Joumnal ofmedical ethics, 1984, 1, 21-26

Doctor-patient dilemmas inmultiple sclerosisAlexander Burnfield Child and Family Guidance Centre, Winchester

Author's abstractThis paper is based on the second7ack Pritchard MemorialLecture given at the Queen's University ofBelfast (1).

The author describes his own personal response tohaving multiple sclerosis (MS), and then examines thepsycho-social aspects ofthe disease in a wider context. Thedistress caused by the emotional difficulties associated withMS is emphasised, and in particular the strain placed onthe doctor-patient relationship at the time ofdiagnosis. Thephysician's ability to cope with the needs ofMSfamilies isexplored, together with the importance ofofferingcounselling.

AIlso discussed is the ethical question ofwhether or notthe patient should be told the complete truth. Patients withMS are seen as having a potential not onlyfor helping eachother, but alsofor being able to share in the management oftheir own health care.

Personal experienceRelationships between doctors and their multiplesclerosis patients are particularly complex. Beforeexamining more fully the issues concerned with suchrelationships I shall describe my personal experience ofhaving multiple sclerosis (MS). I have decided to dothis because I hope that it will enhance the significanceof what I have to say later and also make clear thereason for my special interest in this subject.

Eighteen years ago, while I was studying medicine inLondon, I developed a sharp pain in my left eyefollowed by blurred vision and partial loss of sight.Thinking that I had something wrong with my eye Iconsulted the doctor responsible for medical students.He gave me a full neurological examination, whichalarmed me, and so I went into the library to look at thetextbooks. I discovered for myself that my symptomscould be the start of multiple sclerosis.

I was profoundly shocked; I felt lonely andfrightened. I can remember sitting in the library withsweat pouring off my face and with my pulse beatingrapidly. I saw several doctors over some weeks but

Key wordsMultiple sclerosis; doctor-patient relationship; truth-telling;communication; counselling.

none encouraged my questions, or seemed to be awareof my emotional needs. When I asked about thepossibility of developing MS I was told that as I couldread the textbooks I knew as much as any doctor, andthat only time would tell.

This was not reassuring; the textbooks had alreadyindicated that within 10 to 20 years I could find myselfparalysed, blind, incontinent, unable to speakproperly and even demented!A few months later I was left with only slight visual

loss but the next few years were difficult emotionally.Other symptoms appeared in keeping with thediagnosis ofMS, but I was scared to go to a doctor, andI hid my symptoms and feelings from others. I feltisolated and very depressed at times and I wasoccasionally unable to work properly.About five years later while working in Winchester

as a casualty officer I developed numbness andclumsiness in my right arm. This interfered with mywork so much that I saw another consultantneurologist. He told me bluntly that I did have MS andreprimanded me for not coming sooner.

This definite diagnosis was a relief to me and I wasgrateful for this man's frankness, and for the chance totalk to him about my future. He told me that theoutlook was uncertain but I could expect progressivedisability and should make allowance for this. I hadalways been interested in psychiatry, and myexperiences as a patient so far had convinced me thatthe medical profession as a whole tended to undervaluethe emotional and relationship problems associatedwith physical illness. I therefore determined to goahead with post-graduate training in psychiatry as soonas I could. My neurologist was not sure about this, andI remember I laughed when he mentioned that therewere some very long corridors to walk down inpsychiatric hospitals!

So far I have been one of the luckier ones with MS,but I have never forgotten the misery and confusionthat surrounded me at the beginning ofmy illness. Myown emotional adjustment to MS did not end with thediagnosis, and I feel I must complete my story beforemaking more general observations. I had several MSrelapses during my psychiatric training and I alsoexperienced periods of depression; my symptoms werenot easily visible to others and I continued to hide them

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22 Alexander Bumnfield

and to bottle up my feelings.While working as a senior registrar I became so

depressed that in desperation I prescribed myself acourse of anti-depressants because I could not bringmyself to share my troubles with anyone else. Theyhelped me a little but it was counselling from a medicalcolleague that finally enabled me to come to terms withthe disease. She listened to my anxieties, and to mysad, angry and confused feelings. She helped me tounderstand that these feelings were natural andrealistic. I realised from talking to her that it wouldhave been abnormal not to have been emotionally upsetby a very real loss of health and the threat to mysecurity. I was able to express my feelings openly afterthis, to admit to having MS and to make realisticdecisions about my future. For the first time I felt thatI had been understood; I had received counselling fromanother person, who happened to be a doctor.

