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Pale, but interesting
DISSECTING ROOM
Pale, but interesting Vitiligo Hann SK, Nordlund JJ, eds. Oxford: Blackwell Science, 2000. £79·50. Pp 320. ISBN 0632050713. ritten by 27 contributors from several continents (Asia, the Americas, Europe)—and many of them experts on the subject of vitiligo— this book is potentially useful for dermatologists in any part of the world. Vitiligo is divided into five parts covering general aspects, clinical presentation, pathogenesis, treatment, and related topics. There have been few textbooks devoted to vitiligo. One notable book is Ortonne, Mosher, and Fitzpatrick’s 1983 text Vitiligo and other hypomelanoses of the skin (London: Plenum Publishing). Other reviews of vitiligo have to be sought in general dermatology textbooks or in encyclopaedic works on broader aspects, for example, The Pigmentary System edited by Nordlund, Boissy, Hearing, King, and Ortonne (New York: Oxford University Press, 1998). However, the vitiligo chapters in these books
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cannot be compared with a monograph on the topic. In general the book is well balanced. There is some overlap between chapters but this is almost unavoidable in multiauthored texts. Each chapter is a state-of-the-art overview of its subject. Some topics are difficult to find in other sources and are much appreciated, such as extracutaneous findings, psychological effects, and ancillary therapies. Moreover, the chapter on alternative therapies and their (lack of) efficacy is extremely useful for clinicians dealing with patients who nowadays confront them with new “magical” treatments downloaded from the internet. What is missing is a chapter devoted to image acquisition in vitiligo, an extremely important issue in the follow-up of patients and hampered by many technical difficulties that deserve some comment in a book like this. Also, the important issue of
The Refractory Compliance and contamination he ultimate aim of most medical research is presumably to improve people’s length and quality of life. But people’s preferences for immediate pleasure and gratification tend to take precedence over “sensible” behaviour likely to confer longevity and freedom from unpleasant diseases and conditions. Medicine’s scope to interfere at ever earlier stages of major diseases by studying specific population cohorts to identify predictors, potentialities, genetic flaws, excesses of behaviour, or over-indulgences that predispose or exacerbate tendencies to certain conditions, has led to extremes of reaction and action in both populations and health practitioners. In former times when people still expected death, physicians confidently cared for the sick, ministering from their limited armoury. Today, huge numbers of physician/scientists have extended their clientele with the aid of increasingly sophisticated medical technologies and a media hungry
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to “inform” patients about all manner of testing, prescribing, and screening. Population screening and prevention research proposals pose particularly difficult ethical problems. Populations, by their very definition, are heterogeneous—indeed, changes in their composition, attitudes, and expectations are accelerating. Emphasis on mortality reduction in these programmes preys on healthy people’s fears. Behavioural research shows that these fears are based on people’s grossly inflated and distorted ideas of incidence, cure rates, and mortality rates. Screening research requires participants in the non-intervention group to remain “uncontaminated” and “compliant”. This raises serious ethical questions—it can mean that consent is not sought from individual patients and that diagnostic information or counselling provided to the intervention cohort is withheld from patients in the non-intervention group. Does such deprivation constitute an assault on those people’s autonomy? If the provision of available full and accurate
camouflage is not sufficiently covered. In the chapter on depigmentation therapy the potential hazard of exogenous ochronosis induced by hydroquinone compounds in patients with extensive vitiligo is not mentioned. As the editors plan to have a new edition within 5 years, these topics should be included. In general, all the clinical chapters are well illustrated with colour photographs. However, the quality of some pictures, for example those pre-therapy and post-therapy could be improved. There are also some disturbing spelling errors. Vitiligo is an excellent choice for dermatologists and other clinicians who encounter such patients (paediatricians, ophthalmologists) but it is also a welcome source of clinical information for pigmentcell biologists. The book should be available in every department library. Jean Marie Naeyaert Department of Dermatology, University Hospital, De Pintelaan 185, 9000 Gent, Belgium [email protected]
evidence-based information and education of the public is considered a moral obligation, does it not follow that preconsent randomisation is unethical? By contrast, individual informed consent for real patients in research that includes shared decision making and the use of risk communication tools is ethically acceptable. Indeed, such research, which refines the very heart of medicine for sick people—the consultation—explores shared dialogues that take account of each patient’s immediate circumstances, values, and preferences. This not only improves a citizen’s personal satisfaction and well-being, but encourages professional growth and satisfaction, redefines “compliance”, and increases trust. Should not decisions to mount costly non-risk-free screening programmes be society’s responsibility and prerogative? Independently organised citizens’ deliberations involving all stakeholders in a wellregulated forum might offer scope to determine “public informed consent” (assent or dissent) for such difficult screening questions. Refractor C/o The Lancet, London, UK
