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Second Opinion: doctors, diseases and decisions in modern medicine by Richard Horton

A bitter pill from the medicine man

It is the business of editors to prick the prejudices of their readers while challenging the practices of those who wield power. Richard Horton is adept at both. As the youngest editor of The Lancet, appointed almost eight years ago at the age of 33, he has gained a reputation as an iconoclast, taking on the drug industry, the World Health Organisation and the US Food and Drug Administration - to name but three.

Horton is not a man afraid of making enemies. This collection of his writings shows why. He thinks that medicine, driven by commercial pressure, whether private or state, has lost sight of the individual. His preface argues that "a successful future for medicine depends on recovering the notion of human dignity and making its restoration the objective of every practising physician".

It is not easy to follow this theme through all the twists and turns of this volume. Horton's gimlet eye roves over the threat from emerging diseases, the ups and downs of vaccination, the neglect of medical needs in the developing world, and the relationship between doctors and pharmaceutical companies. This, he says, "has now become corrupt".

But some episodes play strongly to his theme. One is the infamous Bristol Cancer Help Centre study, published in The Lancet 13 years ago (before Horton was editor), whose recollection can still send a shudder through any medical researcher. It showed how doctors with an agenda, in this case to rubbish alternative medicine, could commit a fundamental error by ignoring the subjects of their study - the patients.

The study purported to show that women with breast cancer who supplemented standard chemo- and radiotherapy with alternative treatments, such as massage, wholefoods and counselling, died sooner than those who just had chemotherapy. The finding was, literally, incredible. How could massage kill? Soon after publication a fundamental error (not picked up in the peer review process) became clear. The researchers had not noticed that those who had the alternative treatments also had more advanced cancer.

When the truth emerged, with astonishing rapidity, letters of correction were published. But the damage had already been done. One of the authors of the flawed study, Professor Tim McElwain, committed suicide 12 days after the corrective letter was published.

Among the many lessons learnt from the tragedy, Horton singles out the importance of attending to the "patient's own authentic voice" - which he believes has still been only partly heeded. But he also wants to see this principle acted out on a wider stage. Only in the last decade has health been seen as a separate human right, and as "a tool in the struggle for human development and poverty reduction".

Here he returns to the notion of dignity, defined as "the ability to control the circumstances of the situation (or predicament) one is in". Horton is sceptical about the achievements of medicine and derisive of the influences that distort it, but his passionate and vivid defence of dignity demands, and deserves, attention.

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