Litmuspaper: World of Surgery

litmuspaper Published at The Times Cheltenham Literature Festival

Surgeons, designers, scientists, artists: the unexpected connections revealed

5 –14 October 2012

World of Surgery

Welcome Here at Cheltenham Festivals we run four festivals spanning the arts and science – Jazz, Science, Music and Literature. The combination is unique and the creative spark that is generated when our festivals come together is exceptional.

The Literature and the Science Festival teams are working alongside to bring exciting and intriguing science enthusiasts like Marcus Brigstocke, Jon Ronson, Robert Winston and others together for great discussions and fascinating topics.

Through the generous support of the Wellcome Trust we have been able to bring together artists, designers, musicians, authors and scientists to develop LabOratory, a series of events with a biomedical theme across all four of our festivals.

Scientists too are telling extraordinary stories about their quest to understand the world. They are developing captivating plots and the skills to create compelling works that provide an understanding of scientific subjects that may previously have been seen as impenetrable.

We are delighted to be working with Professor Roger Kneebone of Imperial College to develop the World of Surgery. Professor Kneebone is an outstanding communicator and his work crosses boundaries to bring biomedical science to life, to be thought-provoking and to stimulate debate.

Some of you may recognise Litmus Paper, our Science Festival Newsletter. We are pleased to be working with DesignScience to produce this special edition for our Literature Festival.

If you enjoy science at the Literature Festival then please join us from 4–9 June 2013 for the Times Cheltenham Science Festival.

Julia Jenkins LabOratory Project Manager Head of Cross Festival Development 2 | Litmus Paper

Litmus Paper 2012 Produced by DesignScience in collaboration with Professor Roger Kneebone and Cheltenham Festivals www.design-science.org.uk www1.imperial.ac.uk/medicine/ people/r.kneebone/ www1.imperial.ac.uk/medicine/ people/f.bello Editors: Anne Odling-Smee, Lizzie Crouch, Patrick Roberts, Phillip Kent Design Director: Anne Odling-Smee Project Manager: Lizzie Crouch Cover: Phillip Kent Contributing writers: Richard Barnett, Hugh Davis, Steve Fuller, Matthew Harrison, Stuart Hamilton, Mark Henderson, Denise Innes, Mick Jackson, Jacqui Rees-Lee, Carol Watts, The British Library Printed by PrintbyDesign © DesignScience 2012 62 Hatton Garden, London EC1N 8LR T. +44 (0)20 76311570 E. info@designscience.org.uk The views and opinions expressed in this newspaper are those of the authors and do not necessarily reflect the views and opinions held by Imperial College, Cheltenham Festivals or DesignScience.

For enquiries about ‘World of Surgery’ E: l.dawson@imperial.ac.uk Roger Kneebone and Fernando Bello gratefully acknowledge support of the Wellcome Trust and the London Deanery STeLI

OPINION

Heads and hand: the roots of surgical power ‘Surgery’ comes from two Greek words: cheiron and ergon, literally ‘hand-work’.

The exercise of surgical power has always been characterised by a tension between learning and craft, the lecture room and the butchers’ block – in short, between the head and the hand.

Until well into the 18thcentury surgery was a trade with a desperately poor reputation.

Physicians – the ‘head’ of the orthodox ‘medical body’ – sought to develop a holistic perspective on each patient’s life, while mere mechanical knowledge of flesh and bones could be left to vulgar tradesmen like surgeons – the ‘hands’ of the medical body.

In the age of Enlightenment surgeons began to develop a distinctively ‘surgical’ view of the body. Disease was not an imbalance but a lesion, a localised, physical defect that could be identified and treated through surgical intervention. In the secularised hospitals of the French Revolution doctors, too, acquired this surgical gaze.

But in doing so the notion of the patient as an autonomous individual dissolved, to be reconstituted as the ‘case’ – a new entity subject, in every sense, to expert clinicians.

Technical developments in the 19th century such as anaesthesia and antisepsis, helped surgeons to consolidate their new position as the leaders of medical thought. In 1897 the ennoblement of Joseph Lister – the pioneer of antiseptic surgery – became a symbol of how far surgery had come in the 19th century, and how far it would

go in the 20th. But a powerful demographic shift towards the chronic diseases of old age – conditions less susceptible to surgical intervention – has created new challenges for contemporary surgical power and for the regimes of statefunded healthcare in which it is embedded. To the head and the hands we must now add the ballot-box and the purse.