THE LANCET • Vol 356 • October 14, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
Pale, but interesting Vitiligo Hann SK, Nordlund JJ, eds. Oxford: Blackwell Science, 2000. £79·50. Pp 320. ISBN 0632050713. ritten by 27 contributors from several continents (Asia, the Americas, Europe)—and many of them experts on the subject of vitiligo— this book is potentially useful for dermatologists in any part of the world. Vitiligo is divided into five parts covering general aspects, clinical presentation, pathogenesis, treatment, and related topics. There have been few textbooks devoted to vitiligo. One notable book is Ortonne, Mosher, and Fitzpatrick’s 1983 text Vitiligo and other hypomelanoses of the skin (London: Plenum Publishing). Other reviews of vitiligo have to be sought in general dermatology textbooks or in encyclopaedic works on broader aspects, for example, The Pigmentary System edited by Nordlund, Boissy, Hearing, King, and Ortonne (New York: Oxford University Press, 1998). However, the vitiligo chapters in these books
W
cannot be compared with a monograph on the topic. In general the book is well balanced. There is some overlap between chapters but this is almost unavoidable in multiauthored texts. Each chapter is a state-of-the-art overview of its subject. Some topics are difficult to find in other sources and are much appreciated, such as extracutaneous findings, psychological effects, and ancillary therapies. Moreover, the chapter on alternative therapies and their (lack of) efficacy is extremely useful for clinicians dealing with patients who nowadays confront them with new “magical” treatments downloaded from the internet. What is missing is a chapter devoted to image acquisition in vitiligo, an extremely important issue in the follow-up of patients and hampered by many technical difficulties that deserve some comment in a book like this. Also, the important issue of
The Refractory Compliance and contamination he ultimate aim of most medical research is presumably to improve people’s length and quality of life. But people’s preferences for immediate pleasure and gratification tend to take precedence over “sensible” behaviour likely to confer longevity and freedom from unpleasant diseases and conditions. Medicine’s scope to interfere at ever earlier stages of major diseases by studying specific population cohorts to identify predictors, potentialities, genetic flaws, excesses of behaviour, or over-indulgences that predispose or exacerbate tendencies to certain conditions, has led to extremes of reaction and action in both populations and health practitioners. In former times when people still expected death, physicians confidently cared for the sick, ministering from their limited armoury. Today, huge numbers of physician/scientists have extended their clientele with the aid of increasingly sophisticated medical technologies and a media hungry
T
1362
to “inform” patients about all manner of testing, prescribing, and screening. Population screening and prevention research proposals pose particularly difficult ethical problems. Populations, by their very definition, are heterogeneous—indeed, changes in their composition, attitudes, and expectations are accelerating. Emphasis on mortality reduction in these programmes preys on healthy people’s fears. Behavioural research shows that these fears are based on people’s grossly inflated and distorted ideas of incidence, cure rates, and mortality rates. Screening research requires participants in the non-intervention group to remain “uncontaminated” and “compliant”. This raises serious ethical questions—it can mean that consent is not sought from individual patients and that diagnostic information or counselling provided to the intervention cohort is withheld from patients in the non-intervention group. Does such deprivation constitute an assault on those people’s autonomy? If the provision of available full and accurate
camouflage is not sufficiently covered. In the chapter on depigmentation therapy the potential hazard of exogenous ochronosis induced by hydroquinone compounds in patients with extensive vitiligo is not mentioned. As the editors plan to have a new edition within 5 years, these topics should be included. In general, all the clinical chapters are well illustrated with colour photographs. However, the quality of some pictures, for example those pre-therapy and post-therapy could be improved. There are also some disturbing spelling errors. Vitiligo is an excellent choice for dermatologists and other clinicians who encounter such patients (paediatricians, ophthalmologists) but it is also a welcome source of clinical information for pigmentcell biologists. The book should be available in every department library. Jean Marie Naeyaert Department of Dermatology, University Hospital, De Pintelaan 185, 9000 Gent, Belgium [email protected]
evidence-based information and education of the public is considered a moral obligation, does it not follow that preconsent randomisation is unethical? By contrast, individual informed consent for real patients in research that includes shared decision making and the use of risk communication tools is ethically acceptable. Indeed, such research, which refines the very heart of medicine for sick people—the consultation—explores shared dialogues that take account of each patient’s immediate circumstances, values, and preferences. This not only improves a citizen’s personal satisfaction and well-being, but encourages professional growth and satisfaction, redefines “compliance”, and increases trust. Should not decisions to mount costly non-risk-free screening programmes be society’s responsibility and prerogative? Independently organised citizens’ deliberations involving all stakeholders in a wellregulated forum might offer scope to determine “public informed consent” (assent or dissent) for such difficult screening questions. Refractor C/o The Lancet, London, UK
THE LANCET • Vol 356 • October 14, 2000
For personal use only. Not to be reproduced without permission of The Lancet.