Understanding MSI have spent some time describing my own experiencebecause this has been basic to my understanding ofother people with MS, and the problems that they havehad to cope with. Once I had accepted the disease morefully I joined the MS Society. I felt that I could helppeople who were having difficulties with their ownacceptance, and with other associated emotional orrelationship problems. I also wanted to share myexperience with medical colleagues, many of whomseemed to be ignorant of the psychological side of MS.At the same time I wished to help myself by doingsomething positive about the situation: to turn basemetal into gold. By then I had undergone a personalanalysis and training in psychotherapy. I had alsobegun to work with children and families at a childguidance centre where I discovered many parallelsbetween families that I saw there, and familiescontaining a member with multiple sclerosis.Over the past few years my wife, Penny, and I have

talked to many people with MS who had a whole rangeof emotional, relationship, and sexual problems.Where possible we have also seen them with theirpartners. The majority came to us soon after thediagnosis had been made or discovered, or when MSwas suspected. We have seen them at our home, andthey have been referred by physicians, social workers,community nurses, by MS welfare officers and byother MS persons.As a result of this voluntary work we have been made

aware of much criticism, from MS families as well asfrom volunteer helpers, directed at our colleagues inthe medical profession. Many people with MS arebitter about the way they feel they have been treated bydoctors. Our own observations (2) are confirmed by arecent survey (3) which found that a large number ofpatients had not been told by their family doctors thatthey had MS and most resented this.Through my own experience ofhaving MS I am well

able to understand their feelings. Being myself aperson with MS as well as a doctor, I belong to both

groups and I do not pretend to be objective or detachedin my outlook. On the contrary, I am emotionallyinvolved and the views expressed here are theconsequence of living with my own MS and the resultof helping others through counselling, as well as mywork as a doctor. In this dual role I have benefited fromhearing confidences from people with MS not usuallyshared with doctors. I have also been able to listen tothe ideas and anxieties that colleagues have expressedabout their MS patients.MS often leads to a long and complicated illness, and

there are many different occasions when help andunderstanding from a physician are crucial.Particularly stressful for families are the occurrences offrightening relapses and complications. The advent ofincontinence, or bedsores, or the need to depend onaids for the first time, can all precipitate emotional andrelationship difficulties as well as physical ones. Whensexual problems occur, whether for physical orpsychological reasons, or from a mixture of the two,then skilled counselling from the physician is essentialas well as a knowledge of the disease and its manymanifestations. Families also need time, support andinformation when pregnancy is an issue, or when longor short-term residential care are being considered.

Telling the truthA most important time, when the physician's skill isoften tested to the limit, is the time of diagnosis. Poorcommunication of a definite or suspected diagnosis isresponsible for as much distress, misunderstandingand ill feeling as at any other period in the relationshipbetween doctor and patient.The diagnosis of multiple sclerosis may be difficult

to make depending as it does on a pattern ofsymptomsand signs occurring over a period of time. There arestill no reliable diagnostic tests for MS and the diseaseis often suspected before it can be confirmed bysubsequent events. Yet an early diagnosis is desirableto exclude treatable conditions (such as spinaltumours) and to meet the needs of research into thedisease. Equally important are the emotional needs ofthe person with MS and his or her family, who arefaced with a frightening experience to which they mustadjust before they can plan for the future. Honestyfrom the doctor will enhance the doctor-patientrelationship, and will eventually lead to a greater trustin him by his patient. Advances in detecting MS byusing a nuclear magnetic resonance scanner mayeventually speed up the time that it takes to diagnosethis disease. A Lancet editorial (4) optimisticallysuggests that an accurate diagnosis should soon bepossible in most patients during their presentingclinical episode.A great deal of controversy surrounds the issue of

