to the scrutiny of controlled clinical trials in the 1950s and 1960s than they are today in an era of patient autonomy. I agree that those who would subject proposals for controlled trials to ethical scrutiny without recognising the costs and dangers of introducing new techniques and technologies in an uncrontrolled, haphazard fashion had best rethink their ethical priorities. However, those committed to trying to place medicine on a firm scientific footing ought not to view informed consent and patient autonomy as incompatible with such a goal. There is no a-priori reason to believe that patients cannot be made to understand the need for clinical trials or that those who want to do such trials ought do them without at least offering the prospect of informed participation to prospective subjects. Rather, Baum and others committed to the improvement of the knowledge base of medical practice might be better advised to teach their colleagues the evils inherent in failing to organise controlled trials from the very first human application of a new drug, technique, or device. Medical journals ought to think carefully about the desirability of publishing case-reports and pilot studies which tend to lend clinical credibility to interventions that are at best unproven and at worst may be harmful. And ethicists might best be advised to pay greater attention to the question, not of when to initiate a clinical trial, but, of the value choices that must be made in deciding when sufficient evidence has accumulated to stop a trial. The ethical arguments in favour of informed consent in human experimentation are unassailably grounded in both moral and religious theory and in the horrific history of the use of human beings for the purposes of research in the twentieth century. At the same time there can be no arguing with the thesis that more testing and assessment ought be done for all manner of medical interventions. To place the blame of failure zealously to strive to assess the efficacy of medical interventions at the door of informed consent is to miss the opportunity to better understand some of the historical, socioeconomic, and other factors that have long hindered medicine’s willingness to take a long hard look at the efficacy of its

SiR,—Professor Baum (Oct 18, p 911)

directed

at

own treatments.

Hastings Center, Hastings on Hudson, New York 10706, USA

territory. Their social and religious organisation is deeply conservative, and midwifery was a traditional at-home service. Consequently a typical obstetric history included two to three perinatal deaths out of ten or more live births. Since occupation in 1967, the Government has introduced a free community health service similar to that in Israel itself.1 Free obstetric facilities with Arabic-speaking staff are also available at our hospital and at two church-run hospitals in Nazareth. During the citizens in this

INFORMED CONSENT

ARTHUR L. CAPLAN

MEDICAL CARE AND MILITARY OCCUPATION

SJR,—Dr Andersson and Dr Jerden (Sept 6, p 577) report military interference in the provision of medical care in the Gaza strip. Our experience is better in a different region. The Rebecca Sieff Government Hospital is the regional medical centre for the Galilee and the occupied territory of the Golan heights. There are about 12 600 Druz Muslims who are not Israeli

1980-85, the annual number of deliveries in the Druz Muslims of the Golan heights was nearly 300. Of these, an increasing number were cared for at our hospital-106 in 1980 and 172 in 1985. Perinatal mortality was similar to the hospital average. We do not defend the prevention of medical care reported in the Gaza strip but we hope to balance the impression left by Andersson and Jerden’s letter.

years

Department of Obstetrics and Gynaecology, Rebecca Sieff Government Hospital, Safed, Israel 1. Ballas

IZHAR BEN-SHLOMO MUSTAFFA ASLI DORON COLER DALLIA DAHAN ODED AVNI SHIFRA ZHAR

S, Zohar S, Gotfried E, Borstein M. A model of regional perinatal outcome of 4000 births. Harefuah 1982; 102: 365-69.

obstetric

care

and

SiR,—Your readers must have been very concerned to read the item (Oct 25, p 968) from your correspondent in Gaza. Not the least of the problems faced by the Israeli Administration is the evergrowing population, which could reach one million at the turn of the century. Gaza is one of the most densely populated areas of the world and all the other problems of medical services, employment, and water shortages arise from this. Your correspondent should know that the Benvenisti report is based upon information that is more than two years old and Meron Benvenisti himself acknowledges that big improvements have been made, particularly in the medical field, since his research was carried out. I was myself in Shifa Hospital in June this year, and even in the old parts of the hospital I saw nothing of the conditions quoted by your correspondent: it is obvious that strenuous efforts are being made to maintain standards despite the serious overcrowding. Britain/Israel Public Affairs Committee, 126/134 Baker Street, London W1M 1FH

JANE MOONMAN, Director

CLOSURE OF BANSTEAD HOSPITAL

SIR,-Mr McKie (Oct 25, p 987) is quite right to outline the of many people about the alternative provision being made to replace the long-stay mental illness hospitals. But he is wrong to infer that the closure of Banstead Hospital was ill thought-out or resulted in patients being "discharged by the system but with concerns

nowhere else to go". We know where every one of the patients who has been discharged in the lead-up to the closure has gone. McKie makes no mention of Chiswick Lodge, Mary and Abbot Lodges in Kensington, or the newly upgraded Gordon Hospital in Westminster, which have all been designed as real replacement homes for elderly or acute mentally ill people-providing a genuinely improved environment and standard of care for the people coming out of Banstead. MIND’s two researchers did not even visit any of these new units in putting together their report. I suppose that since Banstead was the first major mental illness institution to be closed in this country we must accept that we will be in the firing line on issues of philosophy. The financial problems are there and we are determined to resolve them. Our strategy, which has been six years in the planning and which aims to provide a better life for every one of Banstead’s residents, has succeeded in that aim. We have also set up a new local network of services in central London-all of which were non-existent in 1980-and further developments in the community are in the pipeline. By all means let us talk about the problems we face in