Letters · Correspondance

CMAJ 1999;161:685-8

• A morally irrelevant distinction on euthanasia D. Gorman
• Following the rules in marketing D.J. Stern; M.J. Elston response: J. Lexchin
• Unconventional therapies and cancer M. Bégin, E. Kaegi
• Driving for safety on our roads M. Lertzman, S. Sharma response: S.C. Marshall
• Moon over Surrey A. Walter

I have tremendous respect for people like Peter Lovrics, who frequently treats severely ill patients in the last stages of life. However, his argument against euthanasia (letter)¹ — both active and passive — is founded on a misunderstanding of passive euthanasia as it relates to palliative care. He states that the "distinction between good palliative care and euthanasia (active or passive) ... is clear and important." He then argues that "good palliative care makes euthanasia ... unnecessary." Thus, he presents palliative care as a preferred third option that is inconsistent with passive as well as active euthanasia.

No humane person could be against the provision of good palliative care. All patients who are suffering deserve the highest standard of palliative care possible, and they should never be deprived of this when it has been decided to withhold or withdraw curative or supportive treatment. But palliative care and passive euthanasia are not mutually exclusive alternatives. Lovrics writes that he has been in the "difficult situation of withholding or withdrawing care to allow death on numerous occasions." This, of course, is the very definition of passive euthanasia. Palliative care is care that helps minimize pain and suffering, and it is especially important in the context of passive euthanasia.

Many people do not like the term passive euthanasia, probably because they associate the word euthanasia with active euthanasia, which they do not support. The argument I presented in my essay (full article)² is that virtually everyone already supports passive euthanasia — regardless of what they prefer to call it — and that, in certain circumstances, the distinction between passive and active euthanasia is morally irrelevant. When our efforts to relieve suffering with palliative care fail, active euthanasia may be morally permissible and even preferred over passive euthanasia, for it ends the suffering more quickly.

Lovrics believes that the cases I mentioned in my essay "show the importance of continued medical education, awareness and proper training [in palliative care]." I agree. I also think that these cases remind us that palliative care is not only "hard to do well" but also sometimes impossible to do well. When we cannot, despite our best efforts, adequately control the suffering of terminally ill patients who want to die, active euthanasia may be a means to respect their autonomy and relieve their distress.

Daniel Gorman, MD
New York, NY

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1. Lovrics P. Euthanasia's never an answer [letter]. CMAJ 1999;161(1):18-20.
2. Gorman D. Active and passive euthanasia: the cases of Drs. Claudio Alberto de la Rocha and Nancy Morrison. CMAJ 1999;160(6):857-60.

[Contents]

I am glad that Joel Lexchin is looking after the moral well-being of the CMA and the Pharmaceutical Manufacturers Association of Canada (letter).¹

Without his careful scrutiny I have no doubt we would all descend into a veritable trough of corruption and lose what little self-respect we still have.

Dennis J. Stern, MB BS
Parry Sound, Ont.

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1. Lexchin J. PMAC Code of Marketing Practices [letter]. CMAJ 1999;160(11):1556.

In his recent letter to the editor¹ Joel Lexchin alludes to the mechanism by which Canada's Research-Based Pharmaceutical Companies (CRBPC), formerly the Pharmaceutical Manufacturers Association of Canada, enforces its Code of Marketing Practices, and he provides "2 recent examples" of ways in which "physicians and drug companies sometimes break the guidelines of their respective organizations."

Through his familiarity with our code, Lexchin is well aware of Section 12 (Enforcement), which provides for the adjudication, by our Marketing Practices Review Committee, of allegations of infractions of the code. Such allegations, supported by documented evidence, can be brought forward by an individual or organization encountering what they believe to be inappropriate behaviour in terms of our marketing code. In his letter Lexchin implies that he is in possession of such evidence, yet he did not see fit to bring the matters to the attention of the CRBPC.

One can understand why he did not bring the evidence to the attention of the CMA, since that organization's policy summary on physicians and the pharmaceutical industry² does not provide for an enforcement mechanism. However, Lexchin's concern about the possible loss of the trust of the public and professions should have at least motivated him to bring the "examples" to our attention, particularly in view of the fact that our Marketing Practices Review Committee includes representation from the medical community, a fact of which Lexchin is also aware. Had he done so, he would have been helping to serve the best interests of his own constituency and would not have fallen into the category of those "health professionals [who did not bother] to complain."

