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(i) an intention to do an act, or to omit to act where there is aduty to do so, being grossly negligent whether death orserious injury be caused; and/or (ii) an intention to do an act,or to omit an act where there is a duty to do so, being recklesswhether death, or personal injury, or possibly any injury to"health or welfare", be caused amounts to manslaughter.These combinations ofmens rea and negligence may arguablycover the kind of conduct considered above.Where a doctor is invited to sign a death certificate of a

patient who died from renal failure but who was treatable andwas refused treatment, it would be open to a doctor to refusethe death certificate and it could be argued, indeed, that heshould refuse to do so.

THE PATIENT’S RIGHT TO BE TREATED: ENFORCING A DUTY OF CARE

The National Health Service Act 1977 imposes a duty onthe Secretary of State for Social Services. The only apparentqualification upon his duty is that contained in section 3 (1)which states that the provision of the services listed in thesection is to be "to such extent as he considers necessary tomeet all reasonable requirements". It is uncertain whetherthe court would be bound to accept the Secretary of State’sdetermination of what is necessary and further how "allreasonable requirements" should be interpreted. Since theGovernment, in a letter written to Mrs Elizabeth Ward by the

Prime Minister’s private secretary, Mr Timothy Flesher,dated Aug 31, 1983, admits "the insufficiency of our presentservices for kidney patients is not in dispute, and wasacknowledged by the Secretary of State for Social Services inhis statement on the Yorkshire Television Programme (FirstTuesday)", it is highly arguable that the Secretary of State hasadmitted that he has failed in his duty towards patients withchronic renal disease. The question then remains as to howthe individual patient should set about enforcing the duty toprovide necessary health treatment owed to him. One optioncould be an application for judicial review and an order formandamus to force the Secretary of State to carry out his dutyto treat. An alternative might be to pursue a relator action, butthis requires the Attorney-General to become a party. If herefuses to give his consent the prospective relator has noremedy.The earlier options I mentioned would be punitive rather

than specifically aimed at enforcing treatment, but theymight well be quite effective nonetheless! As pleas for changeby press and doctors and patients fail to elicit any positiveresponse, the only alternative route seems to lie througheither the criminal or the civil arm of the law-though such acourse is dogged by expensive uncertainty.

DIANA BRAHAMS,Barrister-at-Law

Round the World

From our CorrespondentsUSSR, Czechoslovakia

ABUSE OF PSYCHIATRY

IN Chistopol Prison Dr Anatoly Koryagin has been on hungerstrike again and once more is being forcibly fed. Last Septemberarticle 188 of the Soviet criminal code was amended to permit extrasentences of up to five years to be imposed on those who, forexample, protest about the conditions of their confinement.Punishments at the prison include reduced rations (below thephysiological norm). This strict regimen is the reason for

Koryagin’s latest protest. In a letter from prison dated Dec 30, heconfirms that the support of doctors outside the USSR is of value tohim. Writing to the American Psychiatric Association, he says:"As a doctor, I protest against the criminal Soviet laws under which they

starve prisoners. This is a crime against people’s health and life. Pass on thismessage to the doctors of the world through the press. I am fighting for theright to health and life. I will be glad of their support. I am exhausted, I amexperiencing heart pains, and my body is swollen, but I will continue the

hunger strike."Details of a case of psychiatric abuse in Czechoslovakia are now

emerging. Last June, Milan Vlk was transferred to a secure ward inthe Psychiatric Hospital at Horni Befkovice, and strongtranquillisers were administered. This was one month after he hadbeen arrested on a charge of distributing an anti-Soviet leaflet in thetown of Decin. The case featured in Frankfurter Allgemeine Zeitunglast December and the account there mentions a diagnosis of"reforming paranoia" reached by a psychiatrist called in by thesecurity services who were holding Vlk. This label seems to be anapproved one in Czechoslovakia, and the revealing criteria for itsuse are given in a 1983 article in the official handbook of the Czechpolice where a doctor, a major in the security forces, states thatanyone who does not vote for the approved candidate at elections is a"dangerous paranoiac" and that anyone found with forbiddenliterature or expressing unusual opinions "must be considered asick person". Vlk is allowed weekly visits from his family and seemsto be free to send and receive letters. This 21-year-old man, who isnot mentally ill in any conventionally accepted sense of the term andhas not been found guilty of any offence, ends a letter: "I am hereillegally, in a closed ward, behind barred windows and fences and,alas, I have no idea what the future holds for me".

