NON-MEDICAL SCIENTISTS

1198 (b) Meanwhile allow potential organ donation to be contemplated only in designated centres with adequate neurophysiological and possibly neuroradiological services. (c) Appeal to our political masters for funding to extend the necessary services required to provide nationwide medical care of which we have no need to be ashamed.

Walsgrave Hospital, Coventry CV2 2DX

* Dr Alan

Glass

R. PAUL

(University of Birmingham) points out that

the the document issued last year, perpetuates reference errors in the 1976 statement from the Conference of Medical Royal Colleges. These were corrected in The Lancet and B.M.]. of Nov. 20, 1976. Key references to the "strict criteria recommended by the Federation of E.E.G. Societies" should be Electroencephalog Clin Neurophysiol 1974; 37: 530 and 1970; 28: 536-ED.L.

D.H.S.S., in appendix 5

to

NUCLEAR WAR

SIR,-Health is a political issue. According to Ian Kennedy, this year’s Reith lecturer, doctors do not have a good record, concentrating their efforts on problem solving when they should be in the business of prevention. Most, if not all, preventive medicine involves a political commitment for its implementation. It is a worthless exercise simply to define the cause and extent of a problem. The profession has a right and a duty to make recommendations and press for their enactment in society in the same way that a doctor has a duty to treat his patient once a diagnosis is made. It is traditionally regarded that doctors fight shy of any political involvement but their medical degrees should not diminish their responsibility as citizens. Nuclear war is the most important threat we are facing in preventive medicine, as Dr Jones (Nov. 1, p. 976) points out. The debate in your columns and in the newspapers makes the position quite clear-the threat of a nuclear conflict is greater now than at any other time. Indeed R.A.F. pilots in West Germany and those who take part in civil defence exercises think that it is inevitable. This risk is worsened rather than lessened by the acquisition of greater and more sophisticated nuclear weapons. Civil defence against nuclear attack is impossible, as is the medical management of the aftermath, and the public are being misled about the effects of such an attack and are being encouraged in the belief that they will be safe with a few doors and sandbags. Abolition of nuclear weapons is the only available course if a nuclear holocaust is to be avoided. Yet that is a political statement, and many doctors will find it difficult to proceed from an appreciation of the scientific facts to a political conclusion. Political activity has nothing to do with party alignment nor does it mean getting embroiled in unilateralist versus multilateralist arguments. It does mean that as individuals and as a profession we should disseminate as widely as possible correct information about the medical effects of nuclear war and, as your editorial (Nov. 15, p. 1061) sightly argues, attempt to bring medical influence to bear on political decisions. But we must go further than that and declare our opposition to the possession of nuclear weapons, which are medically unacceptable, by our own country and by others in the rest of the world. Only concerted political action by the profession will stand any chance of preventing the medical catastrophe that would result from their use. If it is successful, in this case at least, Ian Kennedy will have been proved wrong.

Department of Medicine, University of Bristol, Bristol Royal Infirmary,

population in favour of the Government. They describe in graplic detail the horrors of radiation sickness and trauma in the victims of a nuclear holocaust, but then, in a step of logic which is beyond me, they conclude that we should opt out of civil defence. This is like a paediatrician who is so distressed by diphtheria that he refuses to give immunisation against it. Far from decrying civil defence we should be demanding of our Government sufficient shelters to enable our population to avoid the worst effects of a nuclear bombardment. I can see no conflict between real civil defence, and the promotion of nuclear disarmament. Indeed I regard the idea that we can save our skins by standing outside our homes waving white handkerchiefs as not only naive but also a betrayal of our responsibilities as doctors. The Chalet, Mount Gardens, London SE26

JOHN M. KELLETT

SIR,-All our efforts in preventive medicine-in cancer, in heart disease, and by screening-will be of little worth if we cannot solve the more immediate international problems posed by fear and territorialism, for it is these instinctive and primitive emotions which prime the nuclear arsenal of which we stand both as co-owner and as target. An aggressive attitude held in fear can generate unpredictable risk-taking behaviour. With the safety catches of the world in the "off’ position, a so-called minimal nuclear exchange could result from a simple non-logical error or an individual’s well-meant but maladaptive response. The consequences would be a loss of health and partial extinction of at least two generations in the U.K. Doctors could do nothing to alleviate this "illness" were it to

happen. At the risk ofbeing accused of being politically motivated, doctors encourage politicians to realise that nothing but annihilation can be the outcome of a continued nuclear arms race. We should encourage an alert but less aggressive stance by the cautiously staged laying-aside of these arms. In this we would act as a model for those Third World countries who are newly acquiring these devices and who traditionally look to Britain for military training and attitudes. May doctors never be put in the position that Laertes was to Hamlet: must

