Issue 1 / 20 January 2014

IT’S a new year, and chances are most of us have started it with good intentions.

But being “good” as a health care professional doesn’t happen in isolation: the framework we work within needs to support good practice and overall good health.

The lead story in MJA InSight this week provides an example of good practice impeded by an imperfect regulatory system. Earlier this month, the NSW deputy coroner handed down his recommendations from the inquest into the 2009 deaths of Nick Waterlow and Chloe Heuston, who died at the hands of a family member so severely affected by untreated paranoid schizophrenia that he was found not guilty of their murders by reason of mental illness.

The coroner’s report (which has not yet been made available online) provides detailed and compassionate insight into the frustrated attempts of family, doctors and other health care professionals to care for a man who clearly required antipsychotic therapy but could not be compelled to accept it under the current NSW Mental Health Act. A review of the Act is now underway, with the coroner’s recommended changes under consideration.

Another of our news stories raises questions about good obstetric practice. A study published in the MJA examining potentially avoidable retrieval of babies born in public and private hospitals without neonatal intensive care facilities has identified planned caesarean at <39 weeks gestation as being a frequent antecedent. While the findings appear robust, the study has ignited a debate on whether they are an indication of the quality of obstetric care delivered to these mothers and babies.

Good doctors sometimes have to be chameleons, inhabiting a patient’s world view in order to enhance the shared making of management decisions. But when this process conflicts with a doctor’s own strongly held beliefs, the situation can feel untenable.

The Medical Board of Australia makes provision for doctors who have a conscientious objection to certain treatments but clarity is lacking on its practical implementation. MJA InSight sought a brief comment from AMA president Steve Hambleton to highlight some of the advice in the AMA’s recently released position statement on this topic.

In Sydney, it’s been an unsettling start to the year, where stories of alcohol-fuelled violence have dominated the public discourse, after the death of yet another young man from a “coward’s punch” inflicted on New Year’s Eve.

In the midst of the widespread outrage, we have heard the voices of doctors who struggle daily to provide good medical care to people affected by this problem and public health experts who are frustrated that good research pointing the way forward is not being heeded.

The authors of a study of alcohol-related mortality in the Americas, published in Addiction this week and summarised in our “News in brief” section, points out that “a wealth of research worldwide has indicated consistently that restrictions on the availability of alcohol beverages, increased prices through taxation policies and marketing control are the most cost-effective interventions to reduce the harmful use of alcohol”.

Late last week NSW Premier Barry O’Farrell foreshadowed the imminent announcement of a “four pronged response” to the concerns about violence, which his government was in the process of “tailor-making”.

Let’s hope this response takes full account of the evidence and advice offered by Australian and international experts, so our good intentions for health in 2014 have some chance of being recognised.


Dr Ruth Armstrong is the medical editor of MJA InSight.

One thought on “Ruth Armstrong: How to be good …

  1. A/Prof Doug Fenton-Lee says:

    Dear Ruth

    I am one of the surgeons working at St Vincent’s Hospital who regularly has to attend those patients who are victims of alcohol-fuelled violence. I am not aware that the number of alcohol related incidents of violence has changed significantly. However, I believe the number of injuries related to the “king hit” is on the rise and that the patients reported to have died as a result of this practice are only the tip of the iceberg.

    The “king hit” has been around in Australia ever since I can remember: it used to be thought of as a despicable, cowardly act to punch an unsuspecting victim. The defence that the aggressor was under the influence of alcohol and not directly responsible for their actions is no excuse. Alcohol decreases inhibitions but the perpetrators of these acts of violence have shown that they have been able to select their victim, line them up and deliver a forceful and accurate punch to the head that results in the victim falling to the ground. Further injury results when they hit their head on the ground. I suggest that these aggressors are getting immense satisfaction from the felling of an innocent and unprepared bystander. The delivery of a punch to a prepared person is unlikely to fell him or her as some avoidance behaviour can be instigated.

    The public needs to be better educated regarding the higher risk of serious head injury from these unprovoked attacks.There is no doubt in my mind that a person who hits a person randomly without provocation should be charged with attempted manslaughter or murder




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