United StatesTHE RIGHT TO DIE:

TANGLES BETWEEN MEDICINE AND THE LAW

MANY people are coming to think that the worst move in thetreatment of patients is to get the law involved. Such are theramifications, the legal pitfalls and tangles, as well as the notoriousdelays. Now many instances of a comatose and dying patient seem tobe on the point of reaching the courts. It has been held, in

California, that to remove life-sustaining equipment from such apatient was justified since the burden of treatment was greater thanany possible benefits. A charge of murder has been brought againsttwo doctors who took the decision to cease treatment. At the trial,the physicians were supported by certain bio-ethicists, thoughothers contested the decision. In the US, bio-ethicism is a growthindustry, posts are being created all over the country, and much heatbut no great light is being generated. Disagreement seems to ariseover almost every decision taken.The interest now centres on a 26-year-old quadriplegic patient, a

victim of cerebral palsy from birth, who has no control of limbs andbodily functions but who has a clear and able brain, which she hasput to good use to the limits of her capacity. She now has severe andpainful arthritis, and is unhappily married to a husband who has hadvarious convictions. She wishes to die and has made her wishesclear. But her capacity to take her own life is limited by her physicaldisabilities and she is utterly dependent on others. She has clearlystated that she wants the hospital in which she is confined to starveher to death, but to ease her death with bodily care and analgesicdrugs. This not only conflicts with the ethical standards of herphysicians but also gets everybody concerne-d-inte-legal tangles. Forabetting suicide is a crime, whether in hospital or at home. A judgein a superior court ruled that the hospital staff could not becompelled to desist from action to prevent starvation, so

intravenous feeding was started.Some bio-ethicists say that the patient has no right to expect the

hospital staff to abet her in a morally unjustified act, as well as incommitting a legal offence. But other bio-ethicists and civillibertarians hold that she has the right to her decision, whichshould, barring exceptional circumstances, be respected. "Whoselife is it anyway?" asks one lawyer, arguing that she should have theright to determine her own fate. Others believe that she should betransferred to a hospice, where she could die. The law is far fromclear; one appellate court has ruled that to remove a feeding tubenecessary to maintain life would be an act of homicide.

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The hospital staff are in an impossible position. If they allow thepatient to starve to death, as she wishes them to do, then they are indanger of the law for abetting a suicide. They are in the sameposition if they discharge her. But to force-feed a patient against herwill is equally an offence, for it constitutes an assault. The clearconclusion is that we cannot have legislation to cover every humanpredicament and surely we would not wish to. No solution may lie inthe multiplication of hospital bio-ethical committees. Even if thephysicians, the clergy, the psychologists, and all consulted in anindividual case agree on the decision to be taken, they are still

subject to pressure from other individuals or bodies who insist onintervening by applying to the courts, even if they have no status, nostanding, and no direct involvement with the case or the individualsconcerned. Many people feel that the decision should be left to theindividual physician in whom the patient has trust.

**An article on this subject from our legal correspondentappeared last week (Feb 11, p 351).-ED. L.

Zimbabwe

HEALTH CARE SINCE INDEPENDENCE

Zimbabwe rarely gets a good press these days, nor has it done sosince the heady pre- and post-independence days when nationsclamoured to contribute to the country, though little of this aid hasyet been seen in Zimbabwe. It may seem inevitable that a newly-independent African state would proceed down the road to

dictatorship, corruption, and economic mismanagement, but such asimplistic picture does not take into account the part played bymultinational corporations and the inappropriate aid and tradepractices of most developed countries.Before independence, health care in Rhodesia was typical of many

developing countries, having a heavy urban and curative orientationdespite efforts by a few enlightened individuals to redress thebalance towards rural areas and prevention. 80% of the populationlived in rural areas; 50% was aged under fifteen and 20% under five.The infant mortality rate for the black population (96% of the totalpopulation) ranged from 21 per 1000 in some parts of Harare to 300per 1000 in remote parts of the country, and was 120-150 per 1000for blacks as a whole. The most common diseases were, and still are,diarrhoea, malnutrition, measles, pneumonia, malaria, andtuberculosis. Nutritional deficiencies abounded and interacted withthe communicable diseases. A nutritional survey carried out by the-Ministry of Health in 1980 found 40% of children aged 1 to 5 to bemalnourished, 15% severely so. Rhodesia had one of the highestper-caput incomes in Africa but the health statistics for blacks inrural areas were similar to much poorer countries. One reason forthis was the inequitable distribution of land: 68% of the populationlived in Tribal Trust Lands, which are poor in quality, inadequatein area, and produce less and less food each year. In the early ’60s150 kg or more of the staple food, maize, was grown for each person,whereas by 1977 only 105 kg maize per person was harvested, 40%less than required. In the waged sector, most workers were paidbelow the minimum necessary for healthy living. The warcontributed to a decline in health by splitting up families, removingpeople from their own land to "protected villages", and disruptingmedical services.Since independence, the situation concerning land and wages has

