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Famous patients can be badly treated, especially if theyare singled out for unorthodox prescriptions of

tranquillisers, sedatives, or stimulants or do not have theiractivities limited after, for example, major surgery or amyocardial infarct. Consideration of the public interest isimportant in the treatment of a leader, and medical decisionsmust harm neither the public nor the leader. Robins askswhether doctors to the high and mighty are self-selected andtherefore more likely under pressure to deviate from normalstandards of medical conduct.That such conduct may result in VIP’s not getting the

best treatment was vividly demonstrated by Mark S. Smith,professor of emergency medicine at The GeorgeWashington University, with a videotaped re-enactment ofPresident Reagan’s treatment after the attemptedassassination in 1981. Routine procedures in the emergencyroom were interrupted and clinical decisions hindered bythe unusual appearance not only of specialist chiefs fromother hospital departments but also of members of theSecret Service, who continued to guard the President. WhatSmith calls the VIP syndrome can only be avoided byensuring standard treatment (not by committees but bythose normally responsible) of the VIP’s condition, and nothis or her fame, fortune, or power.Mark Smith issued another warning. Whatever the VIP

emergency, doctors still have responsibility for their otherpatients, who should not be left in benign (or not so benign)neglect.

Hugh L’Etang

Medicine and the Law

Excessive working hoursDr Chris Johnstone, formerly a senior house-officer at

University College Hospital, is suing Bloomsbury HealthAuthority for damages for requiring him to work 88 hours ormore per week. He is also seeking a declaration that acontract requiring him to work in excess of 72 hours perweek was unlawful. The case has the support of the BritishMedical Association but is being vigorously opposed by thehealth authority. The authority has repeatedly tried to getparts of the claim struck out: on Dec 19 it failed in the Courtof Appeal. The UK Ministerial Group on Junior Doctors’Hours (see Lancet Dec 22/29, p 1543) announced anagreement on Dec 17 but without a convincing statement onresources. The Court of Appeal ruling could provide theimpetus needed to ensure that something is done quicklyand effectively to reduce the hours worked by traineedoctors in Britain.

The Court of Appeal allowed the main body of Johnstone’s claimto stand (Legatt LJ dissenting); it unanimously allowed a cross-appeal by the doctor from the lower court’s decision in June, 1990,that he could not rely on the Unfair Contract Terms Act 1977; it didnot, however, allow Johnstone to claim that the contract was voidfor reasons of public policy.The doctor’s contract (a letter dated Feb 17,1988) stated that his

hours of duty would be the standard working week of 10 units ofmedical time (40 hours) and that he had to be available for class AUMTs averaging 12 (48 hours) a week. Giving the leadingjudgment, Lord Justice Stuart-Smith said that in some weeks theplaintiff might have to work considerably more than 88 hours,though the weekly average must not exceed 88. Payment for anyhours worked over 40 would be "somewhat unusually" not at ahigher rate but at one-third of the basic rate.The doctor alleged that in breach of a duty to take all reasonable

care for his safety and wellbeing, the employing authority required

him to work intolerable hours with such deprivation of sleep as todamage his health and put at risk the safety of patients. A schedulealleges that he sometimes worked for over 100 hours with

inadequate sleep; over one weekend he worked a 32 hour shift andon another weekend he was on call for more than 49 continuoushours during which he was able to sleep for only 7 hours in total.The plaintiff alleged that as a result of being required to work suchhours with inadequate sleep he suffered personal injury-namely,stress and depression, lethargy, diminished appetite and ability tosleep plus physical sickness on occasions and feelings of despair andsuicide.The amended claim now consists of a declaration that the plaintiff

could not lawfully have been required to work under his contract ofemployment "for a continuous period of more than 24 hourswithout a break of not less than 8 hours" and "for so many hours inexcess of his standard working week as would foreseeably injure hishealth, notwithstanding that in consequence the total number ofsuch excess hours worked by him might have amounted on averageto fewer than 48 per week."

