believe that it is healthy and in the long run should ensure a greater degree of protection for the subjects of such studies. As an example, I have recently seen a proposal for a multicentre study that I believe had already been approved by several local research ethics committees. The proposal has, however, now been withdrawn because the objections of one local committee have made the research group rethink the whole project. I believe that the way forward at national level is for there to be a national association of ethics committees, which would meet once or twice annually. This would act as a forum for debate, which should lead eventually to a greater uniformity of approach, even if not of opinion, among local research ethics committees. The job of getting approval from ethics committees for multicentre trials should then become easier. ANTHONY P MADDEN

Sotithmead (Gcncral Hospital, Bristol BSIO) 5NB Various atuthors. Research ethics comnmittees. Br Vied J 1990;300:395-6. glIO February.)

SIR,-The survey of the composition and modus operandi of ethics committees in the United Kingdom' and the recent editorial2 identify a situation that is a cause of concern to all who participate in research on new medicines. One of the questions posed in the editorial was: "But what is the evidence that British laissez-faire has done any harm?" The examples quoted of inadequate protection afforded to subjects are certainly disquieting. There is another side to the variability of ethics committee processes that also may be detrimental. Our experience, based on sponsorship of clinical research on new drugs for treatment of patients with diseases of the central nervous system, suggests that some ethics committees may be restricting research on new medicines by inappropriate interpretation of their responsibility to protect patients. For example, one committee rejected a protocol on the grounds that subjects in a study population who fulfilled the diagnostic criteria for mania were not in a position to give informed consent, hence rendering the study unethical. This particular protocol was approved by the two major teaching hospital committees to which it was submitted. This is one example of a study in which full or legally recognisable informed consent, or both, may not be achievable; others can be cited across broad areas of neuropsychiatric research-for example, studies in patients with psychoses, stroke, and Alzheimer's disease. We would support the establishment of a national ethics committee to ensure that a standardised approach is adopted, particularly for sensitive topics in therapeutic research. Pharmaceutical companies could contribute to the monitoring process by reporting their experiences to such a committee. A RUSHTON G H MURRAY

M\edical Research Department, 1(1 Pharmacetuticals, Cheshire SKI() 4TG I Gilbert G, Fulford KWIM, I'arker C. D)iversitv in the practice of district ethics committees. Br Mlfed J 1989;299:1437-9.

(9 December.) 2 Lock S. Monitoring research ethics committees. Br Med 7

1990;300:61-2. (13 January.)

SIR,-It was precisely to meet the problems in multidistrict research in general practice described by Dr T W Meade that this college established a clinical trials ethics committee in 1981. Since then very many multidistrict protocols have been considered, and to the best of our knowledge

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the approval by our committee has never been questioned by a local ethics committee. When it was first established the committee, under the chairmanship of Sir Eric Scowen, was recognised by the medicines branch of the Department of Health and Social Security as a properly constituted committee for the purpose of the Exemptions from Licence (Clinical Trials) Order of 1981. While most of our work is concerned with protocols for trials, we now consider all forms of research carried out in general practice that include patients drawn from three or more districts. The constitution of the committee is as recommended by the Royal College of Physicians and has members nominated by that body, by the Royal College of Nurses, and by this college. Other members include professors of clinical pharmacology and moral philosophy, emeritus professors of sociology and economics, a lay member who is also a QC, and an eminent statistician. We do not, however, agree with Dr Meade that the opinions of a national committee such as ours should be binding on local ethics committees. There may be local considerations that are unknown to a central committee and should be considered; so we follow the policy of asking organisers to notify local committees of our decisions. We do not believe that this produces problems or causes delays. SIR MICHAEL DRURY Royal College of General P'ractitioners, LIondon SW17 IPU I

\Meade 'lW. Research ethics committees. BrMedJ 1990;300:396. ('10 Februarv.)

