1200

Arbitration for medical negligenceA quicker, cheaper way of compensating victims of medical

negligence was outlined by the Health Secretary, William

Waldegrave, last week. Under the new proposals, based onrecommendations made by Lord Griffiths at a Law Societyconference last year, claims would be dealt with by an arbitrationpanel consisting of two doctors and a lawyer, who would assess thecase on paper evidence (eg, medical records and writtensubmissions from the parties concerned) and would not take oralevidence. The decision to award compensation would be based onproof of negligence, and there would be no appeal, except on pointsof law. Thus the proposed system falls far short of the no-faultcompensation being pursued by a number of MPs and supported bythe medical profession. Because of the rising costs of medicalinsurance premiums, indemnity costs were transferred from themedical defence societies to health authorities in January, 1990.Health authorities and trusts now have to pay damages awarded andlegal costs incurred in cases where medical negligence is proved.The proposed system of arbitration will be voluntary and willsupplement, not replace, existing arrangements.

Camelford revisited

The advisory group appointed to investigate the health impli-cations of the accidental contamination in July, 1988, by aluminiumsulphate of the Lowermoor water treatment works concluded inJuly, 1989, that delayed or persistent toxic effects were unlikely.l,2However, about 400 people, mainly from the Camelford area,continued to attribute their symptoms to the incident, so theadvisory group was reconvened in October, 1990, to assess reportsproduced since July, 1989, of persistent symptoms and clinico-pathological findings. A clinical psychologist joined the originalgroup to help in the interpretation of psychometric test data. Thegroup concludes that there is still no convincing evidence of harmfulaccumulation of aluminium or of an increased prevalence ofill-health due to persistent toxic effects of the contaminated water.3A conference of doctors who had investigated patients after the

incident commented on the high serum aluminium levels found insome specimens,4 but the advisory group concludes that contamin-ation is the most likely explanation for these high levels. None of 48specimens tested at Guildford or four other NHS SupraregionalAssay Service Laboratories had been collected in aluminium-freetubes and all 9 samples reported to have concentrations above40 ug/1 (reference range less than 10 pg/1) had been tested atGuildford, where concentrations tended to be much higher thanthose tested at the other laboratories. Normal serum aluminiumconcentrations had been found in the ten patients thought to beamong the most heavily exposed to aluminium and whose boneshad been biopsied to examine for aluminium; serum aluminium wasalso normal in 27 holidaymakers who had been in Lowermoor at thetime of the incident but who complained six months later of

persistent symptoms. Of the 10 persons who underwent bonebiopsy 1 showed a line of aluminium and the other gave an equivocalresult. Subsequent biopsies from these 2 individuals were negative,as were biopsy specimens from the other 8. Desferrioxamine

challenge in the 2 patients with positive bone biopsies did not releasemuch aluminium into the urine, a point said to reflect the smallamounts of aluminium accumulated.The persistent symptoms most commonly reported were joint

and muscle pains, general fatigue, and malaise. The group foundthat, with a few exceptions, the symptoms represented a worseningor recurrence of pre-existing conditions rather than new complaintsand that the number complaining of musculoskeletal symptoms wasmuch less than the number expected for a population the size of thatin Lowermoor. There was also no evidence to support media

reports of dermatological problems and toenail losses. Surveysindicating an increased prevalence of memory loss could not bevalidated because of methodological flaws.What the group described as a "soundly designed" survey of

pregnancy outcome among mothers pregnant at the time of theincident showed no adverse effect of the incident. Nevertheless,

because it is generally accepted that the fetus is usually susceptible tolower concentrations of toxic substances than is adult tissue, thegroup thinks that developmental follow-up of children who were inurero at the time of the incident is prudent.

Other recommendations that the group makes include the formal

testing of the suggestion that some people might show "sensitivity"to aluminium; continued surveillance of the health of the com-munity because of the uniqueness of the incident and the continuingconcern and worry in the community; and peer review and scientificscrutiny of subsequent studies relating to this incident that seem tohave implications for public health policy.

1. Water Pollution at Lowermoor North Cornwall. Report of Lowermoor IncidentHealth Advisory Group, July 1989. Cornwall and Isles of Scilly District HealthAuthority.

2. Anonymous. After Camelford. Lancet 1989, ii: 288.3. Water Pollution at Lowermoor North Cornwall. Second Report of the Lowermoor

Incident Health Advisory Group. London: HM Stationery Office, 1991. Pp 51.£6.00. ISBN 0-11-321476-6.

4. Anonymous. Camelford two years on. Lancet 1990; 336: 366.

A fetal point of view

Should a woman have the right to choose whether she wants tocontinue a pregnancy or not, or has the fetus an indisputable right tolife? These are the main issues in the continuing debate aboutabortion. A woman is able to express her point of view, but that ofthe fetus can only be guessed at. The nearest we can come to thefetus’ feelings might be those of Jonathan Berkowitz,l who providesa unique and perceptive account of how he was within an hour oflosing his life as a fetus. A strong supporter of women’s right toabortion, he discovered at age 29 how close he had come to beingaborted. By a quirk of fate he lived to tell this tale. He had beenconceived at a time when pregnancy outside marriage was regardedas shameful (1961). His biological father had been persuaded toprovide the money for an abortion, but his mother’s father hadgambled it away the night before the abortion was due. His motherchanged her mind and had her baby in a home for unmarriedmothers, and her son was adopted. Berkowitz was horrified todiscover his near-escape and describes his renewed appreciation oflife. His mother was less fortunate. Berkowitz tells how her

experience left substantial and lasting scars that remained fresh 29years later. She has not recovered from her damaging experience,and Berkowitz is convinced that she should never have gonethrough that trial. He adds the experience of other illegitimatechildren to his pro-choice arguments: not all are fortunate enough tobe adopted and some might be brought up by young motherswithout much parenting skill. Berkowitz, however, regards himselfas a fortunate exception to the rule.

1. Berkowitz JM. How I was almost aborted: reflections on a prenatal brush with death.J Med Ethics 1991; 17: 136-37.

The trouble with pesticidesIn 1861, Mrs Beeton’s answer to moth-eaten clothing was to

put "pieces of camphor, cedar wood, Russia leather, tobaccoleaves, bog-myrtle, or anything else strongly aromatic, in drawers orboxes ...". Such early natural pesticides have been largelysuperseded by complex synthetic chemicals, but what price are wepaying for our weevil-free flour and mouldless bread? In Poisoned77a?TM:,* Robbins attempts to answer this question by providingbasic information about some of the 450 tonnes of pesticides used inthe UK each week in agriculture, in homes, and in industry.

Pesticides are good at what they are supposed to do;unfortunately, because they are also poor discriminators, numerousorganisms unrelated to the target beast may be killed indirectly (forinstance, via the food chain) or because they happen to be in thewrong place at the wrong time (honeybees, for example, are oftenthe accidental victims of insecticide sprays on food crops). Humanbeings are affected not only by direct contact but also throughconsumption of food containing pesticide residues. Robbins argues