Richard Barnett, Wellcome Trust Engagement Fellow, will talk at ‘Power and Surgery’ on Sun 14 Oct

Image from Andreas Vesalius’ De humani corporis fabrica libri septem, 1543.

5–14 October 2012 | 3

OPINION

How to sell biotechnology at the right price

WHEAT SEEDS TREATED WITH BACTERIA COLONIZED IN A PETRI DISH. PHOTO: JACK DYKINGA

Biotechnology is perhaps unique in having been simply inspired into existence. This year marks the 70th anniversary of the Dublin public lecture ‘What Is Life?’, in which the great quantum physicist Erwin Schrödinger predicted that genetics would be soon understood as a biochemical code, the cracking of which would then allow us to create life as easily as we construct

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grammatical sentences.

Members of his audience, notably Francis Crick and James Watson, responded by moving into ‘molecular biology’ and within a decade DNA was discovered to bear the code.

Yet by the late 1960s popular expectations were set pretty much as they remain today. We still hope that specific genes might be switched on or off to

enhance, retard or reverse various humanly relevant traits. Has that hope been in vain? Or are we lucky that it has not been realised?

There is no doubt that over the last fifty years we have come to a better understanding of the structure and function of the human genome. But the practical payoffs still seem quite distant – so distant that pharmaceutical companies are now cutting their research divisions.

Scientists may be right that this reflects shortterm commercial thinking.

However, the public itself needs to be persuaded not only of the eventual positive benefits of biotechnology but also, and more importantly, to accept the costs along the way, which probably include agreeing to open ourselves to much greater risks.

In short, the price of biotechnological progress may be that we become fully paid-up ‘scientific citizens’.

Steve Fuller will take part in ‘The Power of Biotechnology’ on Thu 11 Oct

Litmus Paper asks Mark Henderson about his new book, The Geek Manifesto Do you think you picked the right time to write this book?

Absolutely. I couldn’t have written it five years ago.

Many of the issues it raises about the disconnect between science and politics were as current then as now, but something important has changed.

It seems to me that now more than ever there is a potential solution, and the growing trend among people who care about science and scientific thinking is to stand up for it.

an audience that is already strongly committed to science. One of my main arguments is that science as a way of thinking has much to contribute to all sorts of walks of life.

What do you hope will be the greatest legacy of the book?

I have two hopes. The first is that politicians and civil servants might be inspired to think about how the methods of science might actually help them in what How important is it for you they do. The second is that to discuss the book at the Cheltenham Literature Festival? people with an affinity for science become more active I discussed the book at the Science Festival but in many and engaged as citizens.

Mark Henderson will ways the Literature Festival discuss The Geek Manifesto matters more, because it takes the message beyond on Sun 14 Oct

The CSI effect: scientific accuracy vs fantasy

interfere with rifling marks).

But when entertainment ignores reality it creates its own problems. The somultiple individual roles must called ‘CSI effect’, whereby Scientific accuracy in fiction juries are placing less be amalgamated and there can be a challenge. Science weight on scientific evidence has to be some personal fiction or fantasy make because the experts seem drama. But the technical it easy, just tear up the to be less sure (or ‘more rulebook and imagine wildly! aspects can simultaneously realistic’) than some of the be kept realistic. The last But in my field – forensic more far-fetched dramas is pathology – TV programmes piece of advice I offered to already well recognised in a TV programme was about and novels have to balance courtrooms. a fine line between accuracy whether to use plastic or Pathologist Stuart Hamilton metal forceps to extract a and telling a good story. To make a good story timescales bullet from a body (it’s plastic will take part in a discussion on Sat 13 Oct by the way, metal ones can have to be shortened, 5–14 October 2012 | 5

Welcome to the world of surgery In a unique series of events at the Literature Festival, Professor Roger Kneebone and his team from Imperial College London explore surgery through the eyes of poets, dancers, storytellers, expert craftsmen and surgeons themselves. The team invite you to participate and explore ideas around the complex interplay between head and hands, between thinking, knowing and doing.

What is surgery doing at the Times Cheltenham Literature Festival? Surely surgery is a science, not an art? What has it got to do with novels, plays or poetry?

Yet surgery affects us all. Almost everyone has had an operation or knows someone who has. And who knows when we might fall ill or have an accident? Yet for most, surgery remains a closed world; mysterious, often scary, but oddly alluring too.