improved although there is far to go. Resettlement has been slowpartly because commercial farming land could be sold only on a"willing buyer, willing seller" basis; it could not be forcibly sold.Administrative difficulties of providing support and educationalprogrammes also delayed the process. The institution of a basicminimum wage ensured that most people could live off their wagesbut, because of inflation, it now barely exceeds the poverty line.Only 10% of the Rhodesian health budget went on preventive

measures. The rest was spent on hospitals and clinics-30% to thethen Andrew Fleming teaching hospital based in the white suburbsof Harare. Most hospital staff were concentrated in towns and thoseworking in rural areas were pred6minantly confined to curativework in clinics. Services for whites and blacks were separated and ingeneral the former were much superior. Many doctors treated onlywhite patients because of their ability to pay. The doctor/patient

ratio was 1:830 for whites and 1:50 000 or more for rural blacks.Doctors have been graduating from the medical school in Hararesince 1968 and now 50-60 are trained each year, although numberswill double by the end of the decade. The majority of the earlygraduates have left the country or work in private practice.Two fields in health care which have shown particular progress

since independence are primary health care and medical education.The drive for primary health care was spearheaded by DrUshewokunze who, as health Minister, devoted himself to theWHO principles expounded at Alma Ata. The following aims are inthe process of being realised. The staff of the country’s 55 districthospitals will include three doctors, one with a specificcommunity/preventive orientation. Part-time village healthworkers are being trained locally to provide health care throughoutthe country and these workers, though too few, have already madean impact in reducing the mortality and morbidity from diarrhoealdisease by an emphasis on oral rehydration. Their enthusiasm andmotivation is remarkable. Many hospitals are beginning to practiseprimary health care through the development of outreach services,the practice of immunisation in wards, and the establishment ofcomprehensive clinics for the under-fives. Self-reliance in health isalso becoming a reality. One hospital has started a farm health-worker training scheme which is a model for the country. Anotherpromotes the building of wells and latrines in the neighbouringcommunal land. The Ministry of Health has provided groundnutseed and fertiliser to enable groups of mothers workingcooperatively to grow groundnuts and thereby improve theirchildren’s nutritional status. A review of the medical schoolcurriculum is under way and practical steps are shortly to be taken toensure greater emphasis on community and environmental aspectsof health from the first year of the course; that students are exposedto rural and urban community health and primary health care fromthe first year; and better integration of teaching throughout.Some developments have already taken place. In 1981 the

department of paediatrics started a two-week rural attachment forstudents in their penultimate year. The period is spent in a smalldistrict level (usually mission) hospital attached to a specified healthworker. Clear-cut objectives are laid down so that the student knowswhat is expected of him or her. The hospitals chosen are involved inextension work in neighbouring communal lands. Work is dividedbetween ward, outreach clinic, and community activities so that thestudent will develop a full grasp of the relationship between healthand rural development. Each student is visited by a lecturer duringthe attachment period, and this paediatrician also visits largerhospitals en route as part of an education programme for doctorsand staff in district hospitals. The attachment scheme seems to havebeen successful with students, many of whom have commented thatit opened their eyes to a totally new outlook on medicine.The overall aim of these changes is to train a doctor for Zimbabwe

who is orientated towards total patient care in a district hospitalsituation. Will a curriculum change be enough to persuade doctorsto work in rural areas? Undoubtedly not. A change in two otherareas will be essential: the selection of students must take intoaccòunt their commitment to relevant human medicine and theirinterest in rural areas; and the conditions of work in districthospitals must be improved and incentives provided to encouragemedical staff to work there.

’

There may be lessons for the UK in these reforms in health care.

Encouraging greater community orientation and a better

appreciation of the patient as a person in society is much in vogue.Primary health care is, however, a poorly understood concept inBritain as in Zimbabwe and tends to be equated with generalpractice. The idea of self-help groups working to put pressure onspecific aspects of society which are adverse to health (such astobacco advertising, the package food industry, and poor housing) isfairly new and not always welcome to doctors who feel this is nottheir business. But health is everybody’s business.

Department of Child Health,University of Dundee

Department of Child Health,University of Zimbabwe

TONY WATERSTON

DAVID SANDERS