"No medicine in the world can do thee good; In thee there is not half an hour of life; The treacherous instrument is in thy hand, Unbated and envenom’d; the foul practice Hath turn’d itself on"... Thee and me. Lordswood House, 54 Lordswood Road,

Harborne, Birmingham B17 9DB

ANTON R. DEWSBURY

SIR,-I support the appeal by the Medical Association for the Prevention of War (Oct. 4, p. 739) and wholly agree with their three suggestions. A fourth point, surely, should be a recognition of the Soviet Union’s feeling of isolation and suspicion of the West; we should take steps to break down the barriers which this suspicion builds. Both East and West share, or will share, the common problems of energy and food shortages, and, since these shortages could be initiating factors in conflict, should we not press for a joint venture with the Soviet Union in solving these problems? The contact between Western and Soviet scientists could be a beginning in breaking down the barriers of mistrust, and could also have a most

practical outcome. Ormskirk and District General Ormskirk L39 2AZ

Hospital, A. D.

JOHNSON

M.J.HALL

Bristol BS2 8HW

NON-MEDICAL SCIENTISTS

SIR,-Am I alone in worrying that we have too little civil defence too much? Dr Gleisner (Oct. 4, p. 748) and Dr Jones (Nov. 1, p. 976) draw attention to the way in which the current rather than

arrangements for civil defence 1. Thomas S. Guardian Nov

cynically disregard

14, 1980: 12.

the civilian

SIR,-The basically well-balanced analysis by Dr Booth (Oct. 25, p. 904) of the state of medical research is doubly welcome—firstly. because it warns that though there is presently no cause for panic there is ample cause for concern and action for the maintenance of the vigour of clinical science, and secondly because it comes from someone in a position to take some action, at least on a local scale. I

1199

hope that the

concern

is heeded in other

places, and timely action

taken, but I fear that traditional British vacillation will once more carry the field, as on a much grander scale it is sure to do over the more

important of the recommendations of the Finniston report on

engineering.1

Despite the probable futility of any debate, I would like to add on three points raised by Booth, all related to the key sentence: "Clinical scientists should also perhaps beware that it is not always the best basic scientists who are prepared to work in comments

clinical departments". Booth comments on the effect of total remuneration differentials between clinical practice and the laboratory. He might also have commented on salary differentials within the laboratory. I see no justification for paying people doing equivalent jobs at different rates because of their different primary qualifications. This principle of equivalence is accepted in some sectors-notably, the pathology service disciplines-and its wider application would avoid the frequent situation where a respected scientist has to teach the rudiments of laboratory practice to a medical man not only some years his junior but also drawing a larger salary. Either the medical man must feed his family on job satisfaction, as does the scientist; or the scientist must be paid a salary equal to that of his medical colleagues (a move which would have an obvious effect on recruitment); or the clinician must rely for his earning capacity on professional practice predominantly in the clinic. The relationship between clinicians and scientists was touched on. I fully support Booth’s view that clinicians who can bridge the gap from clinic to laboratory are at a premium and’that they contribute in a unique way to medical research and should be nurtured. But the bridge should not carry one-way traffic ; clinicians with an interest in research ought to draw their scientific colleagues into the clinic, theatre, or post-mortem room and to demonstrate their problems and discuss the adequacy or inadequacy and limitations of their working methods. (The scientist who then sneers at the clinician would not be worth employing.) Were scientists as jealous of their professional ambit as most (emphatically not all) clinicians are of theirs, no clinician could set foot in a laboratory. Clearly things are different in Northwick Park. In the Leeds version of the real world I have been able to identify only three scientists having unlimited tenure contracts (compared with about ninety on fixed-term contracts) working in clinical departments other than chemical pathology, and in none of these cases are the duties of the post full-time research: It is reasonable to suppose that in this, as in many other respects, Leeds is close to the national average. The views of the Association of Researchers in Medical Sciences on employment and clinical research scientists are well known to Lancet readèrs.2,3 Booth gives a false impression of the extent of peer review of research staff: each researcher is subjected to peer review at the ending of each fixed-term contract, and the criteria for promotion are at least as fierce as those for academic staff (that is, where promotion is possible; in many institutions promotion beyond grade 11 of the research and analogous staff category is not possible). I welcome the emphasis on interdepartmental appointments, but it would often be very difficult to identify the "natural scientific department". My own basic training was as a chemist, then as a clinical biochemist-and I now practise largely as an immunologist in an academic radiotherapy department in a regional radiotherapy centre, although some of my activities could equally well be carried on in the university departments of biochemistry or biophysics. When I describe my occupation it is as a "Medical researcher" not as the adherent of any one discipline. These three points may be drawn together under one headnamely, status. I agree with Booth that clinical research needs a considerable boost in status and motivation amongst the medical fraternity ; if remuneration is all that is required, so be it. But we must bear in mind that full-time research is, for a’variety of reasons, only for