Murray J. Elston
President
Canada's Research-Based Pharmaceutical Companies
Ottawa, Ont.

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1. Lexchin J. PMAC Code of Marketing Practices [letter]. CMAJ 1999;160(11):1556.
2. Canadian Medical Association. Physicians and the pharmaceutical industry (update 1994) [policy summary]. CMAJ 1994;150(2):256A-256F. [MEDLINE]

Murray Elston asks why I did not submit a complaint about the alleged violations that I reported in my letter. In order to engage in the complaints process, one must have some confidence in the system. The process used by the CRBPC does not inspire confidence. Recently a colleague filed a complaint about a company that allegedly had paid accommodation expenses for doctors attending a meeting in southern Ontario. The response of the CRBPC's Marketing Practices Review Committee was that the documentation provided did not support the allegation. Apparently the committee had not even bothered to ask the company if it had paid the hotel expenses.

Suppose that I had filed a complaint and it was upheld. What would the consequences have been? As I have previously documented (abstract / résumé),¹ the CRBPC's reporting procedure on enforcement of its code is markedly nontransparent. No information would be given about who filed the complaint, when the complaint was made, when the violation took place, the product involved, the exact nature of the offense, the reasons why the complaint was upheld or the sanctions imposed. All that would appear in Update, the relatively obscure industry newsletter, is the name of the company and the section of the code that was violated.

Public reporting on all aspects of complaints and violations is critical for a number of reasons. First, it is an important accountability mechanism. Second, it should be considered an integral part of any sanctions against companies. Companies have an incentive to maintain compliance with a code and avoid adverse publicity and a possible deterioration in their public image. Third, public reporting is a good way to inform health care professionals about the existence of a code and its requirements. Above all, it is essential for informing health care professionals about misleading claims to which they have been exposed.²

Joel Lexchin, MSc, MD
University of Toronto
Toronto, Ont.

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1. Lexchin J. Enforcement of codes governing pharmaceutical promotion: What happens when companies breach advertising guidelines? CMAJ 1997;156(3):351-7.
2. Regulation of prescription drug promotion in Australia. MaLAM Aust News 1996;4(4/5):1-8.

In their recent letter, David Warr and Ian Tannock question the conclusion that evidence concerning the efficacy of hydrazine sulfate in the management of cancer is "uncertain."¹ They argue that the presence of 3 negative double-blind randomized trials published in peer-
reviewed journals should lead to only one reasonable verdict: ineffective. Finally, they conclude that the reviewers who compiled the information used in the articles did not use conventional rules for ranking evidence.

We would like to assure them that the reviewers (including one of us), as well as the Management Committee of the Canadian Breast Cancer Research Initiative (CBCRI), which commissioned the original reviews, are very aware of the importance of well-designed randomized controlled trials in generating reliable and generalizable research findings. However, the use of a randomized controlled trial design does not automatically confer credibility on research findings. Equally, the publication of a study in a peer-reviewed journal may add weight to the evidence, but it does not mean that readers should suspend their own judgement about the quality of the study.^2,3

Our review of the hydrazine sulfate trials raised concerns about the selection of study subjects, the application of the intervention, the presence of confounders and the analysis of the outcomes. These concerns were reinforced by our review of additional material pertaining to an investigation into the conduct of the hydrazine sulfate trials, which was being carried out by the US General Accounting Office. On the basis of that material, it was entirely reasonable to conclude that the evidence for and against the efficacy of hydrazine sulfate was uncertain.⁴

The CBCRI is a partnership of several organizations, including the Medical Research Council of Canada and Health Canada. Although it is independent from each of these partners, it benefits from their expertise and operates to the same high standards. The CBCRI embarked on its review of some alternative therapies following discussions of its Management Committee. This committee monitored the preparation of bibliographies and acknowledged the expertise, effort and care brought to the difficult task of reviewing the available data. The CBCRI considers that the resulting annotated bibliographies, as well as the summaries produced for CMAJ,^4­9 have proved helpful to researchers, clinicians and patients. It remains committed to supporting high-quality research into a broad range of issues that face breast cancer patients and the cancer-control community. It does this through a process of open-minded, rigorous and fair general competition for research funds, and through a small number of carefully selected targeted activities.

