effects.’ Co-trimoxazole is used to treat Pneumocystis carinii infections, in dosages of up to eight tablets per day; the laxative components of these tablets may exacerbate the chronic diarrhoea, nausea, and vomiting in people with AIDS. I urge practitioners who treat AIDS patients to inform themselves about the fillers of all drugs they prescribe since the problem may not be limited to this one generic antimicrobial.
attitudes, and ultimately behaviours. In many arenas of human affairs we need to redefine the unacceptable. Among those items in need of review, I wish to emphasise the impact of individual healthcare on the wellbeing of the planet. Most physicians seem pathologically focused on individuals, while ignoring the larger whole upon which we all depend. Meanwhile the profession is increasingly dominated by methods that are resource depleting, toxic, and otherwise environmentally (not to mention socially and economically) degrading. Human lives may be saved for the moment, but in the longer run our planet’s capacity to support healthy life is further reduced. In a way, healthcare begets illness, and a vicious cycle is made. We must always consider the balance between care of the individual and care of Earth. This goes beyond conventional notions of economic cost-effectiveness. It will not be easy; soon we may have no choice in the matter. At the very least we can encourage our colleagues, patients, and politicians to think carefully about the ecological costs of healthcare. And when will The Lancet be printed with soy-based ink on recycled, chlorine-free paper?
Janice L Guidotti
1 Goodman and Gilman’s the pharmacological basis of therapeutics, 8th ed. New York: Macmillan, 1993.
Laxative components of
recently found out that Mutual (Philadelphia, Pennsylvania, USA), a manufacturer of generic cotrimoxazole DS, was using docusate sodium and magnesium stearate as fillers in these tablets. Unfortunately, in the USA, the only way a consumer or physician can learn what fillers and excipients a generic-drug manufacturer is adding to a product is to call the manufacturer. In this instance, the manufacturer refused to disclose to me the quantities used, on the ground that this was a proprietary secret. Both docusate sodium and magnesium stearate have laxative SiR-I
Redefining the unacceptable.
Lancet 1995; 346: 1642-43.
Commercialisation of medicine Pandora and the problem of evil SiR-You are right, there will be no rush to provide research funds for inquiries into the nature of evil this year. Most scientists will not make the fundamental mistake that you make (Jan 6, p 17)’about the concept. You say that to deny the existence of evil is scientifically arrogant. But in what sense can evil exist? It is a term of judgment, the subjective assessment of a human being about something he or she abhors. That is perfectly legitimate and common parlance. Clearly such a subjective, abstract notion does not exist in the same sense that Symbion pandora exists. Nor does it exist in the sense that a chromosome exists, or a toxin exists. It may be true that the complex social thinking animal Homo sapiens cannot function without the use of the concept of evil, but that is quite another matter. You have written a bad editorial. However hard I search in the ink and paper of The Lancet, I will not find that badness. Many people define evil (or wickedness) as the absence of good.2 Are you seriously implying that we should look into brain tissues for a cell, or a chemical, or a circuit that could be defined as goodness, and that we could find other brains that did not have this entity? John Gunn Department of Forensic Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK
1 Editorial. Pandora and the problem of evil. Lancet 1996; 347: 1. 2 Midgley M. Wickedness. London: Routledge & Kegan Paul, 1984.
SIR-The commentary by Last (Dec 23/30, p 1642)’ reminds us that human activities are having extremely detrimental effects on the biosphere. Examples are numerous, sometimes painfully obvious (but often subtle and insidious), and may have permanent consequences (such as species extinctions). The solutions, as he rightly points out, will require fundamental changes in our values,
SiR-Gordon’s report (Jan 20, p 139)’ raises issues that can be applied to the USA, UK, and elsewhere. One important cause of the skyrocketing cost of medical care is the commercialisation of medical practice.2 Gordon states that the Ontario minister of health "accused the profession of financially motivated systematic fraud, as well as substantial clinically unnecessary overutilisation". In the USA, the institution of "managed care" has moved the control of medical practice to corporations, where very large salaries of the board and management and earnings for shareholders are achieved through much reduced care for patients in need.3 The various financial schemes in the UK (fund-holding, have been competition between teaching hospitals, &c) reported to have similar consequences for patients. Many of the managed care organisations in the USA are set up by physicians who, after a few years, profitably sell their companies to major health-care corporations. Even before the onset of managed care trends, Blue Cross/Blue Shield and Medicare had no way to ascertain faulty, unnecessary, and erroneous billing. When examples were pointed out to their administrators, they suggested private litigation. For Gordon to suggest that the profession in Ontario was "astounded by a blatantly anti-medical broadside" from the province’s health minister is disingenuous. At last, a true word was spoken by a politician and, of course, the culprits
object. Medical people are as susceptible to motivation by greed and ruthlessness as other individuals in society. The pure fee-for-service system has been, and continues to be, a failure. When will this necessary insight be gained in the USA and elsewhere? Frederick Wolff USA
George Washington University, School of Medicine, Washington, DC,
Gordon M. Government assault on Canada’s physicians. Lancet 1996; 347: 137. Wolff FW. Fraud in medical science. Lancet 1995; 346: 378. Larson E. What your doctor can’t tell you. The soul of an HMO. Time Jan 22, 1996; 147: 44-52.