In ‘World of Surgery’ we explore the idea that surgery involves art and design as well as science; that it depends on handmade skills and creative performance as much as on technology. It is no accident that we talk about ‘performing surgery’ in an ‘operating theatre’. ‘World of Surgery’ is a groundbreaking theme which we will be developing through all four Cheltenham Festivals.

It is an opportunity to think about the craftmanship and physical skills required of surgery, to explore connections you haven’t thought of and to meet experts from fields who don’t normally come together.

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SATURDAY 13 OCTOBER EMERGENCY ROOM: CARDIAC ARREST 12–1.30pm, L281 A highly realistic heart attack simulation.

Discover how heart specialists use technology to save lives by performing ‘angioplasty and stenting’. Watch experts feed a flexible wire up through a patient’s groin into a coronary artery, using a tiny balloon to clear the blockage and keep it open with a miniature wire frame.

CRAFT OF SURGERY 6.30–7.30pm, Parabola Arts Centre, L288 free Explore surgery as craft comparing three experts from different fields. Joshua Byrne is a leading bespoke tailor, Jacqui Rees-Lee is a plastic and reconstructive surgeon, and Denise Innes is a well-known milliner and creative hat-maker. Each will demonstrate key techniques, inviting audience members to try their hand while taking part in an informal discussion.

UNDER MY SKIN 8–9.15pm, Parabola Arts Centre, L289 A three-part performance of dance, poetry and story (8–9.15pm). Choreographer Suba Subramanian stages a dance inspired by the surgeons in the operating theatre, Carol Watts and four other poets present their personal responses to surgery through poetry, and novelist Mick Jackson brings his own quirky perspective to what it means to be a patient. After the performance, broadcaster Quentin Cooper will host a Café Scientifique to discuss the event with the surgeons, artists and performers (9.30pm) SUNDAY 14 OCTOBER POWER AND SURGERY 12–1pm, The Salon Montpellier Gardens, L350 Who makes the real decisions when you need emergency surgery? What does it mean to give consent when you’re critically ill or injured? A lively debate chaired by philosopher and clinician Ray Tallis brings together an expert in research ethics, a medical historian, a paediatric surgeon and a surgical educator. £15 for the series or £6 per event

Litmus Paper by DesignScience Our lives are shaped by science and by design, but despite being inherently connected, these industries are little understood by each other and by society. Driven by the government and the science community, the last two decades have seen a surge in efforts to improve science communication through public engagement. This has produced some defining moments in science communication but much work remains to be done.

A perplexing aspect within this field of science communication is the extent to which design and visual communication expertise is overlooked as a crucial component. As volumes of information around us grow exponentially, so the designer’s role becomes increasingly vital to deliver that information. Design industries are rapidly becoming more sophisticated as a result. In the arts, the role of the designer is generally well recognised and understood. The same level of recognition and understanding must now be established within the science community.

DesignScience, established in 2011, is responding to these oversights by trying to further the connection between design and science.

This edition of Litmus Paper is the second that DesignScience has produced for Cheltenham Festivals. We hope to continue our presence here and welcome your thoughts and opinions: design-science.org.uk @DesignScienceUK twitter.com/DSLitmus

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Cutting for a career Jacqui Rees-Lee explains how surgeons and tailors share similar skill sets

Surgeons and bespoke tailors both cut for a living. One cuts and shapes cloth; the other cuts skin, fat, muscle and bone.

They take their materials and fashion threedimensional constructs that are unique and often beautiful. The skills required are developed during long apprenticeships at the feet of master craftsmen, with hundreds of hours spent maturing the manual dexterity

required to become proficient in their craft.

Learning these cloth and tissue handling techniques (initially on scraps of spare cloth or latex skin) the novice apprentices begin to develop their skills. As they mature, they move on to suit linings or closing wounds in the accident and emergency department.

Finally, as they become more dextrous, they are allowed to work on trousers and jackets, or close incisions during operations in theatre.

But technical ability alone does not make a bespoke tailor or a surgeon. Both surgeons and bespoke tailors have long relationships with their clients based on integrity and trust. These relationships rely on honest communication and realistic expectations.

They must also plan, think and design so that two dimensional cloth and skin can be fashioned into three-dimensional constructs which are unique and bespoke for each situation. Thus, they must also be thinkers, planners, communicators, translators and realists, as well as technicians. These higher order skills have to overlay the developing technical abilities of a budding tailor or

surgeon, and exist in a seamless, harmonious marriage with them.

