Australian Journal of Ophthalmology, 1982, 10, 87-89

UNMASKING MEDICINE ADDRESS BY MARK HARRISON President of the Royal Australian College of Ophthalmologists

On the occasion of the opening of the 13th Annual Scientific Congress, Surfers Paradise, Monday, 28th September, 1981

We believe that as ophthalmologists we are first and foremost medical doctors. In this context it is important to remember that the whole of the medical profession continues to be under siege and that we must respond appropriately. In order to do this we must be aware of the criticisms.

There has been little publicity in Australia for the 1980 Reith lectures entitled “Unmasking Medicine”, a series of important talks by a respected academic lawyer Mr Ian Kennedy, broadcast by the BBC and subsequently pub- lished in June 1981. Mr Kennedy is director of the Centre of Law, Medicine and Ethics at King’s College, London.

Briefly, he believes that medicine has acquired an influence far beyond the competence and skills of the doctors who practise it. He says that “this must be changed. We must become the masters of medicine, not its servants”. Unfortunately he does not state who “we” are, but he probably means the people through their elected representatives.

Mr Kennedy’s three basic arguments are simple and compelling. Doctors constantly make decisions about what constitutes illness and what is an acceptable quality of life. “However well intentioned the doctor it is hard to overstate how such a social arrangement

may undermine the notion of individual re- sponsibility and of course ultimately individual liberty.”

What he is saying is that the doctor’s unfettered freedom to practise as he sees fit must be subservient to the greater importance of his patient’s freedom. Kennedy makes the strong point that the doctor has total control over the decision as to whether a person’s complaint constitutes illness, and thus total control of deciding whether a person is a patient and what treatment he needs. Once the doctor has diagnosed illness he has taken away the patient’s freedom.

His argument states that when we discover that a patient has a cataract, the decision whether to operate is not based on medical or technical criteria but is a complex series of moral and ethical judgements. For example, we have to assess the patient’s quality of life and how it will be altered by a cataract operation. If we are considering an intraocular lens implant with our current lack of knowledge of the long term risks, we must pre-empt God and decide how long the patient will live-a daunting moral and ethical judgement. Although two doctors may be equal in technical know- ledge and expertise, the decision to operate varies with the doctor rather than with the patient.

Reprint requesrs; Dr Mark Harrison, 137 Wickham Terrace, Brisbane, Queensland, 4000.

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These criticisms have justification but I believe that most doctors fully understand that medical ethics are not about fees and advertising and respect for one’s colleagues. Medical ethics touch on all the fundamental problems of the sanctity of life, the quality of life and freedom for patients as well as doctors.

Mr Kennedy believes that most doctors are not trained adequately to deal with the ethical problems that they face daily. Your presence here today and your attention is convincing evidence that we frequently discuss these matters.

Mr Kennedy’s second great criticism is that we have become prisoners of our technology. “The lure of high technology is irresistible to the doctor, serving as both validation and vindication of his training and his image of himself as really the scientist, problem solver and curer.”

Our annual Congress may be seen to be the celebration of this interest in technology. There will be papers on many new technical applica- tions. We have an impressive trade display which is considered an essential part of the Congress bringing the latest equipment to our notice.

Mr Kennedy implies that modern technology has given no significant benefit to community health. Professor Douglas Tracy in his Centenary Oration to the Australian Medical Association last year draws attention to this platitude which despite its absurdity needs constant repudiation.

In ophthalmology we can take immense pride in the technical developments which have occurred during my specialist lifetime. We have seen great improvement in the tech- niques of surgery of cataracts, the cornea and retina, in fact in all facets of ophthalmology.

None of these improve the statistics for life expectancy but they improve immensely the quality of life of many of our patients.

However we should not lose sight of three things. First of all we must not let our obsession with technology blind ourselves to the indignities we may inflict upon our patients in the name of science.

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One of the great advances in technology in recent years is fluorescein angiography , the injection of dye into an arm followed by a barrage of photographs using a powerful repetitive flash directly into the eye. This is a very safe procedure but undoubtedly an ordeal for the patient. We should be satisfied before ordering such a test that its outcome may influence our treatment. In order to help ophthalmologists to make these important decisions, Dr Brian Wilson will at the invitation of our Council deliver a lecture this afternoon on fluorescein angiography - nothing for mad scientists, but for ordinary treating doctors like most of us here today.

