Hora de verdad

Moments of truth

Jane Smith, deputy editor, BMJ

jsmith@bmj.com

The "ethics" strand that runs through this week’s BMJ starts with Nicholas Wright’s editorial on whether or not autistic enterocolitis is a real condition (doi:10.1136/bmj.c1807). He is commenting on Brian Deer’s dissection of the histopathological findings in the now-retracted Lancet paper on autism and the MMR vaccine (doi:10.1136/bmj.c1127). With the paper discredited and the original biopsy specimens not available, Wright concludes that it is hard to tell whether the condition exists: he relies on time to resolve the question, but he also reminds us that coauthorship "means bearing responsibility for what is written."

Silvio Garattini and Vittorio Bertele’ think that responsibility and accountability in drug regulation are best fostered by transparency, and they argue in their Analysis article that the move of the European Medicines Agency from the EU’s Industry Directorate to the Directorate for Health is just the opportunity for the EMA to become more transparent (doi:10.1136/bmj.c1578). The data they want to see are not commercially confidential, they say; patients and taxpayers have contributed to the data, and transparency is a means of reducing bias and improving accountability. They include a revealing little table showing that the types of data the EMA so carefully guards are routinely available from the FDA.

Such "moments of truth" are explored by Daniel Sokol in his Observations piece. The term comes from bullfighting—"hora de verdad"—the moment when the matador places his sword for the kill, when he is put to the test, and Sokol uses it to explore how individuals can prepare for that moment (doi:10.1136/bmj.c1992). Some preparation is practical, honing technical skills, but some lies in developing and exercising virtues such as courage, kindness, and wisdom. The "virtue theorists" think the focus of medical ethics should be on fostering the virtues that will help clinicians in their moments of truth—and Sokol thinks that such fostering is done in wards and surgeries: "repeated, realistic exposure is the key to good ethical training."

If that’s so then the clinicians at Great Ormond Street must get lots of practice. Sophie Cook reviews three BBC2 documentaries set in the hospital that look at the difficult decisions parents and doctors have to make when confronted with seriously ill children (doi:10.1136/bmj.c1934). Great Ormond Street’s high renown means that parents turn up with high expectations, which cannot always be met. The programmes show, through following individual patients and their doctors, how "parents will desperately fight for their children to be treated and the ethical dilemmas that this poses to health professionals who often disagree that further invasive treatment is in the child’s best interest."

These programmes show doctors and patients talking intensely about things that matter, but Emma Hall’s complaint is that she cannot get clinicians to engage in discussion. In her personal view she describes how she has tried to get patients together with researchers and clinicians (under the auspices of the James Lind Alliance) to define the key research questions for prostate cancer (doi:10.1136/bmj.c1845). Firstly, the patients couldn’t understand what the researchers were saying, so she tried to get consensus between patients and clinicians. At the first meeting 30 patients turned up—and only one clinician. "We set out to make our project an equal partnership between patients and clinicians but clinicians won’t come to the party...Do you just not like us treading on your turf?"

Is Britain’s forthcoming election a moment of truth? James Owen Drife doesn’t think so (doi:10.1136/bmj.c2006). In his tribute to the two "Black knights"—James Black (the inventor of β blockers, whose obituary appears this week, doi:10.1136/bmj.c1817) and Douglas Black (author of the Black report on social inequalities, who died in 2002)—he contrasts the recent arguments about health care in the US with those the UK: "There, unlike here, you could see some substance underneath the spin." Next week we’ll be covering the health issues of the election—and looking hard for the substance.

Cite this as: BMJ 2010;340:c2042