Feb 28, 1981 - the occasional howling inaccuracy. (Acceleration isn't the same as induction, Sister.) The film propagandised subtly, with hospital midwives.
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BRITISH MEDICAL JOURNAL
VOLUME 282
28 FEBRUARY 1981
Medicine and the Media
A FTER THE disastrously misleading Panorama programme on brain death screened last October the follow-up, A Question of Life or Death (BBC 1, 19 February), was awaited both with interest and with the hope that at least some of the
misconceptions promulgated would be corrected. The main issue examined was "when is a person dead ?" The Conference of Medical Royal Colleges' team of four doctors prepared a film which clarified the British Code of Practice and presented evidence which to informed viewers fully validated their claims. It became clear that the cases in which it was alleged that the code did not or would not work (most of them stemming from the weak and inadequately based American collaborative study) had either failed to satisfy the preconditions of the code or had not been subject to the high standards of neurological tests of brain stem death carried out in Britain. The opposition consisted of four doctors: three were primarily electrophysiologists not wholly committed to clinical neurology, and one was a neurosurgeon from Oslo. It was of interest that the BBC had had difficulty in recruiting a single British neurologist or neurosurgeon with full-time clinical responsibilities. The opposition film was well presented, and their objections were: firstly, that a diagnosis of death was allowed when only the brain stem was examined; and, secondly, that the criteria of death were not foolproof. Absent brain stem reflexes were recoverable up to 78 hours after apparent brain stem death, but this claim was based largely on American studies, where the primary precondition of a fatal cerebral lesion was not fulfilled in certain instances. The vexed question of persisting electroencephalographic (EEG) activity was hotly debated, but the opponents of the British code failed to provide their own criteria of what constitutes death. Are we to demand that every cell in the body is dead, or can we adopt Dr Pallis's definition of "permanent inability of a patient to recover consciousness, inability to breathe, and therefore inability to maintain a heart beat ?" The opposition failed to answer this question satisfactorily. The debate was skilfully arranged and was chaired in the calm and professional way that we have come to expect from Mr Ludovic Kennedy. In the final debate three main issues were discussed: does brain stem death inevitably mean death of the person ? can brain stem death be accurately diagnosed ? and are tests other than clinical signs of brain stem death needed ? The recent paper by Jennett and others (14 February, p 533) proves conclusively that when the British code is applied arrest of the heart beat follows inevitably within a few days. There were no exceptions to this rule, and the opinions of two distinguished American experts-Professor Fred Plum and Professor Bill Sweet-indicate that the American view is now swinging clearly in favour of the British Code of Practice. The discerning scientist was able to identify in this programme the many scientific weaknesses of the opposition's viewpoint, but unfortunately the layman will remain confused and concerned. The transplant issue applies to only a quarter of the cases under consideration and should not be exaggerated, and it was emphasised rightly that there is no urgency in diagnosing brain death in a potential transplant donor, and therefore no hurry in switching off life support systems. If this brain death debate aimed to resolve the uncertainties of the layman it probably failed, despite the scientific arguments put forward, which did validate the British Code of Practice. Some will feel that on purely humane grounds criteria should be added that
include repeated observations of brain stem death over a defined period of time. The EEG is unnecessary. Its use where available may add, however, to the confidence of relatives, whose peace of mind is more important in these circumstances than the stringent scientific criteria laid down. These minor revisions might lead to uniform acceptance by the profession and the public, which ultimately may settle this wholly unhappy issue. Whether a television debate is the right medium to ventilate this issue is another question. The non-medical friends with whom I have discussed the programme found the overall picture confusing, and, although it constituted an admirably organised medical debate, it has undoubtedly left many questions unanswered in the lay mind. It will be interesting to see the effect of this on the number of transplant donors, but contentious issues of this kind which do not fully resolve the doubts in the minds of the public should probably not be entertainment fodder for the media. Although the content and presentation of this programme was of a high order, it would not have been necessary had the original Panorama programme not taken place.-JOHN PEARCE, consultant neurologist, Hull.
