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mature judgment. The crux of the matter lies in the

interpretation of section 8 of the Family Law Reform Act1969. That Act states that "The consent of a minor who has

attained the age of 16 years to any surgical, medical or dentaltreatment... shall be as effective as it would be if he were offull age". What was omitted, whether deliberately or byoversight, was any express reference to the reverse situation,in which a child might wish to refuse consent to treatment.At first sight, it might seem logical that the right to

consent should go hand in hand with the right to refuseconsent. For an adult to give consent suggests that a decisionhas been made, on the basis of mature reflection on thealternatives, including refusal. However, in the 1991 case ofRe R, Lord Donaldson, one of the judges in the present case,held that consent and refusal were distinct processes. Thelaw had allowed children to give valid, independent consent,but had said nothing about refusal. In an example ofexceedingly restrictive interpretation, Lord Donaldsonconcluded that a child who was mature enough to consentwas not necessarily mature enough to refuse. To put itanother way, the extension to the child of the right to consenthad not taken from her parents (or the local authority, or thecourt exercising its wardship jurisdiction) their own powerto consent on the child’s behalf.This interpretation enables teenage girls to consent to

contraception, yet to be denied the chance to rejectlife-saving treatment. However, closer examination revealsflaws in the argument. To have the right to consent withoutthe right to refuse turns a procedure intended to protect thepatient’s right to bodily integrity into a meaninglessrubber-stamping exercise. If adolescents of 16 or 17 needprotection from their own ill-advised refusals of treatment,then surely the statute is misguided and we should also beprotecting them against acceptance of equally ill-advisedand unnecessary risks, such as cosmetic surgery. On theother hand, if J’s case approves the distinction betweenconsent and refusal proposed in Re R, it would mean that amature 17-year-old would have no right to veto her parent’sconsent to elective surgery, or to participation in a researchtrial, or even to an abortion. Furthermore, as was argued bycounsel before the High Court, the tone of the Children Act1989 is certainly to allow children the right to refuse as wellas to consent. Schedule 3, para 5(5), for example, explicitlypermits mature children who are under supervision ordersto refuse medical treatment.

It is very questionable whether J was in an emotional stateto make decisions. Holding her up as an example of thedanger of allowing full decision-making power to

adolescents who might be entrusted with important choiceswould simply not be appropriate. It would be unfortunate ifthe Court of Appeal were to use this case to imposeunnecessary restrictions on the law relating to the consent ofminors.

Elizabeth Roberts

ObituaryFritz Deinhardt

Prof Fritz Deinhardt, director of the Max von

Pettenkofer-Institut in Munich, died on April 30.Graduating at a time when German medical science was at a low

ebb (1952), Fritz Deinhardt left Germany to be trained in thelaboratory of W. and G. Henle in Philadelphia. He developedrapidly, working on mumps and various other virus/cell systems. By1961 he had a department in Chicago, where he followed up the

interests of the Henles in hepatitis. With his English wife Jean, azoologist, he did the most conclusive work at the time to show that ahepatitis virus could be transmitted to common marmosets. He alsobecame interested in retroviruses of primates, and what he learnedfrom this seemingly peripheral experience proved very valuablewhen AIDS came along. In 1977 he returned to Germany to behead of the Max von Pettenkofer-Institut in Munich, where hecontinued to direct productive research, particularly on hepatitis.

Deinhardt was an international man. His views were much

sought after by WHO and other bodies, and he chaired the ECprogramme EVA (support for research on vaccines against AIDS).He could criticise the three countries with which he was linked-

goading the British for revealing, as they talked, that they thought ofEurope as "them" and not "us". With Jean he complementedformal discussions and committee meetings with relaxed andgenerous hospitality. Many have cause to mourn his passing.

David Tyrrell

Robin Fox adds: When we were assembling The Lancet’sInternational Advisory Board two years ago, Fritz Deinhardt wasan obvious candidate-a careful and thorough reviewer, a medicalscientist of international standing, and a wise man. What we had notknown about was his generous spirit and his affection for thejournal. These emerged as we read a succession of messages fromMunich, consistently warm, positive, and creative beyond the call ofany duty. The Lancet has lost a good friend.

Noticeboard

Monitoring doctors’ competenceConcern about the ability of the medical profession to discipline

itself and about whether state licensing boards had access todisciplinary actions taken against doctors in their own or other statesled to the enactment of the Health Care Quality Improvement Actin 1986 in the USA and to the setting up of the National PractitionerData Bank (NPDB), which collects comprehensive data on punitiveactions taken against, and malpractice payments made on behalf of,health-care professionals. The law requires hospitals to check withthe NPDB the records of a doctor or dentist at time of appointmentand then every two years. Other organisations such as healthmaintenance organisations, nursing homes, and licensing bodiesmay also make inquiries.

In the year since the NPDB started operating on Sept 1,1990, thebank received almost 800 000 inquiries, an average of more than3000 per working day, mostly from hospitals.l 2500 health-carepractitioners sought information about themselves. 2779 (15%) ofthe reports made to the NPDB were of punitive actions taken withrespect to a practitioner’s licence, clinical privileges, or professionalsociety membership. Of the 1968 licensure actions, 35 % were of thepractitioner being put on probation, 17% were of suspensions oflicences, and 13% were of revocations of licences.There are no strictly comparable data against which to set these

findings, so their interpretation is difficult. Uncertainties about thedata are raised by the fact that the number of malpractice paymentsreported to the bank was approximately half that estimated by theGeneral Accounting Office for 1984. Similarly, the number ofmedical licensure actions was about half the number estimated bythe Federation of State Medical Boards (though the Federation’snumbers include actions for reasons other than medical

incompetence). And does the inverse relation between the rates oflicensure actions and the size of a state’s physician populationindicate that small medical communities are better able than largeones to exercise rigorous peer review, or that some feature of areaswith large doctor populations have a beneficial influence on

practice? Studies on how best the bank should operate, how it isbeing used, and its long-term effect on licensing and peer review areunderway or being planned.

1. Mullan F, Politzer RM, Lewis CT, Bastacky S, Rodale J, Hermon RG. The NanonalPractitioner Data Bank. Report from the first year. JAMA 1992, 268: 73-79.