Stuart Smith LJ said that it was common ground that the plaintiffhad a duty to be available for an average of 48 hours beyond the basic40 and that the employing authority had a duty to take reasonablecare not to injure his health. It was the reconciliation of the two thatwas in question. "... the duty of care", he said "is owed to theindividual employee and different employees may have differentstamina. If the Authority in this case knew or ought to have knownthat by requiring him to work the hours they did, they exposed himto risk of injury to his health, then they should not have requiredhim to work in excess of those hours that he safely could have done."The health authority argued that it could not be expected to treat

its house-officers differently according to their physical stamina."But this is not the law", said Stuart-Smith LJ "and to suggest thatthose who could not stand the heat in the kitchen should either getout or not go in (though often a sound principle) would have seriousimplications if applied in these circumstances". The NationalHealth Service is effectively a monopoly employer. "Is the aspiringdoctor who has spent many years in training to this point to abandonhis chosen profession because the employer may exercise its powerto call on him to work so many hours that his health isundermined?"

Johnstone v Bloomsbury Health Authority. Court of Appeal: Sir NicolasBrowne-Wilkinson V-C, Stuart-Smith and Legatt L_7,7, Dec 19, 1990.

Diana Brahams

Obituary

John Dawson

John Dawson, who as head of the British MedicalAssociation’s professional, scientific and internationalaffairs division did much to revive the association’s scientific

ethos, died on Dec 20, aged 44.After qualifying from St Mary’s Hospital, London, in 1970 and

the usual house appointments, he spent two years with the BritishAntarctic Survey. In addition to having challenging clinical

responsibilities in the hostile polar environment, he also made a film,The Ice and the Sky, which enabled him to develop the substantialcommunication skills that were to serve him, and the profession, sowell later.He did a traineeship in general practice but realised that his

horizons were much wider. In 1976 he joined the British MedicalAssociation’s staff as an assistant secretary responsible for thecommunity medicine, medical academic, and ethical committees,where his talents were recognised and appreciated. At the same timehe became one of the first provincial secretaries appointed by theassociation to provide better personal services for members.As part of the normal career progression within the BMA John

was moved to the contractor division, which includes the powerfulgeneral medical services committee, whose raison d’etre is termsand conditions of service for general practitioners. This period of hislife was extremely unhappy, and, even worse, he offended a coterie

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of medical politicians who never forgave him. In 1981 he becamehead of the professional, scientific and international affairs division,which included the board of science. He thrived on the intellectual

challenge and established good relations with three eminent

academic chairmen, Peter Quilliam, Sir Douglas Black, and SirChristopher Booth, who harnessed his drive and energy. Hisoutspokenness in this post made him many friends and a few, butpowerful, enemies.The board’s publications included such titles as Diet, Nutrition

and Health; Young People and Alcohol; The Boxing Report (whichlead to the BMA’s demand for an end to this "sport"); The MedicalEffects of Nuclear War and its sequels The Long Term Effects ofNuclear War and Nuclear Attack; and Ethics and CasualtySelection. These publications reflected John’s own feelings for theneeds of patients and encouraged debate both inside and outside theprofession. Many of the views put forward became BMA policy.Living with Risk won the 1988 science book prize given jointly bythe Committee on the Public Understanding of Science and theScience Museum.

In the ethical field John was involved in the production of, amongothers, The Euthanasia Report, The Torture Report, and The BMAHandbook of Medical Ethics. Doctor’s Dilemmas, which he wrotewith Melanie Phillips, received widespread acclaim.

His greatest contribution was probably in the field of HIVinfection and AIDS. His respect for human rights and his

understanding of the science of HI V and its spread were matched byhis abhorrence of those who from prejudice, fear, or ignoranceportrayed AIDS as a homosexual plague. He was instrumental inpersuading a group of eminent laymen and clinicians to serve on theBMA AIDS working party, which in turn convinced the BMAcouncil that the association needed to take a leading role in educatingthe public, politicians, and above all its own profession.The BMA booklet AIDS and You became a bestseller, won a

"plain English" award, and after translation into several languagesformed the basis of an educational board game for children. Johnwas also a founder trustee and director of the BMA Foundation forAIDS. His responsibility for the committee of doctors in theEuropean Community, and his involvement in WHO conferenceson HIV infection and AIDS led to many invitations abroad and

requests for advice from other national medical associations.

John’s natural gifts were seen at their best in the media,particularly television. The public recognised his obvious caringimage as that of the BMA, and that has stood the association in goodstead during recent medicopolitical storms.

Like his BMA career, John’s personal life had ups and downs.His marriage ended in divorce three years ago, but his happypartnership with Pamela Taylor flourished until his untimely death.He leaves two young daughters.

