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PREVENTIVE MEDICINE AND MORALITY

SiR.—Dr Skrabanek (Jan 18, p 143) argues that the empirical basisof preventive medicine is insubstantial. He also claims that preven-tive medicine is immoral because the advantage to the individual isso small that public participation can only be achieved through coer-cion or deception and any benefit is outweighed by the consequentloss of liberty.

In support of his criticism of the epidemiological basis of preven-tion, he cites Bailar’s discussion of the methodological issues raisedby the conflicting results obtained in two studies of the relationbetween postmenopausal hormone treatment and cardiovasculardisease. It is mischievous of Skrabanek to suggest that Bailar’s paperimplies that all epidemiological research is invalid and to say that thefailure to demonstrate "necessary and sufficient causation" in therelation between smoking and mortality (ie, some smokers are runover by buses and some non-smokers die of lung cancer) casts doubton the efficacy of smoking prevention.Skrabanek’s accusation of immorality is also unfounded. The

existentialist philosopher Berdyaev points out that freedom cannotbe understood simply as freedom from something but must also berecognised as freedom for something.2 For example, cigarettesmoking is a true freedom only if it increases the potential to live lifeto the full-which may be difficult in view of the ensuing chroniclung and cardiovascular disease. Berdyaev also stresses that socialfreedom is not simply the relaxation of constraint but the result of aneducational process: true freedom is thus distinguished from theapparent freedom offered by advertising agencies and commerciallymotivated pressure groups.Preventive medicine has its dangers: it is unethical to inflict any

preventive measure on the public until its efficacy has been demon-strated and its benefits have been shown to outweigh the social costs.However, it is also unethical not to try to assess the value of a

preventive measure which might prevent unnecessary suffering orpremature death. If, after careful consideration of the benefits andcosts, it is obvious that a net gain to the public health will accruefrom a preventive activity, it is then the doctor’s moral responsi-bility not only to inform but also to educate both the patient andsociety, in the interests of freedom.

Department of Community Medicineand General Practice,

University of Oxford,Radcliffe Infirmary,Oxford OX2 6HE DAVID MANT

1. Bailar JC. When research results are in conflict. N Engl J Med 1985; 313: 1080-81.2. Berdyaev N. Cited by Macquarrie J. Existentialism. London: Penguin, 1973

SiR,—Dr Skrabanek attributes to those interested in preventionthe desire to achieve longevity by compulsion but these are neitherthe ends nor the means that are intended. The real benefits of

prevention are the avoidance of premature death and, moreimportantly, the avoidance of disease and disability. One

consequence may be increased longevity, but that is not a primaryaim. Old age may bring with it the risk of dementia, incontinence,and immobility but even some of these hazards may be preventable.For example, many cases of dementia are the result of cerebralarterial disease and in arterial disease there is great scope for

prevention; immobility is often a result of degenerative joint diseasebut some of this is surgically correctable and some is a result ofosteoporosis and obesity (and it is not certain that either is

inevitable).Much of the argument about prevention has depended upon

mortality figures but the record of a death due to, say, cerebralinfarction gives no indication of the months or years of incapacitywhich preceded it and the strain put upon the family. Similarly therecord of a death due to chronic obstructive airways disease gives nomeasure of the years of work lost or the volume of domiciliaryoxygen consumed.

It is not correct to imply that attempts to modify life style with theaim of improving health interfere with liberty. No one is completelyfree; we are all constrained by personal abilities, the law, family ties,social customs, and income. Some people are not free to choose toadopt what is considered to be a healthy life style for these veryreasons. Only the intelligent and well educated can hope to make

any sense of the dietary advice which has been presented lately.Only about 5% of all bread purchased in Sheffield is wholemeal andmost of this is sold in the affluent areas of the city. Unrefined dietitems are simply not available in some areas, and in an attempt tocorrect this a wholefood shop has been established in one ofSheffield’s health centres.Some children are brought up in families who smoke, are taught

by teachers who smoke, and on television watch sports sponsored bycigarette companies. It cannot be said truly that such children arefree to make a choice in matters of a healthy life style.No-one wants to introduce compulsion of the seat-belt type. All

that is asked is that people should have the option to choose theirown life styles without having to pay more for wholemeal bread thanfor white and without having to ingest unnecessary sodium andrefined carbohydrates in ready-prepared foods.Cycling is a very cheap way to travel and a good way to physical

fitness; furthermore for short urban journeys it is the quickest wayto travel. Yet if I use my bicycle for work I am not provided withanywhere to park it which is safe from vandals, thieves, and theweather, while if I use my car I am provided with parking space and,.for some journeys, the NHS will pay me 27 - 2 p per mile.

Doctors must point out to government and population alike themedical consequences of some of the changes of life style over thepast fifty years. The individual must be able to make a moreinformed choice and needs more freedom of choice and not less. Themost important liberty of all is freedom from disease.Northern General HospitalSheffield S5 7AU A. KENNEDY

SIR,—I share Dr Skrabanek’s distress that doctors might refuse totreat people because of their behaviour, for health services have tocope with the consequences of human frailty. And I am alsoconcerned that disease prevention programmes may be imposedbecause of sloppy thinking and failure to observe the "rules ofevidence" of epidemiology. However, I must question some ofSkrabanek’s statements. Longevity is only one aspect of disease prevention programmes. More important is the reduction ofchronic illness and disability during whatever length of life isallotted to an individual. Not everyone is plagued by loneliness,incontinence, and dementia in old age, and it is defeatist to view anearly death as preferable to the risk of reaching old age in one ormore of these distressing states. Although health promotion anddisease prevention programmes are influenced by ethical, political,and vested interests, they must be based on thorough scientific evaluation.

11 Queen’s Road,Gillingham, Kent ME7 4LP VERNON K. HOCHULI

SIR,-I am not sure whether Dr Skrabanek is attempting to followSwift and Butler in an essay on irony or whether he is serious. Isuspect the former, but fear that many readers may assume thelatter.He alleges that some doctors are now refusing to treat patients

who continue to smoke against medical advice. This merely provesthat some doctors are eccentric. There are indeed fates worse thandeath-the worst I have witnessed is patients dying by slow "

suffocation from lung cancer. We may be approaching the timewhen people with cancer of the lung will have grounds for claims formassive compensation against tobacco companies (and whenwomen with cervical cancer will have similar claims against theNational Health Service).The implication that people would prefer to be ill or dead is not

borne out by discussion with the vast majority of sick people, andmany of the remainder have a treatable depression.East Yorkshire Health Authority,Westwood Hospital,Beverley, North Humberside HU17 8BW A. V. SHEARD

JOURNAL REFEREES’ REPORTS

SIR,-I am not certain which American journal Dr Evans refers toin his letter (Jan 18, p 158) discussing its editor’s refusal to let himand, presumably, his colleagues see the comments of one of tworeferees. One review procedure is for referees to send a two-part