As well as avoiding unnecessary indignities to our patients in the name of technology, we should also remain sceptical of so-called technical advances requiring, in the words of Trevor-Roper, “Even more finicky micro- manipulations, through machines which are so complicated that they often require a special technician like a mahout for each of their costly programmings between operations”.

We should also remember that some of the great leaps forward in the whole of medicine have been made by ophthalmologists without recourse to modern technology. Jonathan Hutchison did most of the work on congenital syphilis ; John Lockhart Gibson of Queensland did the same for lead poisoning; while Norman McAlister Gregg’s elucidation of rubella cataracts remains the greatest single discovery in modern times in handicaps of the new-born.

In ophthalmology we all realize that it is tempting and easy to use technical aids to examine a patient and only take a history if it is then thought necessary. They increase the risk that in the daily practice of our speciality we are more likely to fall short because of our failure to meticulously follow our general medical training than by failure to apply the latest technology.

We may manage without constant recourse to microsurgery, but inadequate history taking, inadequate communication and inadequate reassurance not only disappoint the patient

AUSTRALIAN JOURNAL OF OPHTHALMOLOGY

but blight the hope of each one of us to become another Gregg.

Lastly Mr Kennedy discusses the central problem of public accountability of monopol- istic professional groups. Last year Geoffrey Harley reminded us that Bernard Shaw wrote that a selfgoverning profession is a conspiracy against the laity, and Kennedy’s similar views have the advantage of following the current trends which wish to introduce consumerism into the doctor-patient relationship by setting standards, measuring performance and provid- ing sanctions by a Board or Committee which will hake consumer representatives.

Dr Conor Cruise O’Brien, the eminent editor of the London Observer newspaper, asks - how many people want political power over medicine extended? He continues “Opinion surveys show that people have much more respect for doctors than for politicians. Why then should people - the patients of doctors, the electors of the politicians - want power transferred from those whom they respect to others whom they respect much less?” This is not to say that doctors should not be criticised and we must be prepared to respond to criticisms, not with reflex rebuttals but with action.

The response of the Royal Australian College of Ophthalmologists to some of these criticisms has been to make even higher the high standards for entry into our branch of the medical profession. The doctors who receive their coveted diploma today bear witness to this standard of excellence. Our Qualification and Education Committee has also recently greatly expanded its activities to provide more con- tinuing medical education to all Fellows.

Expansion of surgical and medical audits and other forms of peer review, however boring and time consuming they may be, may prevent others from seeking to insist that we conform to standards and principles laid down by them. Unfortunately audits tend to occur in large teaching hospitals where there is already critical scrutiny by colleagues, trainees, medical students, nurses and administrators. Rather than seeing this criticism by our colleagues as interference with our liberty we should welcome it as a means of continually forcing us to be self-critical.

We must continually re-examine our relations with our own patients, but any abuse of medical power by the doctor can best be controlled by the individual informed patient who can exercise his privilege to ask for a second opinion or change his doctor. I believe that the great advantage of the referral system by the family doctor lies in its ability to constantly monitor our performance.

To this end we must not relax in our efforts to teach ophthalmology to medical under- graduates, to other doctors and through the media to the public as well as to ourselves, if we are to be seen to deserve to remain a self-regulating profession.

References 1. Kennedy I. The unmasking of medicine. London, Allen

and Unwin, 1981. 2. Tracy GD. Evolution of responsibilities in the care of

health. Med J Aust 1980; 2: 593. 3. Trevor-Roper P. Doyne Memorial Lecture; The noysome

cataract. Trans Ophthalmol SOC UK 1980; 100: 279-307. 4. Harley G. Presidential Address. Aust J Ophthalmol

1981 ; 9: 87. 5. Shaw GB. The doctors dilemma. London, Constable,

191 1 : xxii. 6. OBrien CC. Lawyer unmasks a doctors’ plot. Observer,

London, 15th Feb 1981 ; 9886: 13.

ADDRESS OF MARK HARRISON 89