Over the last 3–4 years, Jacqui Rees-Lee (plastic surgeon with an interest in surgical education), Roger Kneebone (surgeon and surgical educator) and Joshua Byrne (Savile Row bespoke tailor) have been exploring the world of bespoke tailoring from the perspective of a surgeon. They have tried to illuminate areas of a surgeon’s practice which may be hidden from view and begun to define what makes a mature, thinking surgeon.

A good surgeon knows how to cut, a really good surgeon knows how not to – Direct Red, Weston 2009 On Saturday 13 October, 6.30pm Jacqui, Roger and Joshua will talk about this work from their own perspectives, demonstrate some of the technical skills required in their jobs and offer the opportunity for you to try suturing a wound and access your cloth handling skills.

See Joshua Byrne and Roger Kneebone in discussion online at www.assemble.org.uk

Instruments Poet Carol Watts is working with surgeon Professor Roger Kneebone to create a series called ‘Instruments’. You can hear her poems at the Festival on Saturday 12 October. They are also available as a podcast from Radio 3’s The Verb with Ian McMillan, Friday 21 September 2012.

1 this uncertain instrument shadowed etiquette cut at full force where hands maintain a failure to habituate stress tensor might solve array thought like you might be saved by it & then you weren’t or was it this dear flesh delayed in coming to light a few more days incision of choice finds you intern in life performance classically used & meantime hastened towards touch a face gloved up a love faced to grasp removal the ending of organ backstop verdure gone the way of loss vulnerable keloid its strickening 2 blunt instrument is capital resection finds me cavernous scar forest attached to all the world & you through the spleen its journeying & absences am I patient while medical magazines took your picture is it my cardiac story sending out guide wires in bleedback prevention I would have you ambulate sooner come back in dark pulses as you are in all the missing I find parts & limbs ranged on the sill & blooming are so many orchids cut & gathered I strain to scent them their late light 3 this instrument detects collisions is long & slender tool-tissue work seeking organ force beyond this data capture feeling is gripped algorithm or wooziness its drunken feedback sang Hitler Has Only Got One Ball as she went under it was her infancy as trauma returning he saw torque in an elegance of machine gesture shadow & plane distinguished burnt off without puncture in golden section she would sing to him if she could coming round shame without knowing why she could still belt it out 5–14 October 2012 | 9

Designing simulations

I

used to faint in biology lessons at school.

Just contemplating a diagram of an internal organ could make that part of my body ache, turn me as white as a sheet and send me out of the room. It is undoubtably one of the influences behind my journey to engineering and design so I was surprised in 2008 to find myself observing a real laparoscopic (keyhole) operation first hand, with my new business partner Cian Plumbe.

We were in an operating theatre at St Mary’s Hospital, Paddington, to observe the realities and dynamics of the contemporary operating theatre. Cian and I had started working together at the Helen Hamlyn Centre, Royal College of Art, a research centre dedicated to putting users at the heart of the design process.

We were trained to go the extra mile in understanding the experience of the people we were designing for, so when Dr Roger Kneebone (now Professor) and his colleague Dr Fernando Bello asked us if we could create a simulation of an operating theatre we headed straight to the real thing.

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It was this experience that led us to create the ‘igloo’ – the inflatable surround and collection of parts that make up the simulated operating theatre. It had to be portable, inexpensive and as high-fidelity as possible. We used the term high-fidelity rather than realistic as the emphasis was on recreating the high stress atmosphere of the operating theatre, rather than accurately reproducing every fitting and fixture.

The principle aim of the igloo is to be a barrier between the simulation and the arbitrary environment in which it takes place. First, it blocks out what shouldn’t be there in the room. Second, it sets a stage. Another key feature is the portable operating lamp which holds an embedded video camera and microphone allowing simulations to be recorded and reviewed.

The first simulations Roger and Fernando developed were laparoscopic procedures.

Clinicians were practicing removing gall bladders from porcine organs through small holes in a fake silicone skin. The action was focussed on a very small area

FAR LEFT: PHOTO BY LUCY CULLEN; LEFT: OPERATING THEATRE LAMP GRAPHICS BY CIAN PLUMBE, STUDIOHEAD

Designer Matthew Harrison describes how his company, Studiohead, work to create effective surgery simulations

so we designated much of the surrounding apparatus to set dressing. We represented the anaesthetic machine on a printed exhibition banner, and it worked! When the artificial heartbeat changed during the simulation, experienced clinicians looked up at our photograph of an anaesthetic machine expecting to see an explanation.

