1989. Can Med Assoc J 1991; 144 (7 [suppl]): 1-38 3. McGlynn EA, Kosecoff J, Brook RH: Format and conduct of consensus development conferences. Int J Technol Assess Health Care 1990; 6: 450-469 4. Skrabanek P: Nonsensus consensus. Lancet 1990; 335: 1446-1447
[The principal coauthors respond.] We thank Dr. Clarfield for the interesting insights regarding disagreement within consensus conferences. We applaud the CCCAD for their three-pronged approach to disagreement: democracy, dissent and delay. The CCCAD carefully provided safety valves to avoid the impression that unanimity of opinion was present when in fact it was not. The approach to rating levels of agreement among participants is similar to that of the Rand panels in rating the appropriateness of procedures.' With three dissenters the CCCAD did not reach "consensus" (the collective unanimity of opinion); rather, it followed a model for arriving at judgements that is similar to the model provided by the Supreme Court - that is, judgements are conveyed in conjunction with a vote count and majority and dissenting opinions. This model is clearly preferable to those that attempt to force the semblance of unanimity in the presence of uncertainty. Additional measures are needed to foster credible results. A wide range of opinion must be sought, heard and reported in order that the consensus conference not become a preordained emanation from a group of people who already agree, coming together to agree some more. Perhaps the alternative to "nonsensus or consensus"2 is to ban the term "consensus" in all such exercises and to recognize that when it is used it is automatically suspect. Whether clinicians pay attention to and use the results of more credible syntheses of opinion AUGUST 15,1992
about uncertain matters remains an open question. Finally, Clarfield takes issue with our point about the paucity of formal mechanisms for dealing with disagreement. That the CCCAD provides one such mechanism does not invalidate this statement. Hence, we cannot completely agree with Clarfield, but, when we do, we do so wholeheartedly. Antoni S.H. Basinski, MD, PhD, CCFP C. David Naylor, MD, DPhil, FRCPC Health Services Research Group Clinical Epidemiology Unit Sunnybrook Health Science Centre Toronto, Ont.
References 1. Park RE, Fink A, Brook RH et al: Physician ratings of appropriate indications for six medical and surgical procedures. Am J Public Health 1986; 76: 766-772 2. Oliver MF: Consensus or nonsensus conferences on coronary heart disease. Lancet 1985; 1: 1087-1089
Educating prisoners about AIDS s a
follow-up
to Susan
A TThome's article "Education the main weapon as prison officials defend against AIDS threat" (Can Med Assoc J 1992; 146: 573, 576-577, 580), I am pleased to inform CMAJ readers that effective Jan. 1, 1992, the Solicitor General of Canada permits the distribution of condoms to inmates of federal institutions to reduce the transmission of human immunodeficiency virus
(HIV).
Since late 1985 there have been only 15 confirmed cases of acquired immunodeficiency syndrome (AIDS) in prison inmates; 2 of these have died, 9 have been released, and 4 are currently incarcerated. However, 105 HIVinfected inmates have been identified, 50 of whom remain in federal institutions.
The Correctional Service of Canada (CSC) is working closely with the National AIDS Secretariat, Department of National Health and Welfare, to establish additional programs in education, management, prevention and treatment for people with AIDS. A new training program in infectious diseases has been developed for CSC staff, which will be delivered this year. We are also updating a videotape entitled AIDS in Prison to ensure that it reflects current knowledge and practice. Furthermore, we have been revising our policy on confidentiality so that it is consistent with the ethical standards of the Canadian medical community. In late 1991 a regional HIVAIDS advisory committee was established in the Ontario Region, CSC, to deal with AIDS. Its mandate encompasses a wide spectrum of activities focusing on education, prevention, counselling and support as well as research and links to the community. I look forward to providing further updated information as our programs develop. Jacques H. Roy, MD Director general Health care services Correctional Service of Canada Ottawa, Ont.
