'How can you defend someone if you know they're guilty? The answer is, you never know'
People imagine being a criminal defence barrister involves dealing with the devious, dishonest and depraved, that every day is a moral rollercoaster. That's why we're always asked: "How can you defend someone if you know they're guilty?"
The answer is, you never know. In most cases the rights and wrongs are hard to call. Of course I've represented people guilty of dishonesty, violence, drugs and sex offences. It would be ridiculous to assume every client told me the truth. But there have been very few I haven't got on with. I've met lots of interesting and genuine people, and lots of lonely, desperate and misguided people. I rarely have to challenge my own ethics. I just get on with the job.
Most barristers have a similar attitude: you don't get personally involved. It's normal to meet your opponent and talk frankly about the case, making disparaging remarks about defendants, witnesses or police. I almost always get on with my opponent – only last week I was prosecuted by a close friend. It does not affect my ability to do the job. But police officers almost always take a case personally. They can be desperate to see a defendant convicted.
The perception that criminal barristers make a mint is wrong: I'm self-employed and most of my work is legal aid. It's poorly paid, and the quality of advocacy is getting worse because the prosecution increasingly uses inexperienced in-house lawyers. The public might get a shock if they sat in their local crown court for a day.
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Charlotte NorthedgeDoctors who cave into patient pressure create demand
Last month the government proposed allowing pharmacists to substitute prescriptions for branded medicines with generic alternatives. A letter of protest appeared in the Times, signed by various patient groups and experts, with positive coverage in the broadsheets. "Plan to switch to cheaper medicines will harm patients, say experts," reported the Times. They even had a case study: "Patient given Seroxat substitute felt unwell within two days."
But Margaret McCartney GP, writing in the British Medical Journal, has been digging: in fact the letter was coordinated and written by the PR company Burson-Marsteller, paid by the drug company Norgine. Norgine's chief operating officer, Peter Martin, , despite being the major influence behind the campaign, did not sign the letter himself. Asked why not, he said: "There was no conspiracy. The frank truth, the honest truth, is that I thought that having a pharmaceutical company in there would sully the message somewhat."
Meanwhile the "stay at home" campaign, covered in the Times, Telegraph, Mail, and BBC, encourages people not to go to their GP with mild self-limiting conditions. This campaign was organised by the Proprietary Association of Great Britain, which represents the manufacturers of over-the-counter medicines and food supplements in the United Kingdom. I think we're unhealthily obsessed with pills of all varieties, but the association did at least have the courtesy to sign its own letter, and its case is stronger. But its report missed one of the most fun trials ever published: a randomised controlled trial of the social phenomena of medicalisation.
Doctors commonly prescribe treatments, even when they know they're not effective, in the face of assertive patients. But does this really reduce their workload?
Most sore throats are caused by viruses. Doctors usually avoid antibiotics, with provide only marginal benefits. Explaining the evidence, prescribing "watch and wait", and being told the average duration is five days can provide reassurance. But measuring the benefits of that empowerment requires imagination.
Paul Little and colleagues took 716 patients, who consented to a "study looking at how quickly sore throats settle." Patients were given antibiotics, advice to watch and wait, or a delayed prescription which they could use if things hadn't settled in a few days.
Each group got better at much the same rate. But more of the patients given antibiotics came away with the view that antibiotics were effective (87% vs 55%).
So while prescribing antibiotics had marginal benefits at best, it hugely enhanced belief in antibiotics, and intention to go back to the GP. Researchers returned to the same patients one year later and found that the patients who had been prescribed antibiotics originally were 39% more likely to go back to the GP when they had a sore throat.
The evidence-based medicine journal Bandolier (available online, and highly readable) summed this up by translating the figures from both studies into what would happen in a real surgery, after doctors' behaviour changed. "If a GP prescribed antibiotics to 100 fewer patients with throat infection in a year, 33 fewer would believe antibiotics were effective, 25 fewer would intend to consult with the problem in the future and 10 fewer would come back within the next year." Sometimes the most helpful consultations involve no pill at all.
Ben GoldacrePeter Forbes on a book that decodes the future
Francis Collins was appointed director of the National Institutes of Health (equivalent of the Medical Research Council) by President Obama in August 2009. He is the Pete Seeger of molecular biology. When he has made a great discovery he writes a song about it. And the connection is not just a matter of uplifting songs: Collins is a geneticist, but his spiritual, emotional and political inheritance comes from Roosevelt's New Deal (his parents worked with Eleanor Roosevelt), folk music and God, just as much as from Darwin, Mendel and Crick.
The cover of The Language of Life carries Obama's endorsement: "His groundbreaking work has changed the very ways we consider our health and examine disease." His is a brilliant appointment, albeit controversial among some scientists: Collins is the highest-profile scientist and public administrator who is also a proselytising Christian. His previous book, The Language of God, contains both the most concise exposition I have read on why evolution is demonstrable fact and a moving account of his religious conversion from early atheism to strong belief. This stance has brought him into conflict both with Richard Dawkins and with Christian groups in the US. But, as right-wing attacks on evolution and global warming science broaden into a generalised anti-science movement, Collins is an important figure – someone who can wrong-foot people who have polarised attitudes.