PHOTOS BY MATTHEW HARRISON, STUDIOHEAD

Design is an exploratory discipline; you look for inspiration in the wider world around you and apply it to the subject at hand.

One of the most valuable insights from our visits to the operating theatre was understanding the importance of sound.

You could get away with a greatly reduced physical reality if appropriate background sounds were used. The heart monitor’s rhythmic beep is obvious, but incredibly powerful. We also found that including ambient noise; the sounds of doors banging, machines gurgling and humming, and staff chattering just out of earshot, were incredibly valuable in allowing participants to forget they were in an ‘igloo’.

Later we created a more realistic anaesthetic machine. The aim was to give the anaesthetist a greater role in the simulation, and explore the dynamic between surgeon and anaesthetist. We used iPads for the

machine screens and created apps that allowed technicians to alter the vital signs, including heart rate and blood pressure.

The game changed a little when Roger met Max Campbell. Max made incredibly realistic silicone models of human organs; a skill he had honed on the set of Holby City.

This opened up the world of realistic open surgery simulations. Max could make whole sets of ‘giblets’ and make them squirt blood.

Now we wanted to simulate emergency procedures. For Cian and myself this meant designing body shapes that could house these magnificent organs, and present them in a convincing manner, as well as keeping them simple, hygienic and reusable.

As designers, we deliver physical products, graphic designs and electronic interfaces. For us design is an exploratory discipline; you look for inspiration in the wider world around you and apply it to the subject at hand. In this work we have been given the time and freedom to do that.

Studiohead is a London-based design practice run by Matthew Harrison and Cian Plumbe. www.studiohead.com L to R: simulated operating theatre set up for a laparoscopic procedure; design sketches for the simulated operating theatre lamp; simulated anaesthetic machine, incorporating iPads controlled from a remote iPhone; simulated patient with removable plastic tub that houses silicone organs.

5–14 October 2012 | 11

Anatomical artworks The British Library’s Science Team explore the scientific basis of artworks within their collections

I

n he 1950s, novelist and University of Cambridge physicist C.P. Snow controversially argued that there was a lack of communication between sciences and the humanities, and that this was a hindrance to solving many of the world’s problems. As modern science has become more specialised and reductionist in approach, some argue that this view is relevant today.

While the idea of bringing disparate disciplinary perspectives to bear on a particular problem might seem to tap into a new zeitgeist around interdisciplinary working, it is actually an approach that has been around for centuries. One area where the intermingling of the disciplines has been particularly apparent is in the field of anatomy, where drawing was used as a documentary record of the early explorations of the structure of the human body.

Leonardo Da Vinci (1452–1519) is known both as a great artist and as a scientist.

His prolific work included spectacular anatomical drawings that demonstrated both. Remarkable as they are, in the Renaissance integrating art, design and science as tools to explore and understand the world was normal. Andreas Vesalius (1514–1564), widely regarded as the father of anatomy, was also an accomplished 12 | Litmus Paper

LEFT: © BRITISH LIBRARY BOARD (MUSCLE MAN (DE HUMANI CORPORIS FABRICA), C.54.K.12, PG.181) RIGHT: DR J MAROOTHYNADEN, IMPERIAL COLLEGE LONDON (TAKEN FROM ANATOMAGE TABLE, USA)

draftsman. His classic De Humani Corporis Fabrica (On the Fabric of the Human Body) was fundamentally an anatomical text. But while communicating serious science, it also tapped into a renewed interest in classical sculpture during the Rennaisance, and many of the bodies in Vesalius’s book stand in dramatic, even humorous poses.

In order to create the illustrations, Vesalius performed dissections to produce charts of the circulatory, skeletal and nervous systems.

His work as an anatomist allowed him to build up a thorough understanding of the 3-dimensional body and emphasised how important this knowledge was in medicine.

However, it was the hand-drawn illustrations which allowed a wider audience to appreciate the science they contained – they were the precursor to modern day medical imaging.

Methods for understanding the structure of the human body have advanced dramatically since Renaissance times.

