doi:10.1016/j.ijsu.2005.10.010


International Journal of Surgery (2005) 3, 233e234

www.int-journal-surgery.com
EDITORIAL

Distributive justice, starfish and natural disasters
What does the earthquake in Kashmir have to do
with the mammographic screening for early breast
cancer? The link is tortuous but never the less very
relevant for the readers of this journal. Last night I
was giving a lecture to the PhD students at the
Ludwig Institute of Cancer Research in London. In
it I described the great advances that we are
making in the medical treatment of breast cancer
and the decreasing importance of the role of the
surgeon in this disease. I then went on to expound
on my thesis concerning the timing of the appear-
ance of metastases in relation to the act of surgery
and its link to the biological responses of the
healing process.1 Indirectly this is also related to
the controversy whipped up by the paper from
Retsky and his colleagues published in the last
issue of the Int. J. Surgery.2 They suggested that
the increase in the short-term mortality from
screening women under the age of 50 was related
to these mechanisms [see editorials and corre-
spondence in this issue]. Even if you reject that
as implausable, taking the most optimistic assess-
ments from the screening advocates you still
have to screen about 1600 women for 10 years to
save one life!3

At the end of my talk a bright young student
asked me if as a result of these data whether I
could see a time when surgery would no longer be
a part of breast cancer management and if so how
would I spend my time. After a moment’s hesita-
tion I replied that yes I look forward to that day but
by then I would be fully retired from clinical
practice! After another moment’s hesitation I
went on to say that there are many traditional
areas in the surgical treatment of chronic disease
when surgeons will enjoy less and less of a role yet
at the same time we will always need surgeons for
trauma on the roads, and for the results of natural
disasters and global terrorism.
1743-9191/$ - see front matter ª 2005 Surgical Associates Ltd. Pu
doi:10.1016/j.ijsu.2005.10.010
Justice

This then leads me into a consideration of the
ethical imperative of justice in health care. What
do we mean by justice?

The shorter Oxford English dictionary defines
justice as:

‘‘The quality of being (morally) just or righteous’’

Lord Chief Justice Devlin provided a more useful
definition e‘‘We can use the word to mean social
justice and then we say that the law is just if it
conforms to some social principle, such that all
men are equal; that is justice in rem.’’4

Note the distinction between the law and justice.
However, as far as the practice of medicine is

concerned Tom Beauchamp makes it clear that our
primary concern is distributive justice.

‘‘The principle of justice is really many principles
about the distribution of benefits and burdens e to
cite one example, an egalitarian theory of justice
implies that if there is a departure from equality of
distribution of health care benefit and burdens,
such a departure must serve the common good and
enhance the position of those who are least
advantaged in society.’’5

It can therefore be judged that the principle of
justice will often be in conflict with the principle
of autonomy. In fact most of the toughest ethical
dilemmas we face result from the quite appropri-
ate tension between the ethical principles of
justice and autonomy.

The parable of the starfish

My late brother, Professor David Baum, was a pae-
diatrician of great distinction who died in office as
blished by Elsevier Ltd. All rights reserved.

http://www.int-journal-surgery.com


234 Editorial
President of the Royal College of Paediatrics and
Child Health. He had a massive myocardial in-
farction whilst leading a charity bike ride to raise
money for the children in the camps of Kosovo. He
was committed to equality of global health care
for children in the name of justice. He was fond of
quoting the parable of the starfish:

One can sympathize with the old man when
faced with the enormity of the task and also with
boy whose action saves one life.

As surgeons we have the dual responsibility to
care for the individual and to oversee the just
distribution of scarce resources in our clinics, our
hospital, our health district, our nation and the
under-privileged of the third world. I anticipate
your cry:

‘‘We are practical men Professor how on earth are
we to achieve these goals?’’

For a start whenever we are prioritizing our
waiting lists we are exercising the principle of
justice. We must resist the politician waiting list
initiatives and insist clinical need comes before
political expediency. In the inevitable wrangle over
hospital resources, always remember your freedom
to carry out as many varicose veins as you damn
well like may mean another old lady waits another
year for a hip replacement. However, taking
a global perspective is even more daunting. The
best way we can discharge this responsibility as
surgeons is to encourage and reward our junior
colleagues for taking leave of absence to work in
the third world. This will increase the number of
doctors in the host country and provide better
experience than a 40-h week in a teaching hospital!

In addition as a consultant, why not take
a sabbatical and save some starfish from the sun.
I know many who have done so and the reward is in
the smiles of those who have lived life without
hope or expectation of reaching adulthood. I
passionately believe that when we consider the

An old man walking the beach at dawn noticed
a boy picking up a starfish and

throwing it into the sea. When asked why the boy
explained that the stranded

starfish would die if left to lie in the morning sun.
‘‘But there are millions of starfish on the beach’’.

Said the old man. ‘‘How can
your efforts make a difference?’’
The boy picked up another starfish.
‘‘It makes a difference to this one,’’ he said.
ethics of distributive justice, as surgeons we must
accept a global perspective. Over the last two
weeks the number of deaths in the Kashmiri
disaster has risen to 80,000. Many of these deaths
were preventable had there been adequate surgi-
cal support on the ground. Yet here we are
debating the value of mammographic screening
for the under 50s, that ties up millions of dollars of
resources and thousands of surgical man hours
chasing up microscopic foci of borderline pathol-
ogy with procedures that might even do harm in
the short term. What kind of world do we live in
when the poor of the third world die in their tens
of thousands from natural disasters such as floods
and earthquakes whilst the oh so precious women-
folk of the richest countries of the world consume
huge medical resources in chasing up phantoms?

As I was watching the news bulletins about the
earthquake and the Tsunami, I was moved to tears
and feelings of guilt. On both occasions I stretched
out my hand from the comfort of my arm chair and
phoned up the number for donations that
appeared on the screen at the end of the broad-
casts, pledging £60.00 (90 euros, $100). I soon found
out that I couldn’t buy peace of mind or salve my
conscience so cheap. If you feel the same as me,
please write a letter and let us know how you think
the surgeons in the developed world might organize
themselves to help the overworked and under
resourced surgeons of the developing world.

References

1. Baum M, Chaplain M, Anderson A, Douek M, Vaidya JS. Does
breast cancer exist in a state of chaos? Eur J Cancer 1999;
35:886e91.

2. Retsky M, Demicheli R, Hrushesky WJM. Does surgery induce
angiogenesis in breast cancer? Indirect evidence from
relapse pattern and mammography paradox. Int J Surg
2005;3:179e87.

3. Rembold CM. Number needed to screen: development
of a statistic for disease screening. Br Med J 1998;317:
307e12.

4. The judge, Patrick Devlin. Oxford: Oxford University Press;
1981.

5. Beauchamp TL. The four-principles approach. In:
Gillon Raanan, editor. Principles of health care ethics. Chi-
chester, New York, Brisbane, Toronto, Singapore: John Wiley
and Sons; 1994.

Michael Baum
University College London, Portland Hospital,

212-214 Great Portland Street,
London W1W 5QN, UK

Tel.: þ44 2073908447; fax: þ44 2073908448.
E-mail address: michael@mbaum.freeserve.co.uk

mailto:michael@mbaum.freeserve.co.uk

	Distributive justice, starfish and natural disasters
	Justice
	The parable of the starfish
	References