THE GREAT brain death debate
was a most
interesting
piece of television, and as entertainment for the intellectual
it must rank with the famous prewar debates in the Oxford Union. As a vehicle to encourage public acceptance of the current criteria for the diagnosis of brain death it was, sadly, a failure, even though I believe that the evidence presented justified the status quo. Emotion, however, speaks louder than reason.
Let us first examine the main objection to the programme
design. As a formal debate it was staged and chaired with impartiality-indeed, viewed as a trial with a defence and prosecution, the same could be said. Lacking, however, were a judge to sum up and a jury to produce a verdict. Just as any legally unqualified jury will require direction on points of law, so will the medically unqualified require direction on technical points. Also, is this judicial balance fair in a discussion of a question such as brain death ? A case could be made for a party political broadcast system, where he who holds the support can claim the air time. Were this system to have been adopted the critics of the criteria would have been allotted a far smaller proportion of the programme to state their case and the public would not have concluded that medical opinion was evenly divided on the issue. With this major caveat, to which I return obliquely later, let us now examine the content of the debate and provide a summing-up. We saw first two short films, one from the Colleges' side (which I call the defence) and one from the criteria critics' side (the prosecution). These and points arising from them were then debated by the two sides. The defence produced a film heavy with fact and light on emotion. The prosecution's film, and, indeed, as it transpired its entire case, were nearer in style to a party political broadcast than a factual review. In places they verged on the hysterical. Many parts of the prosecution's evidence were simply a rehash of "facts" already refuted in the medical press. Strike one to the defence. It soon emerged that the prosecution had shifted its ground and was not going to justify the original programme. It concentrated on the contention that the cerebral cortex could be
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alive even if the brain stem were dead. The defence hammered at the unanswerable argument that, if the brain stem was thoroughly dead and vital functions could not be maintained, then the organism as a whole was effectively dead. How many parts of the organism had to be dead before the prosecution accepted that its whole was, they asked. The prosecution finally conceded that brain stem death did lead inexorably to cortical death and all they were worried about was the short interval when the brain stem was dead but the cortex wasn't. The defence demanded evidence in proof of this belief, pointing out that comatose patients who recovered remembered nothing. Rather foolishly the prosecution suggested that the onus was on the defence to disprove the hypothesis, which is of course impossible. Strike two to the defence. Next emerged the question of the EEG. The defence film quoted the Danish work that has led to the abandonment of the EEG there. The prosecution's case implied that British doctors were remiss in never having started to use the EEG, which of course is not the case. The debate following the second two films was a walkover, marred as it was for the prosecution by their dramatic introduction of new and unpublished "evidence" which took the defence completely by surprise. Given that the columns of the medical press had for weeks been full of requests for publication of such evidence and that no such publication had appeared this was indeed an irresponsible move aimed, it appeared, at sensation and seemingly with little regard for scientific accuracy. The prosecution continued to sing the praises of the flat EEG in confirming cortical death and again raked over the details of the collaboration study. The defence countered that this study would not stand rigorous scientific examination, and sharp ears may have heard that the criteria for apnoea were altered halfway through. This admission, from a member of the prosecution team actually involved in the study, was a damaging blow to their case. The defence obviously missed this admission, but pressed on with counter questions, pointing out that a flat EEG did not exclude deep activity in the cortex or cerebellum and thus that the prosecution to be logical would have to drill holes in the skull and sample the deep layers. As for four-vessel angiography there was again no reply to the defence contention that this technique, in a patient with a severely compromised brain stem, could itself be lethal. Strike three to the defence. Thus the debate was drawn to a close and one was left with the impression that the differences between the two sides related only to a short period of time, following confirmed brain stem death, when parts of the cortex might be alive and aware. That the use of an EEG can solve this metaphysical dilemma is conceptual nonsense. If