1. Finniston M. Engineering our future: Cmnd 7794. London: 2. Editorial. Not wanted at thirty-five. Lancer 1979; i: 912. 3. Editorial. ARMS and the MRC. Lancet 1980; i: 985.

HMSO,

1980.

the few. I would go further than Booth and suggest that clinicians of the right temper who may initially be attracted towards the laboratory will only keep coming back to this alien world if there is someone there with whom they may meaningfully interact and who is willing and able to meet them halfway. Medical research, which must grow through cross-disciplinary fertilisation and meeting of minds, will continue to be inhibited, indeed strangled, so long as one group of contributors has such vastly inferior career prospects, security, status, and remuneration. My message should by now be obvious: attract better clinical scientists with proper conditions, and the scientific clinicians will appear. University Department of Radiotherapy, Cookridge Hospital, Leeds LS16 6QB

JOHN P. DICKINSON Chairman, A.R.M.S.

AFTER ROTHSCHILD

SIR,-Your note entitled "Goodbye Lord Rothschild" (Nov. 1, p. that only courtesy restrained you from adding "good riddance". If so, that would be a pity, and unjust. At the time of the original proposals I was in a minority of those who believed the general policy-not necessarily the organisation-to be a move in the right direction. The experience of the years since then has not changed my view. The administrative arrangements may not have worked very well, but a glance at the latest D.H.S.S. Handbook of Research and Development shows an impressive body of research,

986) implies

much of which would probably without Rothschild.

never

have got off the

ground

The organisation-how much D.H.S.S., how much M.R.C.—is only a means to an end. The end is the greater focusing of research, which is paid for by the public, on matters of public importance. In the long run, whether that end is achieved depends on the attitude of scientists. Medawar2has commented on the peculiarly British humbug of "self-righteous disengagement from the pressures ofnecessity and use". I know from my own experience that the application of science to practical problems has its own challenges and its own satisfactions. It also, perhaps more often than not, raises theoretical questions which had not previously been thought about. Rothschild’s initiative provided a stimulus for more scientists to take up these challenges and to give our national scientific effort a better balance. His contribution should not be forgotten. Department of Human Nutrition, London School of Hygiene and Tropical Medicine,

J. C. WATERLOW

London WC 1E 7HT

PARTICIPATION OF NURSES IN ABORTIONS

SiR,-Doctors for a Woman’s Choice on Abortion would agree with one point in Lord Denning’s ruling on the role of nurses in abortions induced by prostaglandins (Nov. 15, p. 1091). The nurse should not be doing the doctor’s job, as Lord Denning indicated, and we sympathise with any nurse who is having to (though the 1967 Abortion Act allows any nurse to abstain, on grounds of conscience, from doing abortions). However, the ruling that nurses are not legally covered to participate in any way with "the procuring ofa miscarriage" (to use the terminology of the 1861 Offences against the Persons Act upon which the ruling is based) does not require a radical change in the practice of late abortions (which, incidentally, constitute only 7% of terminations) or any change in the law. Prostaglandin abortion can be done without a nurse. With the extra-amniotic technique, a very cheap pump can be used to give subsequent doses of prostaglandin (the function normally performed by the nurse) through the catheter left inserted through the cervix after the first dose has been given by the doctor. Alternatively, the intra-amniotic method can be used, where prostaglandin is instilled into the amniotic sac via a needle passed through 1.

Department of Health and Social Security. ment

1979. London:

2. Medawar PB. The

art

HMSO,

DHSS handbook of research and

1980.

of the soluble. London:

Methuen,

1967: 121.

develop-