'telling the patient' and many people with MS haveclaimed they were not told the truth in astraightforward manner. Some have found out byaccident, whilst others have had to resort to subterfugesuch as steaming open doctors' letters, or reading

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Doctor-patient dilemmas in multiple sclerosis 23

hospital notes upside down. Sometimes the patient'sspouse has been informed of the diagnosis butinstructed not to tell his or her partner. This inevitablyplaces a great strain on family relationships.Even when the diagnosis is certain a doctor's

reluctance to tell may be justified on the grounds thatthe patient cannot cope with the diagnosis. Yet timeafter time people with MS speak of relief at knowingtheir diagnosis. Naturally, many are shocked anddistressed, but at least they know the truth and canbegin to come to terms with it. The truth is rarelyworse than the unknown. An American studypublished in 1982 (5) found that a great deal of conflictoften arose between MS patients and physicians duringthe pre-diagnosis period. Many patients began to takean active role in establishing their own diagnosis andconflicts extended to relationships with family andfriends; but naming the disease led to a reduction instress and the investigators urged physicians toconsider these emotional factors when decidingwhether or not to inform patients of a tentativediagnosis of MS.

How much to tell: an ethical dilemmaSome physicians consider that it is not always in thebest interests of multiple sclerosis patients to be toldthe truth at an early stage, or even to be told the truthat all. They argue that the doctor's first duty is therelief of suffering and that to tell the truth could causeunnecessary anguish rather than be conducive to peaceof mind.

In support of this it is pointed out that a patientpresenting early in the course of the disease, havinghad only two or three MS symptoms, could be freefrom further clinical episodes for many years or evenfor a life-time. Other justifications for deceivingpatients about their prognosis are that it is impossibleto predict the future with certainty, and that patientsare not able to understand the complexities involved.Not knowing whether a patient really wants to face

the truth can be a reason for being cautious about howmuch to tell. But dishonesty justified on these groundscan sometimes result from the doctor's own discomfortwhen discussing emotionally painful issues. In suchcircumstances the doctor's unconscious anxieties couldbe the real cause for not being truthful, rather than agenuine regard for the patient's needs.A few people with MS have told me they resented

being given their diagnosis early because they hadaltered family and career plans unnecessarily in thelight of subsequent events. In these cases the failurecould have been in how they were told rather than howmuch.

Alternatively a gloomy picture of the future mayhave been given by doctors with an over-pessimisticview of the disease based on treating severely disabledpatients in hospital. But many people with MS livenormal lives and may have little or no disability evenafter many years.

In my experience the vast majority of MS patientshave wanted to know the nature of their disease as earlyas possible. They have been keen to discover all theycould about the disease to enable them to make theirown decisions about the future. Many have felt theyhad a right to know about their illness and toparticipate in their own treatment.A moral question for the physician is whether to do

what he or she thinks is right when this differs from thepatient's wishes. It is difficult for the doctor to be surethat he accurately knows what the patient really wants.Although there are no simple answers to thesequestions they emphasise a need for the doctor not justto understand the patient, but also to be aware ofhis orher own feelings and attitudes. The physician must beprepared to consider what the truth could mean for aparticular patient, and it is surely right to respect apatient's need to make his or her own decisions. Thedoctor's prime task must be to serve the patient and thepatient's family and to provide them with theinformation and support they require to adapt to thedemands of an uncertain future.