What is medically pointless? SIR, -In allowing doctors to stop artificially feeding an irreversibly comatose woman the Dutch courts have taken artificial feeding to be an essentially medical procedure, whose appropriateness is a matter of medical efficacy alone-uninfluenced by considerations of the quality of the patient's life.' Discussing this, Professor H J J Leenen argues that, in The Netherlands, the only legal way to end the life of a comatose patient is "to stop medical treatment when it has become medically pointless" and that most doctors and lawyers in The Netherlands would accept that in the case in question it was medically pointless to continue feeding. Presumably something is medically pointless when it cannot achieve the medical purpose intended. Suppose that the medical purpose of a certain drug is to reduce inflammation. Administering the drug becomes pointless if it proves ineffective, if the inflammation has already subsided, or if an allergic reaction vitiates its purpose. Deciding whether something is "medically pointless" means being clear about the medical purpose of the procedure in question. Furthermore, medical purposes may serve other non-medical goals. For instance, doctors are well placed to advise on overcoming certain forms of infertility. But if a patient is mistaken in believing that her route to fulfilment lies in having a child then tubal surgery will turn out to be pointless even if the operation succeeds. But, of course, it would not be medically pointless. What therefore is the medical point of feeding the irreversibly comatose patient? If nasogastric feeding of Mrs S is "medically pointless" it must be because the medical purpose of such treatment is taken to be an improvement in her quality of life while the nature of her coma seems to rule out such an improvement. But what sort of pointlessness is this? The medical point of nasogastric feeding is surely to keep her alive. In this it succeeds: it is not medically pointless at all. By contrast, it might be morally pointless. The Dutch courts sharply distinguish between

quality of life considerations and medical considerations. The appeal to the medically pointless is being used to establish this distinction. It is easy to see why: the quality of a patient's life is essentially a matter of moral judgment, which the courts and doctors wish (understandably) to avoid. The notion of the medically pointless gives such judgments a spurious scientific gloss. Of course, it might be morally right to withdraw feeding in this case. That is a view which may be taken and defended-but not by making confused or illicit appeal to medical considerations. What is really in question is not the medical pointlessness of feeding, but the moral pointlessness of Mrs S's continued life. I imagine that her husband is clear enough about this: no doubt the doctors and lawyers can become clear about it as well, but at the moment the notion of the "medically pointless" stands firmly in their way. MARTYN EVANS

Centre for Philosophy and Health Care, University College, Swansea SA2 8PP 1 Leenen HJJ. Coma patients in The Netherlands. Br Med J 1990;300:69. (13 January.)

Patients' right to know SIR,-Your editorial footnote to Dr Charles Essex's letter rightly points out that when things go wrong between doctors and patients failures in communication are often at the root of it.' Problems in communication and inadequate information are arguably the most frequent concerns expressed by patients when describing their consultations with doctors. Not surprisingly, doctors are generally considered poor and, more worryingly, reluctant communicators. Although the problem of communication is now being addressed by medical schools and postgraduate institutions, doctors continue to limit the amount of information they might reasonably give to patients (or, in paediatrics, to parents) in both verbal and written forms. Verbal information relating to a doctor's. assessment of patients in the outpatient clinic is usually given to a varying extent, but there is little evidence that the same, or further information, is given by doctors in written form. Other than in exceptional circumstances parents have the right to know my full assessment and advice on their child's problem and also have the right to question my understanding of the history and whether my plan of management given to the general practitioner is the same as that understood and expressed in the outpatient clinic. Accordingly, I have recently completed a pilot study of parents' reactions and responses to my practice of sending them copies of all correspondence relating to the care of their children as outpatients, most of which was letters sent to their family doctors. Along with a letter of explanation and a copy of the outpatient letter, I asked parents by questionnaire whether they found this practice helpful or unhelpful, whether it made them worried or less worried, and whether they wanted the practice to be repeated in future. They were also asked to discuss any concerns or misunderstandings with me by telephone or with their family doctor. Of 253 families who were sent copies in this way, replies were received from 224. Of these, 222 replied that the practice was helpful, that it made them less worried, and that they wanted it to be repeated. Two found it helpful and wished it to be repeated but had been worried by receiving a letter with a hospital franking mark until they read the contents. One family found it helpful and less worrying but did not wish it to be repeated. I received 27 telephone calls, mainly expressing interest and requesting clarification and further information. Three general practitioners were un-