Medical Aid Foundation of Canada T n he Medical Aid Foundation of Canada appeals to readers of CMAJ and hospitals and their suppliers to contribute superfluous or used medical equipment and supplies for our world-wide relief efforts. Through volunteers the foundation, a 13-year-old charitable organization, initiates and supports international medical aid for people who are destitute and usually in remote areas of underprivileged nations. CAN MED ASSOC J 1992; 147 (4)
403
[The principal coauthors respond.] We thank Dr. Clarfield for the interesting insights regarding disagreement within consensus conferences. We applaud the CCCAD for their three-pronged approach to disagreement: democracy, dissent and delay. The CCCAD carefully provided safety valves to avoid the impression that unanimity of opinion was present when in fact it was not. The approach to rating levels of agreement among participants is similar to that of the Rand panels in rating the appropriateness of procedures.' With three dissenters the CCCAD did not reach "consensus" (the collective unanimity of opinion); rather, it followed a model for arriving at judgements that is similar to the model provided by the Supreme Court - that is, judgements are conveyed in conjunction with a vote count and majority and dissenting opinions. This model is clearly preferable to those that attempt to force the semblance of unanimity in the presence of uncertainty. Additional measures are needed to foster credible results. A wide range of opinion must be sought, heard and reported in order that the consensus conference not become a preordained emanation from a group of people who already agree, coming together to agree some more. Perhaps the alternative to "nonsensus or consensus"2 is to ban the term "consensus" in all such exercises and to recognize that when it is used it is automatically suspect. Whether clinicians pay attention to and use the results of more credible syntheses of opinion AUGUST 15,1992
about uncertain matters remains an open question. Finally, Clarfield takes issue with our point about the paucity of formal mechanisms for dealing with disagreement. That the CCCAD provides one such mechanism does not invalidate this statement. Hence, we cannot completely agree with Clarfield, but, when we do, we do so wholeheartedly. Antoni S.H. Basinski, MD, PhD, CCFP C. David Naylor, MD, DPhil, FRCPC Health Services Research Group Clinical Epidemiology Unit Sunnybrook Health Science Centre Toronto, Ont.
References 1. Park RE, Fink A, Brook RH et al: Physician ratings of appropriate indications for six medical and surgical procedures. Am J Public Health 1986; 76: 766-772 2. Oliver MF: Consensus or nonsensus conferences on coronary heart disease. Lancet 1985; 1: 1087-1089
Educating prisoners about AIDS s a
follow-up
to Susan
A TThome's article "Education the main weapon as prison officials defend against AIDS threat" (Can Med Assoc J 1992; 146: 573, 576-577, 580), I am pleased to inform CMAJ readers that effective Jan. 1, 1992, the Solicitor General of Canada permits the distribution of condoms to inmates of federal institutions to reduce the transmission of human immunodeficiency virus
(HIV).
Since late 1985 there have been only 15 confirmed cases of acquired immunodeficiency syndrome (AIDS) in prison inmates; 2 of these have died, 9 have been released, and 4 are currently incarcerated. However, 105 HIVinfected inmates have been identified, 50 of whom remain in federal institutions.
The Correctional Service of Canada (CSC) is working closely with the National AIDS Secretariat, Department of National Health and Welfare, to establish additional programs in education, management, prevention and treatment for people with AIDS. A new training program in infectious diseases has been developed for CSC staff, which will be delivered this year. We are also updating a videotape entitled AIDS in Prison to ensure that it reflects current knowledge and practice. Furthermore, we have been revising our policy on confidentiality so that it is consistent with the ethical standards of the Canadian medical community. In late 1991 a regional HIVAIDS advisory committee was established in the Ontario Region, CSC, to deal with AIDS. Its mandate encompasses a wide spectrum of activities focusing on education, prevention, counselling and support as well as research and links to the community. I look forward to providing further updated information as our programs develop. Jacques H. Roy, MD Director general Health care services Correctional Service of Canada Ottawa, Ont.
Medical Aid Foundation of Canada T n he Medical Aid Foundation of Canada appeals to readers of CMAJ and hospitals and their suppliers to contribute superfluous or used medical equipment and supplies for our world-wide relief efforts. Through volunteers the foundation, a 13-year-old charitable organization, initiates and supports international medical aid for people who are destitute and usually in remote areas of underprivileged nations. CAN MED ASSOC J 1992; 147 (4)
403