Emotional reactionOnce the diagnosis of MS is known a period ofadjustment will follow. In many ways this process islike bereavement; the patient has to mourn lost healthand adjust to a new identity, to a different picture ofhim or herself and of the future. He or she will feelshocked, angry and depressed, and may try to denywhat has happened. This is a normal reaction and itshould neither be discouraged nor over-indulged.Counselling at this time may help people to workthrough confused and painful feelings and to accepttheir limitations.A particularly distressing feature of MS is the fact

that the course ofthe disease varies greatly from patientto patient; people in the early stages live with alarminguncertainty about their future. Added to this is theremarkable variability of symptoms within oneindividual; not only does the patient have to cope withmajor relapses and remissions but he or she must alsolearn to live with ups and downs from day to day, andeven from hour to hour.Many MS symptoms are subjective and invisible to

other people. This is especially so with fatigue, acommon problem in MS, made worse by exertion andhot weather. It may fluctuate markedly and can causea great deal of misunderstanding. This symptom canbe extremely disabling but it seems to be inadequatelyrecognised as a handicap by many doctors.

Physicians need to understand that the way in whicha person reacts to MS does not necessarily relate to theseverity of the disease. A person who is only mildlyaffected can be psychologically devastated, whilstsomeone else who is severely handicapped might copewell. Many factors play a part in determining anindividual's response: these include the effect of thedisability on the person's way of life, his or her

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personality, and the amount of support received fromfamily as well as from health care workers.

Adjustment can sometimes be more difficult whensymptoms are mild; the patient is unsure whether toperceive him or herself as normal or handicapped.When physical signs are obvious it may be easier toaccept a new identity, but people may then have tocope with the stigma of disability. They may try todeny their handicap; some refuse to use a stick,preferring to stagger about dangerously; neighbours orpassers-by may suspect them of being intoxicated.

Other people with MS will not adjust their life-styleand may attempt impossible tasks to prove tothemselves that they are still 'normal'. At the oppositeextreme are patients who take to a wheelchair althoughthey can still walk reasonably well. In such cases thereis often an over-protective relative, and therelationship can become a 'hostile dependent' one inwhich anger and guilt are mingled.

People with MS have to find a happy mediumbetween complete denial on the one hand and giving inon the other. Only by doing this can they discover theirstrengths. The best encouragement for someone withMS is to be valued and wanted by others. We all needto contribute in some way, however small, and thepatient should be given respect and responsibility byhis medical advisers wherever possible.

DoctorsBut what about the doctors? We need to understandthem too! In these modern days of 'high-tech'medicine, doctors may feel trained to cure rather thanto care for their patients. It seems that medical studentsare selected primarily for their ability to passexaminations rather than for their more humanqualities. Medical training perpetuates this bias anddoctors can come to see their role as that of technicalexperts in the diagnosis and treatment of disease. Theymay prefer to see quick and positive results and mayonly feel that they have succeeded as physicians if apatient gets better. While being useful in some welldefined medical conditions such as pneumonia, forinstance, this approach can leave a doctor feeling lessconfident when faced with the vague and recurrentsymptoms of long-term illness, and more particularlyhe or she may find it difficult to cope with theemotional side of disease.

Technical expertise and medical knowledge, thoughessential, are not enough. A doctor must combine thesewith communication and counselling skills to bewholly effective. A balance between bedside mannerand technical competence is needed today just as it wasat the end of the sixteenth century when Francis Baconwrote: 'Physicians are some of them so pleasing andconformable to the humour ofthe patient, as they pressnot the true cure of the disease; and some others are soregular in proceeding according to art for the disease,as they respect not sufficiently the condition of thepatient. Take one of middle temper; . . .' (6).