John Marks

Noticeboard

Aspirin and alcohol

A new year dawns; the light is too bright, the mouth feels as if ithas been used as a latrine by some small creature of the night, and adull headache beats in time with the pulse. Many people in such astate will reach for an aspirin, if they can move at all. But whatshould they wash it down with? Beware the hair of the dog. Workersfrom New York1 found that blood ethanol concentrations in five

healthy volunteers who drank 03 g/kg body weight ethanol an hourafter a standard breakfast were significantly increased if 1 g aspirinhad also been taken at breakfast. In-vitro studies in rats and manindicated an effect of aspirin on gastric alcohol dehydrogenaseactivity, thereby increasing the bioavailability of ingested ethanol byreduction of gastric ethanol oxidation.

1. Roine R, Gentry RT, Hernández-Muños R, Baraona E, Lieber CS. Aspirin increasesblood alcohol concentrations m humans after ingestion of ethanol JAMA 1990;264: 2406—08.

Feed the mother, feed the child

In Keneba, the Gambia, "eating for two" has taken on a newmeaning for pregnant and lactating women. Health workers

attending a recent meeting of the International Child Health Groupin Newcastle upon Tyne heard that dietary supplementation inpregnancy with a daily biscuit ration of about 450 kcal led to areduction in the number of low-birthweight babies born duringtimes of seasonal food shortages. This in turn led to an overallincrease in the weight of the village children to around 1 kg aboveaverage at age 2 years. Only malnourished mothers needed thesupplement. Supplements given during lactation made no

difference to child growth, unless the mother herself was severelymalnourished. However, supplemented mothers were healthier,felt better, and could work harder-hence cared for their childrenbetter.

"Feed the mother, so that she may feed the child" is a soundprinciple, but child health and growth depend on much else besides.The interaction between infant diarrhoea and malnutrition is a

continuing source of concern in developing countries, and theprevalence of diarrhoea could be greatly reduced if bacterialcontamination of weaning feeds could be prevented. There is

evidence, however, that traditional customs of food preparationshould not be abandoned without very good reason. Research inGhana and London has shown that fermentation-a traditional

practice discouraged by health workers because of its supposed lackof hygiene-actually reduces the food’s bacterial content.

In Romania, one of the sad legacies of the Ceausescu regime is thelarge number of children left abandoned in orphanages-the resultof a deliberate policy to enlarge the population by a Governmentunable to provide parents with enough food for the large familiesthey were encouraged to raise. Anaemia in the severelymalnourished orphans was treated with transfusion of blood-which was contaminated. As is well known, many of the childrennow have AIDS, and one suggestion put forward at the meeting wasthat the source of infection had been soldiers in local army camps,recently returned from Africa. Once world attention turned to theplight of these children and medical and other relief workers beganto arrive in Romania, conditions began to improve. But even nowmore AIDS children are dying of malnutrition than from thedisease itself.

The International Child Health Group is an independent organisation ofchild health doctors and health workers, which is affiliated to the BritishPaediatric Association. The convenor is Dr R. Richardson, Institute of ChildHealth, 30 Guilford Street, London WCIN 1EH.

Further thoughts on microdiscectomyThe optimum choice of treatment for lumbar nerve root

compression caused by intervertebral disc prolapse remains thesubject of strong opinion but continues to attract little in the way ofobjective evidence to settle the controversy. The traditional regimenof six weeks of bed rest and analgesia for a first attack is stilladvocated by most orthopaedic and neurosurgical specialists.Refractory or recurrent episodes may be treated with either

discectomy (via a laminectomy or laminotomy) or chemonucleolysiswith chymopapain. Disc excision often leads to substantial tissuedisruption and frequently requires blood transfusion.

Complications include infection, arachnoiditis, and neurologicalinjury. Chymopapain injection offers a less invasive alternative thathas fewer complications but a higher failure rate (up to 25%).Chemonucleolysis is the final conservative treatment option beforerecourse to discectomy.The description in 1977 of a microsurgical procedure that was

claimed to be fast, to minimise tissue disturbance, to allow directvisualisation of the damaged disc, and possibly to become anoutpatient treatment raised great hopes. Microdiscectomy has sincebeen criticised,l cautiously welcomed,z and uncritically supported3according to which fount of surgical knowledge one consults. Thatit is successful (in over 90% of cases) in decompressing the nerveroot is not contested. However, the claims made about this

technique’s advantages have yet to be proven in comparative trials,and while the benefits seem clear, definitive proof of improved