Along with technological developments, the combining of physics, chemistry, and computer science over the course of the 20th century has led to a range of imaging and scanning techniques such as microscopy, X-ray and magnetic resonance imaging (MRI), which reveal the inner structures of the human body in extraordinary detail.

When combined with computer modelling, these images can be used to build complete 3-dimensional views that can be explored and examined from all angles. As such, anatomy remains a field of science driven by the interpretation of visual images.

The British Library (which holds more than 11,000 books on anatomy) actively encourages interdisciplinary research, by creating a space for ideas where knowledge from science, design and art can be exchanged, transferred and developed.

It is clear how much can be achieved when we work in cross-disciplinary ways.

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Mad as a hatter?

DENISE INNES, FLOWER MADE FROM KNITTED WIRE MANUFACTURED FOR THE MEDICAL INDUSTRY

Director of the British School of Millinery Denise Innes explains how millinery skills connect with surgery.

process I must follow a specific sequence of actions, whist keeping in mind the client’s brief and aesthetics of the finished product.

In the last century materials used in millinery have been changing. Steel wire has been replaced by plastic wire. Base blocking fabrics have always been eco-friendly but recently new self-sustainable materials such as banana fibre (from the bark of the banana tree) have been introduced. The development of nylon thread has enabled milliners to create invisible stitches and more lightweight hair adornments. New materials provide a constant creative challenge. Most recently I have used knitted wire manufactured for the medical industry and used in surgery for stents.

I have manipulated it and transformed it into flowers and headdresses including a headdress for jazz musician Paloma Faith.

I feel a sense of urgency to make educationalists aware of the importance of practical dexterity and handmade skills

I

work in an industry with a 4000 year history, where the use of mercury once made madness an occupational hazard. Millinery has moved on with new technologies, but skills developed and practised in the past still resonate today.

While manufacturing has enabled mass production of hats, it has been at the expense of losing the unique qualities of handmade millinery.

In order to design the hats I make today I have had to perfect the techniques of my trade. Like all techniques, the best way to improve is practice, practice, practice. Each material I use requires different handling, for example felt needs soaking and heating overnight, straw needs soaking then stiffening. At each stage in the hat-making 14 | Litmus Paper

Working with Professor Roger Kneebone has made me aware of the links between his work and mine. In the current education climate I feel a sense of urgency to make educationalists aware of the importance of practical dexterity and handmade skills. In the 21st century these skills will be more important than ever and we are in danger of losing them. I look forward to a future where all of our budding graduates will be ‘all round’ students: academically minded and practically equipped. Ready to challenge their practitioners and prospective teachers with new technologies, materials, tools and share thoughts on how we can design the future of science.

Denise Innes will be part of ‘The Craft of Surgery’ on Sat 13 Oct

Emergency treatment; emergency research When seeking our consent might kill us: we might even have to trust our doctor! Hugh Davies explains.

W

hen we need urgent treatment it is unlikely we are in a position to decide what is best for us. In this situation we would usually turn to our nearest and dearest to represent us and provide an opinion. But are they in any better position?

Is it even fair to ask them? Consider yourself in such a predicament. Would you be happy to make a decision that might have serious consequences for your relative’s life?

It would seem questionable. Yet it is demanded of those treating us to ask us, their patients, what we wish to be done. They must allow their patients, or their relatives to choose. But why is this a problem? Well, we now have evidence that current emphasis on informed consent and autonomy can result in meaningless and fallacious ‘agreements’ that may even seriously harm us (Roberts I et al, 2011). Doctors might be killing people in their quest to ‘respect our autonomy’.

So what does this mean for emergency medicine? We may have to trust our doctors and give up our right to choose which course of treatment we get given, but while this might challenge (and horrify) academic ethicists, it may not be such a problem for patients and a public who still seemingly regard doctors as the most trustworthy groups in society.

We, as society, should not obsequiously hand out our trust; unaccountable trust is unwise and dangerous. We have a responsibility to ensure that doctors earn our trust. In giving them the authority to

make decisions that affect us we have the right to expect high standards. Doctors must demonstrate this to us, not vice versa.

It is fair that trust should be hard won and easily lost.

