Population control and uncertainty—a doctor’s role

Several readers have pointed out that the BMJ’s recent coverage of climate change has ignored a key issue—the need for population control. John Guillebaud and Pip Hayes give the same rebuke in their editorial this week (doi: 10.1136/bmj.a576). They may be right that “population” and “family planning” are taboo words. The BMJ hasn’t actively avoided these issues, but we could do more to highlight them. As Guillebaud and Hayes portray it, every week an extra 1.5 million people need food and somewhere to live, amounting to “a huge new city each week, somewhere, which destroys wildlife habitats and augments world fossil fuel consumption.”

Population control need not be coercive, they say. Half of pregnancies worldwide are unplanned. Simply by meeting women’s unmet contraceptive needs, several developing countries have halved their fertility rates. Clear evidence points to the demand for contraception increasing when it is available, accessible, and properly marketed. Guillebaud and Hayes call on doctors to take an active role in overcoming barriers to the universal availability of contraception and ensuring that patients and the public understand the environmental consequences of population growth. Controversially, as evidenced by the responses to the editorial since it was published online on 24 July (http://blogs.bmj.com/bmj/2008/07/29/david-payne-its-the-economy-mum-and-dad/), they say that doctors should advise patients on limiting family size for environmental reasons and should set their own example.

Not everyone will agree that this is a doctor’s role. Most will agree, however, that it is the role of doctors to deal with uncertainty. Raising the stakes further, Iain Chalmers says doctors should not just manage therapeutic uncertainty but should force it into the open (doi: 10.1136/bmj.a841). A new series in the BMJ on clinical uncertainties aims to do just this (doi: 10.1136/bmj.a834). Chalmers reminds us that guidance from the UK’s General Medical Council (GMC) explicitly states that doctors must help to resolve uncertainties about the effects of treatment. This means being open about uncertainty with patients and the public. It should also mean, says Chalmers, using treatments for which there is limited evidence only in the context of research.

The case that Chalmers uses to illustrate the disincentives facing those who want to confront therapeutic uncertainties is that of David Southall and his trial of continuous negative extrathoracic pressure (CNEP) in neonates, the same case that Jonathan Gornall unpicks in his forensic investigative report on p 258 (doi: 10.1136/bmj.a907). Southall and two other paediatricians were under investigation by the GMC for 15 years until the case was thrown out earlier this month. Gornall uncovers a trail of incompetence and maladministration, which the GMC will find an uncomfortable read.

You can vote at www.bmj.com/#poll in the BMJ poll: should doctors advise people to limit the number of children they have for the sake of the environment?