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happy with the practice, mainly because they thought a consultant's opinion should be exclusive to them. With this practice I have not needed to change the content, nature, or sentiment of any letter I have wanted to write, perhaps because the content is only that which would have been fully discussed directly in the clinic, and I have not excluded any patient episodes or letters from this practice. Occasional discrepancies between verbal information as understood by families and that appearing in the letters have easily been resolved, with greater understanding on mine and, I believe, the family's part. The practice has been received enthusiastically by nearly all the families, and the only concern has come from some family doctors, as mentioned above, and from the hospital administration in respect of medicolegal implications. I think the practice is a step forward in altering the public's perception of the doctor's role in medicolegal aspects of practice. The approach is now standard practice for my patients. I accept that patients will frequently find medical language and jargon difficult to understand, and sending them copies of letters requires a willingness on the part of doctors to modify their style of letters and use of words. Nevertheless, the benefits of this practice greatly exceed the disadvantages and problems. After all, patients have the right to know what we are doing to them and for them, and why not in writing? GEORGE RYLANCE

Birmingham Children's Hospital, Birmingham B16 8ET I Essex C. Terminal careless. BrMed 71990;300:333. (3 February,.)

Impotence after prostatectomy SIR,-Minerva,' in referring to a method of prostatectomy described elsewhere,2 asks "Should patients concerned to preserve potency make sure that the surgery planned for them is of the low risk type?" The claim ofa reduced incidence of postoperative impotence warrants further scrutiny. The aetiology of impotence after transurethral prostatectomy has not been established but seems to be either psychological or neuropathic. Zohar et al3 in a prospective study, showed that the likelihood of impotence is related directly to the patient's level of anxiety and his ignorance of the operation and inversely to his general satisfaction with life. Preoperative counselling reduced the incidence of impotence after prostatectomy to zero, implying a psychogenic aetiology. This was subsequently supported by So et al, who showed no significant difference in recordings of nocturnal penile tumescence before and after transurethral resection.4 Furthermore, Bolt et al observed that the incidence of impotence after transurethral prostatectomy is higher in men who suffer from minor degrees of erection dysfunction before their operation.5 Evidence for a neuropathic aetiology is based on the exhaustive anatomical dissections performed by Walsh and Donker. The cavernosal nerves were shown to be very close to the apical part of the prostatic capsule and the distal prostatic urethra. Lue et al pointed out that in this position these nerves are vulnerable to damage during any form of prostatectomy.7 At a time when doubts have been raised over the perceived morbidity associated with the various methods of prostatectomy' any evidence that adds to that debate is to be welcomed. In their version of open prostatectomy Dixon and Lord have shown a seemingly effective method of relieving outflow obstruction without causing retrograde ejaculation.2 As they presented a retrospective survey of a limited number of patients,

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however, their claims to have reduced the risk of impotence are less tenable. This will remain so until either more is known about the aetiology or there are sufficient prospective comparative data available. H W GILBERT J C GINGELL

Andrology Research Unit, Southmead Hospital, Bristol BSI0 SNB I Anonymous. V'iews. Br.Med7 1990;300:134. (13 January.) 2 Dixon AR, Lord PH. Sexual functioning following prostatectomy: Can impotence and retrograde ejaculation be avoided? Sexual and Marital Therapy 1989;4:127-3 1. 3 Zohar J, Meiraz D, Maoz B, Durst N. Factors influencing sexual actisvity after prostatectomy: a prospective study _7 Urol 1976;116:332-4. 4 So EP, Ho PC, Bodenstab W, Parsons CL. Erectile impotence associated with transurethral prostatectomy. Urology 1982;19: 259-62. S Bolt JW, Evans C, Marshall VR. Sexual dysfunction after prostatectomy. BrJ Urol 1987;59:319-22. 6 Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into aetiology and prevention. J Urol

1982;128:492-7. 7 Lue TF, Zeineh SJ, Schmidt RA, Tanagho EA. Neuroanatomy of penile erection: its relevance to iatrogenic impotence. J Urol 1984;131:273-80. 8 Anonymous. TU or not TU [Editorial]. Lancet 1989;i: 1361-2.