The doctor must also be able to cope with his or herown feelings of inadequacy or frustration when facedwith an MS patient, and must not take personally theanger and bitterness projected onto him by the patient.Most importantly doctors need to realise that they canhelp their patients best by giving them time andinterest, and by 'just listening' on occasions. A patientcan gain a great deal of relieffrom sharing his fears andconfused feelings, and by being accepted as a fellowhuman being.A person once diagnosed as having MS must live

with a disease which is both humiliating anddepressing. He or she has to cope with loss of healthand security as well as changed roles in the family andat work, which can be devastating to selfrespect. Manypeople feel angry and may look for someone to blame.Often, eager to find an explanation and cure, patientsturn to 'quack' remedies or diets. In both of thesecircumstances a patient's doctor will be the naturalscapegoat and may be rejected or treated unfairly.Unfortunately at this point some doctors take thepatient's reaction personally, and may feel unable tocope with the relationship in a positive way. Theoutcome of this can be that the doctor does not wish tosee this patient more than he has to, or that he passeshim or her on to somebody else.As well as coming to terms with loss of health the

person with MS has to cope with the vague initialsymptoms of the disease, which are subjective but veryreal. These symptoms are often difficult to describewithout appearing to be 'neurotic' or 'ahypochondriac'. Such labels are sometimes used bydoctors but they serve only to undermine the trust andgoodwill in the relationship between the patient anddoctor. Visual or sensory symptoms, and in particularmultiple sclerosis fatigue, are hard for patients andclose relatives to understand. It is important thatdoctors give reassurance and explanation in order tojustify the sick role taken on by the person who hasmultiple sclerosis. Because of the difficulties involvedin communicating subjective symptoms, some patientsmay deny or hide them; others may exaggerate thesymptoms, often in an emotional way, and soperpetuate the doctor's suspicion that they are purelypsychological. Both of these strategies will mostprobably lead to a further breakdown incommunication.

Counselling the familyCan communication between doctor and patient beimproved? Telling someone a disturbing diagnosis orprognosis is not just a question of the transfer ofinformation but of establishing an appropriaterelationship. It is difficult to take in more than a littleinformation in the clinical atmosphere of a consultingroom at a time ofemotional shock. Patients often forgetwhat they have been told under these conditions andmay sometimes deny that they have been given adiagnosis at all!

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Doctor-patient dilemmas in multiple sclerosis 25

Diagnosing and managing MS is not just aboutinforming the patient of the facts, but about beingsensitive to his or her emotional needs and reactingappropriately to them. It is often best for a patient andclose relative to be seen together for as long as theyneed to ask questions and to express their feelings.Opportunities must be provided for them to return formore information and support as they require them,and time is necessary for people to work through theirfeelings of shock, fear, anger and sadness at each stageof the disease. Some people need to deny part of thetruth until they can cope with it all, and skill is neededto assess how much someone really wants to know atany one time. The truth should not be forced on peopleanymore than it should be withheld completely.A question often discussed by people with MS is

whether the neurologist or the general practitioner(GP) is the best person to inform patients that theyhave MS. Each case is unique and will depend on thecircumstances surrounding it.

It is often appropriate for a neurologist to tellsomeone that he or she has MS, or to discuss suspicionsthat this might be so, and I know that many see this as

their particular responsibility. But this will only besatisfactory if the neurologist has enough time to offerthe patient and family the chance to be seen on severaloccasions. I stress again that only such an approach willallow them to question the neurologist, work throughtheir feelings and obtain the necessary emotionalsupport as well as information.

In many cases it will be the GP who has the time andskills necessary especially if, as the family doctor, he orshe has already established a trusting relationship withthe patient.Whatever is decided by the doctors concerned it is

essential that general practitioners and neurologistswork closely together, and are absolutely clear abouttheir individual responsibilities. Unfortunately this isnot always the case and patients may find themselvescast adrift 'between the devil and the deep blue sea'.When one member of a family has multiple sclerosis

the whole family will be affected; children can be verysensitive to anxiety and may become disruptive andattention-seeking if their needs are ignored. Factsshould be explained to them and if they are involved inmajor family decisions they will not feel excluded andresentful.The process of grieving that surrounds loss of health

and future security may last a long time. Patients andrelatives will need to be permitted to express theirnatural feelings and this can be painful for thoseworking or living with them. If this process is blockedthen there is a risk that personal and relationshipdifficulties will occur, requiring psychiatric help at alater stage.