The CBCRI is pleased to stand by its record.

Monique Bégin, PC
Chair, CBCRI Management Committee, 1995­1999
Ottawa, Ont.
Elizabeth Kaegi, MB ChB, MSc
Director, Medical Affairs and Cancer Control, 1993­1996
National Cancer Institute of Canada and Canadian Cancer Society
Toronto, Ont.

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1. Warr DG, Tannock IF. Alternative views on alternative therapies [letter]. CMAJ 1999;160(12):1698-9.
2. Greenhalgh T. How to read a paper — the basics of evidence based medicine. London: BMJ Publishing Group; 1997.
3. Elwood JM. Critical appraisal of epidemiological studies and clinical trials. 2nd ed. Oxford: Oxford University Press; 1998.
4. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 4. Hydrazine sulfate. CMAJ 1998;158(10):1327-30.
5. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 1. Essiac. CMAJ 1998;158(7):897-902.
6. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 2. Green tea. CMAJ 1998;158(8):1033-5.
7. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 3. Iscador. CMAJ 1998;158(9):1157-9.
8. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 5. Vitamins A, C and E. CMAJ 1998;158(11):1483-8.
9. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 6. 714-X. CMAJ 1998;158(12):1621-4.

[Contents]

The questionnaire used by Shawn Marshall and Nathalie Gilbert to assess the knowledge of Saskatchewan physicians of risk factors related to medical fitness to drive (full article)¹ has 2 significant omissions.

First, it is well documented that patients with sleep disorders have more motor vehicle accidents than control groups. The prevalence of obstructive sleep apnea in the North American population is between 2% and 4% and increases with age.² The odds ratios for vehicular accidents have been reported as 1.5­4,³ 2.99,⁴ and 7.3.⁵ Furthermore, the accident rate decreases significantly when patients are treated with nasal continuous positive air pressure (CPAP) therapy (from 0.8 to 0.15 per 100 000 km).⁶

Second, epilepsy should have been considered. There is certainly abundant information on this subject, including recommendations regarding fitness to drive.⁷

Morley Lertzman, MD
Satyendra Sharma, MD
Section of Respiratory Medicine
University of Manitoba
Winnipeg, Man.

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1. Marshall SC, Gilbert N. Saskatchewan physicians' attitudes and knowledge regarding assessment of medical fitness to drive. CMAJ 1999;160(12):1701-4. [MEDLINE]
2. Lertzman M, Wali SO, Kryger M. Sleep apnea a risk factor for poor driving [letter]. CMAJ 1995;153(8):1063. [MEDLINE]
3. Aldrich MS. Automobile accidents in patients with sleep disorders. Sleep 1989;12:487-94. [MEDLINE]
4. Wu H, Yan-Go F. Self-reported automobile accidents involving patients with obstructive sleep apnea. Neurology 1996;46:1254-7. [MEDLINE]
5. Young T, Blustein J, Finn L, Palta M. Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults. Sleep 1997;20:608-13. [MEDLINE]
6. Cassel W, Ploch T, Becker C, Dugnus D, Peter JH, von Wichert P. Risk of traffic accidents in patients with sleep-disordered breathing: reduction with nasal CPAP. Eur Respir J 1996;9:2606-11. [MEDLINE]
7. Fauci AS, Braunwald E, Isselbacher Kj, Wilson JD, Martin JB, Kasper DL, et al. Harrison's principles of internal medicine. New York: McGraw-Hill; 1998. p. 2324.

Medical fitness to drive can be affected by many impairments, both physical and psychological. We conducted our survey via written questionnaire and therefore there were limitations on the number and types of questions that could be asked. In fact, we did not directly address a number of important impairments in this survey, including epilepsy, dementia, traumatic brain injury and alcoholism, each of which is well known to affect driving.^1­11 Sleep apnea is also known to affect crash rates.^12­14 In particular, we did not include epilepsy, one of the most common reasons to report impairment regarding fitness to drive, because driving restrictions for epilepsy vary among Canadian provinces and American states and we felt that the respondents' answers may have been confounded because of these differences.¹⁵

We used multiple-choice questions in our survey, a format that has been shown to be the best for sampling a large body of knowledge.¹⁶ We believe that our study reflects the knowledge and attitudes of the respondents.

