47

ter financial support for one-parent families. But they alsoendorse most of the report’s other 230 recommendations thatstill await implementation. Among these are proposals forfamily courts and for a conciliation service. Good counsellingis often needed if the bitterness and anger that may lead to a

separation are to be prevented from driving away the non-cus-todial parent, and it can do much to reduce the initial stressesof access visits.

Anecdotal evidence suggests that many people visit generalpractitioners immediately after a marital separation. G.P.s arewell placed to point out the potential dangers to childreninherent in such situations and, where appropriate, to guidetheir patients to professional and voluntary counsellingservices that already exist. Given the risks to health of unsup-ported parenthood for both children and parents,5-8 suchactions should constitute very effective preventive medicine.Medical Psychology Unit,Departments of Experimental Psychology and Medicine,University of Cambridge,Cambridge CB2 3RF MARTIN RICHARDS

STRIKES BY DOCTORS: AN ETHICALALTERNATIVE?

SIR,-Surely, both you (Nov. 4, p. 973) and the secretaryof the British Medical Association (Nov. 25, p. 1144) are mis-taken if you are assuming that there is no way in which doc-tors can strike except by harming patients? May I indicate away in which withdrawal of some of their labour could

actually benefit both patients and the N.H.S., and perhaps alsohelp the politicians.

Highly qualified clinicians increasingly spend valuable timeaway from patients because of a persisting belief that it is

necessary to immerse them in the present form of N.H.S."management". The administrative reorganisation which

aggravated this state of affairs is now widely regarded as hav-ing been a serious error-yet it is one which doctor-managers,and those who advocate them, are helping to perpetuate. Poli-ticians of all parties, as well as doctors, seem to want the sys-tem changed but, with no Royal Commission report yet insight, there is unlikely to be any action for some time.

Is it too naïve to believe that an effective withdrawal by themedical profession of its committee labour could bring manybenefits? Patients would find doctors, who in recent years hadbeen locked in committees for hours a week, more available forthe wards, outpatient clinics, surgeries, and visits. The nextreorganisation of the N.H.S. might well be hastened, and shedof its redundant layers. The Royal Commission might reachbetter conclusions, and reach them sooner. The politicianscould either blame or praise the doctors according to the expe-diency of the measures that they would be forced to take. Theprofession would find itself immeasurably stronger and moreinfluential for having dissociated itself from a wasteful and in-competent administration, and for having itself promoted anecessary change. It could also initiate a more responsiblestrength and influence by providing an independent advisorysystem available equally to the new management of the N.H.S.and to the community health councils. It would no longer beidentified with the bureaucracy and thought to be workingagainst the interests of its patients and potential patients whoconstitute "the community". A strike against bureaucracycould attract public support, and for all this the B.M.A. couldclaim credit. It would have shown how this new perplexedcreature, the professional trade union, could use the strikeweapon solely for beneficent purposes.Where then are the snags? Many doctors now conscien-

5 Ferri, E. Growing up in a One-parent Family: a long-term study of child de-velopment. Windsor, N.F.E.R. Publishing 1976.

6. George, V., Wilding, P. Motherless Families. London, 1972.7 Wynn, M Fatherless Families. London, 1964.8 Marsden, D Mothers Alone. London, 1969.

tiously engaged in committee work may cry out that I am urg-ing chaos and anarchy. I would ask any who do so to considerseriously whether they are not overvaluing the work they aredoing, and if, in the long run, they might not serve the publicbetter if they stopped it. They have tried valiantly, but thechaos and anarchy with which they are already associated aresuch that a little more will make no difference. Does any doc-tor seriously believe that a single patient would really suffer ifhe left his committees tomorrow? If he does, he underestimatesthe resourcefulness of those truly dedicated to the care of thesick individual. I expect also to be told that old story that "ifthe doctors don’t involve themselves in management and ad-ministration, others will take over and make the decisions".Not so. Time has amply shown that the now vast involvementof clinicians in the committees of the N.H.S. has diminishedrather than preserved a proper medical influence in the service.The take-over by others has already occurred, and the pre-sence of doctor-managers has only facilitated it and associatedthe profession with a bad system.

Perhaps the chief snag is that too many clinicians may havebecome so addicted to committee work that they would notwish to deny themselves an activity which now provides some-thing of a refuge from their real work, which they onceenjoyed when morale was high. This is where the B.M.A.’s roleas a trade union would be tested, and where its new place-of-work representatives would need to discover the extent towhich the profession. had itself become so converted to

bureaucracy that a call for this sort of strike might gounheeded.

I have been referring only to clinicians, those who havepatients; and I well realise that purely administrative doctorswould be put to much inconvenience if their clinical colleagueswere to appear to be deserting them. But many medical admin-istrators are, I know, much concerned at the way their own in-fluence has become diminished, and would welcome the oppor-tunity to be able to do more, as ’doctors, to counteract theexcessive power over medical matters which finance officersand other lay persons are fast acquiring.

It would be for the B.M.A., of course, to recommend actionof the sort I have outlined. My purpose is to draw an ethicalalternative to the attention of those who at present share with

you and the B.M.A. a preoccupation with only those strikeswhich may harm patients.

°

Radcliffe Infirmary,Oxford OX2 6HE JOHN M. POTTER

TYPING REFERENCE LISTS

SIR,-Miss O’Connor (Dec. 23/30, p. 1373) implies thatlast January’s Vancouver declaration on uniform requirementsfor articles was sprung on to an unsuspecting world by a"coterie of clinical editors" (what a splendid collective noun).Lest your readers are misled, may I point out that the pro-posals to use numbered references and the style of the IndexMedicus are merely an extension of those agreed by 30 Ameri-can clinical journals as long ago as 1970’ and found to be ac-ceptable by both editors and authors. I have had many lettersabout the Vancouver proposals, all but two (one of them fromMiss O’Connor) in favour of ending the present time-consum-ing chaos and adopting one uniform style.The participants at the Vancouver meeting did not think up

their plans in an ivory tower: no fewer than six of the eightmedical editors present are engaged in the hurly-burly of pro-ducing a weekly or monthly journal. None of them had strongviews on the actual style, but all agreed that the proposals hadto be based on the possible. Miss O’Connor states that a "uni-form style for citing references in the text is clearly unattain-able," but why? Surely, it is already beginning, and the jour-

1. New Engl J. Med. 1970, 282, 48.