'Telling the truth' to the patient and relatives isbasically a counselling exercise, requiring anunderstanding of psychological processes, selfawareness and relationship skills. But the doctor doesnot always have sufficient time or even the required

counselling skills. Often a nurse or a social worker willbe able to help on these occasions and may be in a betterposition to provide the regular follow-up that is sonecessary when a diagnosis ofMS has been made. Forthis to happen there must be a shared understanding ofeach other's roles by medical and non-medicalpersonnel as well as mutual trust and respect.

Encouraging self-helpMany MS persons and their partners find it helpful tomeet others who have successfully come to terms withsimilar experiences. Self-help groups have grown inthe last few years and there is a strong potential forinvolving others with MS, as well as volunteers, in theprovision of emotional support. Workers in the UnitedStates of America (7) have described the groupcounselling ofMS patients in a hospital setting, whilst'Crack MS' self-help groups in the United Kingdomnow form an important part of the MS Society's workin the community.

It must not be forgotten that patients have aresponsibility to communicate with the doctor.Doctors are not mind-readers and they cannot guesswhat is worrying their patients unless patients askquestions and state their fears. Sometimes a patientwith long-standing MS can become an expert in thedisease and may become disillusioned with a doctorwho has only limited experience. This puts a strain onthe relationship but it is unfair to expect a GP to knoweverything aboutMS when he or she may only have oneor two patients with the disease in the practice. MSwelfare officers can also become frustrated with a localdoctor for similar reasons.Some doctors are prepared to admit their ignorance

of MS and to acknowledge the expertise of MSpatients. One lady told me that her GP's reaction to aconsultant neurologist's confirmation of the diagnosisof MS was to share the letter with her, and to say 'Idon't really know much about MS; let's find out whatwe can together'. And that is exactly what they havesince been doing, with great benefit to each of them Ifeel sure. Similarly, another doctor, when dealing withcomplications of multiple sclerosis, said to his patient'You're the expert: tell me what you know about thisproblem and I'll do my best to help'.We can contrast these encouraging responses with

the reply given to a patient who asked whether it mightbe useful to meet someone else with MS. The doctor, inthis case a consultant neurologist, answered 'Don't beso silly! The next thing that you will be doing is writingto the MS Society for leaflets'. Unhelpful responseslike this are all too common, and I hear reports of thiskind quite regularly.

Doctors should respect their patients and notundermine their confidence and power. LikeKostoglotov in Solzhenitsyn's 'Cancer Ward' patientsneed to feel able to say to their doctors 'Can't we getaway from this tone of voice? You sound like a grownup talking to a child. Why not talk as an adult to an

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adult? . . . You start from a completely false position.No sooner does a patient come to you than you begin todo all his thinking for him. After that, the thinking'sdone by your standing orders, your five minuteconferences, your programmes, your plan and thehonour of your medical department. And once again Ibecome a grain of sand, just like I was in the camp.Once again nothing depends on me' (8).

Like Kostoglotov all of us with MS must begin toquestion and actually to manage those whom we ask togive us medical help. In another book Patienthood bySiegler and Osmond we find the following. 'The doc-tor-patient relationship resembles that of the elephantand the mahout (the elephant driver). Elephants havemany virtues: they are an excellent means of transpor-tation in difficult country, and they can use their greatstrength to move heavy obstacles. They are not cheapto feed, but everyone knows that. All things beingequal, one is lucky to have a good, strong, kindlyelephant at one's disposal. However, for all their goodnature, elephants are dangerous simply because oftheir size. They may sit, stand or roll over on you quiteinadvertently. . . Elephants are like doctors in that thevery qualities which make them so useful - theirpower, strength, and sagacity - also make themdangerous. Patients are like mahouts, in that they needthe elephants and can get essential services out ofthem,but they must learn how to manage them and how toavoid being trampled upon. They must also avoidstampeding them inadvertently' (9).