the EEG is flat it does not exclude cortical activity. It is as futile to prolong the discussion as it is to argue whether the head of a criminal is aware after it has been guillotined. The prosecution tried to climb out of the pit of logic into which its arguments had led it by insisting that the tests of brain stem death should be repeated and that the Code of Practice did not require repetition. In fact the code says that the interval between tests must depend on the primary pathology and clinical course of the patient's condition. So again there is no argument. It is presumably clear from this piece where my initial symphathies lay, but even when trying to lay these aside and make a judgment on the trial in the BBC courtroom I concluded that the prosecution case had failed and the defence had scored a resounding victory. Having arrived at this conclusion I return to the subject of the programme's design. What an opportunity was lost in not asking a medical studio audience to contribute to the debate and then to vote. Only then would the emotion and the technicalities have been stripped away and the public reassured by an informed decision. This would have gone a long way to reinforcing the fact that doubters of the criteria are a small minority within the medical profession and that, in the
main, their doubts have little in the way of hard facts to back them up.-ANDREW BAMJI, senior registrar in rheumatology, the Middlesex Hospital. THE caring going out of childbirth ?" asked Radio Times, "ISand Horizon's "Who Will Deliver Your Baby?" (BBC2, 16 February) examined the role of the midwife-a subject crying out for analysis as maternity services become more doctor-orientated and midwifery becomes demoralised. Christopher Riley's script chose the anecdotal approach-more photogenic than boring old facts and figures-and followed the late pregnancies of three London women, all delivered by midwives and all happy with the result. Jacky, a middle-class parous woman, had a home delivery and said, "It was perfect." Ruth, a primigravida under hospital care, had premature rupture of the membranes: not surprisingly her labour was the trickiest of the three, but the programme implied that her dextrose drip, Syntocinon, analgesia, and ever-so-slightly-flat baby were the result of the hospital's approach rather than her obstetric problem. Ruth's labour was directly contrasted with that of Carol, a parous woman looked after under a general practitioner scheme by Sister Wilmot, a community midwife. Sister Wilmot was the star of the show, a television natural apparently permanently on call; her missionary's smile was a wonderful advertisement for midwifery and compensated for the occasional howling inaccuracy. (Acceleration isn't the same as induction, Sister.) The film propagandised subtly, with hospital midwives positioned like Star Trek characters in front of banks of machinery, and the hospital delivery photographed from a low angle with harsh sound-mixing. The narrator kept putting the word "doctor" into verbal quotation marks. Riley contented himself with the role of illustrator rather than informer: he did not discuss the reasons for the run-down of domiciliary midwifery, or its risks. He contrasted an idealised community midwife delivery with a less-than-straightforward hospital delivery. How many Sister Wilmots would be needed for Islington's 5000 deliveries each year ? Such matters were judged too complicated for Horizon's audience. Amid swipes at many aspects of obstetrics-from overcrowded clinics to episiotomies-the film hit its intended target a few glancing blows. Mrs Renee Short's Social Services Committee has considered the problems of midwives, and this programme put over the message that midwives are unhappy and publicised the Government's failure to act on Mrs Short's report.JAMES OWEN DRIFE, lecturer in obstetrics and gynaecology, Bristol.
its contribution to the International Year of Disabled People the Royal National Institute for the Blind has produced a guide to the services and opportunities available for the newly blind. Information for people who are losing their sight covers visiting the doctor when sight first begins to fade, education and employment opportunities for blind and partially sighted people, rehabilitation services, and help for those who are both blind and deaf. As well as describing some of the more usual jobs that blind people do the booklet also gives the firm advice that no one working in business or a profession should resign until he has talked to one of the RNIB's specialist officers. Indeed, it describes clearly the services provided by the RNIB to complement those provided by statutory authorities. While the guide is not a detailed account of how to obtain the various services it does provide an overall picture of the scope of help available and tells the reader who to get in touch with. It is available free (but please enclose a stamped, addressed envelope) from the RNIB, 224 Great Portland Street, London WIN 6AA. -JANE SMITH, staff editor, BM7.
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