In his new book, he is here to tell us that the era of personalised genetic testing is nigh. No one could be a more authoritative messenger than Collins. He directed the Human Genome Project – a 15-year international collaborative programme to sequence the entire 3.1 billion-letter code of human DNA – from 1993 to its completion in 2003. Since then, genome sequencing has followed the trail blazed by computing power. A new major animal genome is sequenced every few months (recent acquisitions include the platypus, the zebra fish and the domestic cow) and there are now more than 1,000 bacterial genome sequences. There is an international race for human genomes to be sequenced at a cost of less than $1,000, and Collins believes this will be achieved within five to seven years. He is unlikely to be wrong.
What does this mean? We, and more importantly Collins, can foresee the day when our genetic knowledge of disease and concomitant preventative care and treatment will be systematised and as routine as the internet and email are today. But presently we are still in the lower foothills: sometimes a land of serendipity but, more often, of missed connections. Collins tells some poignant stories, the most remarkable being a coincidence in which a family (known as "the family of 15") with a very high incidence of breast cancer was being studied and the collaborative research team, including Collins himself, were homing in on a breast-cancer gene now famous as BRCA1. "Susan", one of the family, had decided to have a double mastectomy even though she was healthy, having seen her two sisters develop the disease (one died). She was referred by chance to one of the doctors in the research team, who realised that she was one of the family of 15. Work was now so advanced that the team believed they could test to see if she had inherited the gene – the research programme had now become an urgent clinical case. Susan took the test, was clear, and was thus spared the operation.
In a different kind of coincidence, two strands of Collins's life converged on the figure of Woody Guthrie. Collins's father's folksong collecting meant that the young Francis imbibed and loved Guthrie's music. When Collins went on to become a gene hunter, one of the early successes he made with his team was to track down the gene for Huntington's disease, the degenerative condition that killed Guthrie.
So far so good, but this was a single gene disease (there are a few more of these – cystic fibrosis, Tay-Sachs disease and sickle cell anaemia are among the best known). Even so, Collins likened the hunt for the cystic fibrosis gene and its mutation to "looking for a single burned-out light bulb in the basement of a house somewhere in the United States". He poses the problem for the really big diseases even more starkly: in diabetes, cancer, heart disease and schizophrenia there are "a dozen or more light bulbs to discover, and they weren't even expected to be burned out – just subtly dimmer than they should be". But genomics will eventually detect even these slightly less incandescent bulbs.
In the first place, the new genomic knowledge of disease will assist diagnosis and preventative medicine. The promise of genetic cures – inserting good genes for bad – is still some way off. Collins discusses the dilemmas facing families who, if tested, will learn of percentage risks in most cases, and certainties in others. We all have individual genetic makeups that predispose us to some diseases; we are, in fact, walking agglomerations of risk factors.
In this screening and prevention scenario, the technique of preimplantation genetic diagnosis (PGD) will be crucial. Couples who know they have a high risk of having a baby with a major genetic disease can opt for this technique in which fertilisation is achieved in the lab from many eggs and the embryos then tested. Only healthy embryos are implanted.
Collins discusses the risks of this technique being used for sex determination and for the creation of designer babies. He pours scorn on the latter. PGD can eliminate the risk of single-gene diseases entirely, but just as most diseases, such as diabetes, cancer and heart disease, are multifactorial, so are desirable human traits such as musicality, beauty and brains. Even if it were possible to optimise, say, 10 genes involved in musical ability, a woman doesn't produce sufficient eggs in a lifetime to create the millions of embryos that would be needed. The joke about George Bernard Shaw and the actress comes to mind. The actress suggested to Shaw that they should have a baby together: "But Madam," Shaw retorted, "what if the child has my looks and your brains?"
For someone so powerful, Collins has an engagingly modest and open style. He encourages individuals to take responsibility for their health, and he is comfortable with the idea of direct-to-consumer genetic testing, without the mediation of a medical expert. He begins the book by subjecting himself to genetic analysis by the big three private genome testing companies in the US and discusses their findings with us. Throughout the book, he stresses that the best data we have on our genetic risk factors comes not from the new genomics at all, but from old-fashioned family history.
They do things differently in the US – sometimes better, sometimes worse. The Language of Life has a universal message, but the American bias means that some "translation" is needed for UK readers – not in the medical science but in terms of health policy and administration. Collins points the US reader to many useful programmes in which they can enrol. British readers will need to research to find UK equivalents.
Collins makes it clear where all this is leading. Piecemeal medicine is inefficient and brings a huge human cost in failures through inappropriate treatment and adverse reactions. Nothing less than complete genome sequences for all is his goal – having sequenced one platonic human genome, he now wants 7 billion individual ones. It seems very likely that one day the two most universal possessions will be a mobile phone and a personal genome record.
Or will they? Collins ends with two fictional scenarios for a 21st-century life. A baby named Hope, born in 2000, has parallel lives: in one, Collins's prognostications come true – she and her husband live happily to 100 years thanks to preventive genomic medicine. In the other scenario, present-day trends of private US healthcare, poor diet, obesity and lack of exercise continue and Hope dies of a heart attack at 50 while her husband's undetected colon cancer is about to spread to his liver. It's a neat summation of the crossroads we have reached.
Peter Forbes's Dazzled and Deceived: Mimicry and Camouflage is published by Yale.