So patients as well as doctors need to fulfill their partin the relationship if it is to function at its best!

Working togetherIn conclusion I shall outline ways in which we can helpdispel some of the misunderstanding between the doc-tor and his MS patient. Firstly we must clearly defineto the medical profession the special psychologicalneeds of people with MS. In particular we shouldexpress our dissatisfaction with the low priority givento counselling skills at all levels of medical education.MS patients can be difficult to deal with, but it is ulti-mately the doctor's responsibility to overcome prob-lems, and to understand that they are often due to apatient's response to a frightening and confusing dis-ease. Indeed, sometimes the disease itself can causedirect psychological symptoms which may includememory loss, irritability, mood swings and, in severecases, dementia.

Several medical students have told me of their dis-satisfaction with a training curriculum which includesso little, if any, training in counselling skills. At oneuniversity the students are considering organising suchtraining for themselves - a sad reflection on currentmedical education but good news about the attitudes ofsome of our future doctors at least!

Secondly the MS Society can compensate for thecurrent lack of counselling by training welfare officersto acquire their own counselling skills and so cope bet-

ter with their clients' psychological problems. Givingadvice or providing aids and holidays, whilst impor-tant, is certainly not enough. The MS Society couldalso train those who are disabled as counsellors andfurther encourage the development of self-help groupsas in the 'Crack MS' movement. This is alreadyhappening in some places in the UK mostly due to thedirect inspiration of and pressure from MS personsthemselves.Thirdly, we can all encourage patients to stand up to

their doctors and make their needs clearly known, andthen support them when they do so. We can encouragethem to ask more questions and to complain if they arenot satisfied with the service they are getting. Perhapsthere could be more meetings between professionalsand volunteer helpers. The Multiple Sclerosis Societyhas an important role to play in this area and I shouldlike to see local branches taking more responsibility forliaison with the medical profession. In the end poorcommunication results from the fact that some doctorsfind it hard to talk or listen to MS patients whilepatients often find it hard to listen to and question theirdoctors. We all have a role to play, not just as critics orwatchdogs which is far too easy, but constructively, ascatalysts and as mediators. It is encouraging that somedoctors are now taking counselling skills more seri-ously, but the medical profession has a long way to goin its understanding of the fears and feelings surround-ing what is still a frightening and mysterious disease.

References and notes(1) Jack Pritchard was Professor of Anatomy at the Queen's

University of Belfast until his death in 1979. He alsoserved as Chairman of the Northern Ireland Branch of theMultiple Sclerosis Society of Great Britain and NorthernIreland, taking an active interest in its work for peoplewith multiple sclerosis and their families. The JackPritchard Memorial Lecture takes place every two yearsand is sponsored by the Queen's University and theNorthern Ireland Branch of the Multiple Sclerosis Soci-ety.

(2) Burnfield A and P. Common psychological problems inmultiple sclerosis. British medical journal 1978; 1: 1193-1194.

(3) Elian M, Dean G. Need for and use of social and healthservices by multiple sclerosis patients living at home inEngland. Lancet 1983; 1: 1091-1093.

(4) Anonymous. Treatment of multiple sclerosis (editorial).Lancet 1983; 1: 909-910.

(5) Stewart D, Sullivan T. Illness behaviour and the sick rolein chronic disease; the case of multiple sclerosis. Socialscience and medicine 1982; 16: 1397-1404.

(6) Bacon F. Essay XXX: of regiment of health. Modern edi-tion. London: JM Dent and Sons, 1972: 98-99.

(7) Hartings M, Pavlou M, Davis, F. Group counselling ofMS patients in a program of comprehensive care. Journalofchronic diseases 1976; 29: 65-73.

(8) Solzhenitsyn A. Cancer ward. London: Bodley Head,1968: 85-87.

(9) Siegler M, Osmond H. Patienthood. New York: Macmil-lan, 1979: 69-70.

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