Scuba divers with asthma SIR,-Drs P J S Farrell and P Glanvill in their survey of asthmatic scuba divers concluded that the Sub-Aqua Club's recommendations of not diving within 48 hours after any wheezing were adequate.' I assume that they mean adequate from the point of view of safety, but I do not support this. None of their subjects admitted to having had an asthma attack while diving. I suggest that their sample, which was drawn from people who answered an advertisement in Diver magazine, was highly biased as only those who do not experience problems with their asthma while diving will continue to dive and be interested enough to read the magazine. In support of this I have my own evidence, albeit anecdotal. I have extremely mild asthma, which manifests perhaps once every three years for a brief time during a respiratory tract infection. As I did not encounter any asthmatic symptoms during strenuous high altitude mountaineering I thought it would be reasonable to try scuba diving. I learnt to dive in a warm shallow swimming pool and experienced no difficulties during this or my first sea dive. During my first deep sea dive, however, I had an extremely severe and sudden attack of bronchospasm at a depth of 30 m. I barely made it to the surface, where my obvious distress and lack of speech caused my partner to inflate my life jacket, thus compromising my respiration further.. It was a frightening experience and I have not dived since. I wonder how many other prospective divers have had experiences like mine and have therefore given up diving? Those asthmatic divers who continue to dive successfully are obviously those who can tolerate the cold, dry, high pressure air and may constitute a small fraction of the total. J J MARTINDALE Leatherhead, Surrey KT24 5HE 1 Farrell PJS, Glanvill P. Diving practices of scuba divers with asthma. Br MedJ 1990;300:166. (20 January.)

SIR,-The article by Drs P J S Farrell and P Glanvill on the diving practices of scuba divers with asthma presents a disturbing picture of medical advice provided to divers, and the authors rightly conclude that divers should be examined by doctors with appropriate training. ' This problem is not unique to Britain. Similar difficulties were encountered in Australia by Edmonds.2

The conclusion reached by the authors (that the British Sub-Aqua Club recommendation-not to dive within 48 hours of wheezing-is safe) cannot, however, be justified on the basis of the data presented, is likely to be misinterpreted, and may lead to even more variation in the advice given to divers. Asthma is well recognised as a potential risk factor for pulmonary barotrauma, and the elements of asthma- bronchoconstriction, mucosal oedema, and mucus plugs-may impair the free flow of expanding gas out of the lungs on ascent. Asthma represents an absolute contraindication for commercial divers in the United Kingdom,' and doctors who dive adhere to the guidance provided by Davis: "Any patient with currently active bronchial asthma should be strictly forbidden to dive."4 Evidence that asthma is a risk is limited, but the Divers Alert Network in the United States is accumulating evidence that asthmatic people are overrepresented among those who have died owing to sport diving. Such evidence is based on a population of sport divers that is many times greater than that in Britain. Death due to diving may have several contributory causal factors, and in people with asthma the dangers of rapid or uncontrolled ascent must be magnified. It would be interesting to know whether the 12000 dives logged by the divers who were surveyed by Drs Farrell and Glanvill included episodes of rapid or uncontrolled ascent. Doctors who perform medical examinations on sport divers must not only understand the medical aspects of diving but also must ensure that divers are informed of the potential hazards associated with any condition from which they suffer. Doctors are not in a position to prevent anyone from diving, but if asthmatic people insist on diving they must be aware of the risk and some guidance such as that provided by the British Sub-Aqua Club may be appropriate as a measure to reduce the risk. The risk may be small, but that is not the same as saying that diving is safe for these people, and the difference could have important medicolegal connotations. STEPHEN J WATT WILLIAM J GUNNYEON

Offshore Medical Stopport, Aberdeen AB2 3NG I Farrell PJS, Glanvill P. Diving practices of scuba divers with asthma. BrMedJ 1990;300:166. (20 January.) 2 Edmonds C. The Mickev Mouse medical. Pressure 1986;15:6. 3 Health and Safet' Executive. IThe medical examination of divers. London: Health and Safety Executive, 1987. 4 Davis JC. Medical examination of sport scuba divers. San Antonio, Texas: Medical Seminars, 1986.

AUTHORS' REPLY, -It is unfortunate that the inadvertent substitution for "safe" by "reasonable" in the final sentence of our paper has probably contributed to the concern of Drs S J Watt and W J Gunnyeon. With regard to their letter we would like to make the following comments. Firstly, the reference to currently active asthma begs the question what is meant by this phrase. Can a person who has one or two episodes of bronchospasm a year be deemed to have current active asthma and hence be strictly forbidden to dive? If not, where should the line be drawn, by whom, and on what basis? Secondly, Drs Watt and Gunnyeon refer to the fact that the Divers Alert Network in the United States is accumulating evidence that people with asthma are overrepresented among those who die owing to sport diving. We note that the authors do not give any references to support this assertion; the percentage of asthmatic people in the United States diving population needs to be known before it can be stated categorically that asthmatic divers are overrepresented in fatality statistics. We agree that it would be interesting to know whether any of

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