For debate: the virtuous public health physician.

This paper argues that although public health physicians have shown interest in ethical dilemmas relating to specific problems within the specialty, few have addressed the central ethical dilemma in public health, namely the conflict between the rights of the individual and the responsibilities of society for all its members. The paper reviews a number of public health programmes, where different approaches have been taken to this central dilemma. It then examines a number of schools of ethics, in an attempt to resolve the problem. Of these, only virtue ethics, perhaps supported by the insights of feminism and the ethics of care, appear to help with an irreconcilable conflict. The paper then makes an attempt to apply the concept of virtue ethics in public health medicine and to answer the question, 'what would a virtuous public health physician look like?' Finally, it lists some of the consequences of such an approach.

Autonomy in the medical profession in the United Kingdom--an historical perspective.

This paper reviews the concept of professional autonomy from an historical perspective. It became formalised in the United Kingdom only after a long struggle throughout most of the nineteenth century. In its pure form professional autonomy implies unlimited powers to undertake medical investigations and to prescribe treatment, irrespective of cost. Doctors alone should determine the quality of care and the levels of remuneration to which they should be entitled. In the second half of the twentieth century a steady erosion of professional autonomy occurred in the United Kingdom. The level of remuneration has been restricted for most doctors for nearly fifty years, whilst the costs of health care have steadily reduced the doctor's ability to provide unrestricted care within the health care system. Reorganisation of the National Health Service in 1983 and 1991 has substantially eroded professional autonomy, to the point where research developments, clinical judgement and ethical standards are all now being placed at risk.

Retreat from Nuremberg: can we prevent unethical medical research?

The prosecution of doctors guilty of appalling human rights abuses at Nuremberg was achieved on the mistaken premise that the research community already had a code of conduct which, if applied, would have made such abuses impossible. In fact, not only was there no such code but when the 'Nuremberg Code' was published after the trial it continued to be ignored by many doctors for some thirty years afterwards. Indeed its central principle of informed consent has itself been eroded by subsequent international agreements on the ethics of medical research. This review shows that the mechanisms for approval of medical research which have now been promulgated in England and Wales, in practice, are applied on a very variable basis. Research in vulnerable groups unable to give fully informed consent such as children, prisoners and the incompetent elderly require the application of more rigorous standards of ethical control than those currently in operation. The use of vulnerable populations in the developing world and the application of international standards to them is also considered. A number of suggestions for improvements in current procedures in all these areas are put forward. The proposals for the United Kingdom would meet the requirements of the European Convention on bioethical research and the recent government consultation paper on medical treatment and research in incompetent adults.

Do doctors read forms? A one-year audit of medical certificates submitted to a crematorium.

To determine the thoroughness and accuracy with which medical certificates for cremation are completed, a record was made, during normal processing of the documents, of the number of questions that were not answered or answered wrongly, or in which clarification was required. Of 835 sets of forms only 346 (41%) were completed sufficiently accurately for the cremation to proceed without further enquiry. Junior doctors contributed the most errors but general practitioners and consultants also contributed large numbers of errors. Doctors ought to be far more accurate and thorough in completing cremation certificates than were those audited here. The results cast doubt on the reliability of information supplied on other forms. In view of the high frequency of poorly completed forms, review by a medical referee remains essential.

Research, ethics and privacy: the limits of knowledge.

This paper considers the need for personal privacy within the context of epidemiological research. It concludes that privacy can be protected by early anonymization and aggregation of personal health data without prejudicing the viability of a research project. During the period before anonymization, however, a secure legal framework is necessary to prevent unauthorized access to potentially sensitive information. Within such a framework ethical codes need to be identified and monitored by an appropriate Local Research Ethics Committee (or a Multicentre Ethics Committee acting on behalf of a number of local committees). Present arrangements within the health care system in the UK for the handling of such data remain very unsatisfactory and put patient privacy at risk.

Criteria for decision making in local research (ethics) committees.

This paper briefly reviews the role in medical ethics of the British Medical Association and the General Medical Council. It describes the origin of local research ethics committees and then outlines the criteria which should be used in such committees to assess the ethics of research protocols, based on current best practice in the United Kingdom.

Vancomycin-resistant enterococcus: an emerging nosocomial pathogen and its implications for the operating room setting.

Enterococci, an emerging group of nosocomial pathogens with high-level resistance to various antibiotics, will demand effective, conscientious, and continuous use of Universal Precautions to combat their pernicious threat. Effective Universal Precautions/body substance isolation infection control precautions and methodologies and innovative medical and surgical procedures will play a significant role in containing these highly infectious pathogens.

Medical ethics and the public health.

The development of preventive medicine is reviewed from an historical perspective. In its third and current stage of development preventive medicine has become involved in the life cycle of individual diseases and this presents a number of ethical difficulties for doctors and not least those concerned with the public health. Some proposed responses are considered and rejected. It is concluded that participants should be given more detailed information about screening tests and that doctors are under an ethical obligation to consider with the utmost care any contra-indications to a particular vaccination or a screening procedure in an individual patient. Serious reservations are expressed about the ethics and scientific justification of some government preventive medicine programmes currently in operation or projected.

Length of stay in general medical beds; implications for the NHS White Paper of variance within one performance indicator.

Data over several years have shown that the average length of stay in general medical beds in the Royal Preston Hospital is approximately 20 per cent above regional average. To investigate this we carried out a prospective study of 259 successive medical admissions to the hospital. We also carried out a retrospective study of routine data from the Korner episode system (KES) for the specialties of general medicine and geriatrics, using standardization techniques. After correcting for age and diagnostic group, the average length of stay in the hospital was close to the regional average. It is concluded that difference between districts in respect of age and diagnostic group can cause substantial difference in average length of stay. Future contracts between purchasing and providing health service authorities will need to take such difference into account if valid comparisons are to be made between two or more apparently similar alternatives.

Comparison of auditory brainstem response and behavioral audiometry in infants.

Sixty-three normal hearing infants, ranging from 1 to 12 months of age, were evaluated with Behavioral Observation Audiometry (BOA), Visual Reinforcement Audiometry (VRA), and Auditory Brainstem Response Audiometry (ABR). BOA thresholds decreased with increasing age for infants 0 to 6 months of age, while ABR threshold were essentially constant as a function of subject age. In general, VRA threshold were obtained only for infants over 4 months of age, and were relatively constant for the age range of 4 to 12 months. For neonates, BOA thresholds were significantly higher than ABR thresholds. BOA, VRA, and ABR thresholds tended to converge at a subject age of approximately 6 months, with VRA yielding the lowest and BOA the highest threshold. ABR provided the most consistent threshold for all subjects tested, regardless of age.