Patients and public… still seemingly regard doctors as the most trustworthy groups in society Care and research are difficult to disentangle (even, if indeed, we should attempt this separation). People are dying because we have done insufficient research, and we receive care that has no evidence base. (I use ‘we’ deliberately – it is a shared responsibility). A recent study (CRASH: www. crash.lshtm.ac.uk) has shown that an accepted treatment of serious head injuries does more harm than good. So doctors must research the care they provide (it is even in their General Medical Council terms and conditions!) and we must help them. Yet there is a dearth of trials on trauma care. Large trials are needed but circumstances mitigate against these. Funding is limited, collaboration in trials not adequately rewarded and the regulatory environment is increasingly complex and demanding.

Given our concern about consent as discussed above, how is this fairly conducted if consent is not possible? That is the question we put forward for debate. What conditions should we all attach to such care and research?

Hugh Davies is Research Ethics Advisor at the NHS Health Research Authority, London 5–14 October 2012 | 15

About the cover

by Phillip Kent

process of tiling, executed by the programming language, Processing. A hexagonal tile design is repeatedly copied and The two elements of this image tiled to fill space. The neat thing contrast a regular woven texture about the hexagonal tile is that and a random organic pattern. it can be rotated to any of six The juxtaposition was suggested positions which all inter-connect. by the surgical theme and by Lucio By manipulating the design and Fontana’s famous cut canvases. orientation of each tile, using The image is generated by a randomness or regularity, rich (surprisingly) simple mathematical sets of patterns can be generated.

EXPLORE THE TILING PROCESS FOR YOURSELF Go to the interactive version of the cover at www.designscience.org.uk/litmus-paper.

You can download the source code to your own computer to work on. You are also invited to contribute any code that you modify/create to our social coding website. phillip@design-science.org

Science at The Times Cheltenham Literature Festival

UNDERSTANDING ANIMAL RESEARCH Wed 10 Oct, 4–5pm Join scientist and broadcaster Adam Rutherford and cancer researcher Fran Balkwill to learn how animal research is boosting animal welfare, increasing alternatives to animal use and creating tougher regulations on animal testing while still making medical breakthroughs.

SILENT WITNESS Sat 13 Oct, 6.30–7.30pm The bestselling exponent of taut and compelling Scottish noir Ian Rankin, forensic anthropologist and author Kathy Reichs, and forensic pathologist Stuart Hamilton, Fellow of the Royal College of Pathologists discuss the true relationship between writing about murder and getting the science right.

WORLD OF SURGERY: UNDER MY SKIN Sat 13 Oct, 8–9.15pm Dance, poetry and storytelling fuse to explore the fascinating and intimidating world of surgery and the emotions it can arouse.

The evening concludes with a discussion chaired by BBC Radio’s Quentin Cooper from 9.30pm.

WORLD OF SURGERY: EMERGENCY – CARDIAC ARREST Sat 13 Oct, 12–1.30pm Compare the perspectives of patient and doctor through a realistic full scale simulation.

Roger Kneebone and his creative team from Imperial College London show what happens if you are rushed to hospital to have surgery for chest pain.

WORLD OF SURGERY: POWER AND SURGERY Sun 14 Oct, 12–1pm We explore how issues of power and control permeate surgery. In a lively panel discussion, ethicist Hugh Davies, historian of medicine and Wellcome Trust Engagement Fellow Richard Barnett, paediatric surgeon Laura Coates and clinician and educator Roger Kneebone highlight some controversial issues before widening the debate to the audience. Chaired by philosopher Raymond Tallis.

THE MODERN FAMILY Sun 14 Oct, 6–7pm Family psychologist Susan Golombok, scientist Doug Turnbull, ethicist Julian Baggini and Mark Henderson from the Wellcome Trust look at the ethics and evidence for the modern family.

L335 THE GEEK MANIFESTO Sun 14 Oct, 8–9pm From public health and clean energy to education and crime, Mark Henderson argues that science matters to every aspect of society and politics. Hear his rallying call to all geeks and wannabe geeks to join together in a new force our leaders cannot ignore.

For the full Festival line-up visit cheltenhamfestivals.com/literature or call 08448 808 094 to book tickets

CHELTENHAM LITERATURE FESTIVAL ‘WORLD OF SURGERY’ ILLUSTRATION BY ALEX BEECHING

CHILDBIRTH Sun 7 Oct, 12–1pm 2012 Wellcome Book Prize judges authors Brooke Magnanti and Ruth Padel, journalist Sue Matthias and neurosurgeon Henry Marsh join Mark Lawson to discuss births in literature and the impact of these scenes from a literary, historical and scientific viewpoint.