Shawn C. Marshall, MD
Division of Physical Medicine and Rehabilitation
University of Ottawa
Ottawa, Ont.

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1. McLachlan RS, Jones MW. Epilepsy and driving: a survey of Canadian neurologists. Can J Neurol Sci 1997;24:345-9. [MEDLINE]
2. Fisher RS, Parsonage M, Beaussart M, Bladin P, Masland R, Sonnen AE, et al. Epilepsy and driving: an international perspective. Joint Commission on Drivers' Licensing of the International Bureau for Epilepsy and the International League Against Epilepsy. Epilepsia 1994;35:675-84. [MEDLINE]
3. Priddy DA, Johnson P, Lam CS. Driving after a severe head injury. Brain Inj 1990;4:267-72. [MEDLINE]
4. Van Zomeren AH, Brouwer WH, Minderhoud JM. Acquired brain damage and driving: a review. Arch Phys Med Rehabil 1987;68:697-705. [MEDLINE]
5. Van Zomeren AH, Brouwer WH, Rothengatter JA, Snoek JW. Fitness to drive a car after recovery from a severe head injury. Arch Phys Med Rehabil 1988;69:90-6. [MEDLINE]
6. Reuben DB, St George P. Driving and dementia: California's approach to a medical and policy dilemma. West J Med 1996;164:111-21. [MEDLINE]
7. Trobe JD, Waller PF, Cook-Flannagan CA, Teshima SM, Bieliauskas LA. Crashes and violations among drivers with Alzheimer disease. Arch Neurol 1996;53:411-6. [MEDLINE]
8. Drachman DA, Swearer JM. Driving and Alzheimer's disease: the risk of crashes [published erratum appears in Neurology 1994;44:4]. Neurology 1993;43:2448-56. [MEDLINE]
9. O'Neill D, Neubauer K, Boyle M, Gerrard J, Surmon D, Wilcock GK. Dementia and driving. J R Soc Med 1992;85:199-202. [MEDLINE]
10. Friedland RP, Koss E, Kumar A, Gaine S, Metzler D, Haxby JV, Moore A. Motor vehicle crashes in dementia of the Alzheimer type. Ann Neurol 1988;24:782-6. [MEDLINE]
11. Kaszniak AW, Keyl PM, Albert MS. Dementia and the older driver. Hum Factors 1991;33:527-37. [MEDLINE]
12. American Thoracic Society. Sleep apnea, sleepiness, and driving risk. Am J Respir Crit Care Med 1994;150(5 pt 1):1463-73. [MEDLINE]
13. Findley LJ, Unverzagt ME, Suratt PM. Automobile accidents involving patients with obstructive sleep apnea. Am Rev Respir Dis 1988;138:337-40. [MEDLINE]
14. Wu H, Yan-Go F. Self-reported automobile accidents involving patients with obstructive sleep apnea. Neurology 1996;46:1254-7. [MEDLINE]
15. Petrucelli E, Malinowski M. Status of medical review in driver licensing: policies, programs and standards. Springfield (VA): US Department of Transportation, National Highway Traffic Safety Administration; 1992. Report no DOT HS 807 892. p. 1.
16. Gray J. Primer on resident evaluation. Ann R Coll Physician Surg Can 1996;29:91-4.

Nancy Hotte's letter¹ concerning a new method for prostate examination confirms that the conventional digital rectal examination with the patient in the left lateral position involves an awkward contortion of arm and hand for right-handed physicians. A left-handed doctor probably has no difficulty with this position.

For several years I have been using a method in which the examiner remains seated and the patient stands, assuming the "moon" position. The patient faces away from the examiner and bends over to 90°, with his hands on a chair. Alternatively, the patient may stand flexed to 90°, with his chest on the examining couch. In this position both right- and left-handed physicians have ease of access to the prostate gland. I find that I can palpate further up the prostate when I examine in this manner. The posterior rectal wall is examined by changing the hand from the prone to the supine position. The examiner may wish to stand at this point.

Anthony Walter, MB BCh
Surrey, BC

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1. Hotte N. New method for prostate exam [letter]. CMAJ 1999;160(12):1697.