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Cockcroft, A., Soper, P. and Insall, C. (1990). Antibody response following hepatitis B immunization in a group of health care workers. BY. 1. Indust. Med., 47,

Williams, J. R. and Flowerdew, A. D. S. (1990). Uptake of immunisation against hepatitis B among surgeons in Wessex Regional Health Authority. BY. M e d . J., 301, 154. Berridge, D. C., Galea, M. H., Evans, D. F., Pugh, S., Hopkinson, B. R. and Makin, G. S. (1990). Hepatitis B immunisation in vascular surgeons. BY. J. Surg., 77,

Porteous, M. J. LeF. (1990). Operating practices of and precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus during surgery. BY. Med. I., 301, 167-169. Joint Committee on Vaccination and Immunisation (1988). lrnrnunisation Againsf Infectious Disease, pp. 70-77. HMSO, London. Scully, C. and Matthews, R. (1990). Uptake of hepatitis B immunisation among United Kingdom dental students. Health Trends, 22, 92.

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26. Grady, G. F., Lee, V. A., Prince, A. M. et al. (1978) Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial. 1. Infecf. dis., 138, 625-638.

27. Werner, B. G. and Grady, G. F. (1982). Accidental hepatitis-B-surface-antigen-positive inoculations. Ann. Infern. Med., 97,367-369.

28. Anonymous (1991). BMA calls for mass jab plan on hepatitis B. Hospital Doctor, (211, (31).

29. Perillo, R. P., Schiff, E. R., Davis, G. L. et al. (1990). A randomised, controlled trial of interferon alfa-2b alone and after prednisolone withdrawal for the treatment of chronic hepatitis B. N, Engl. 1. Med., 323,295-301.

30. Carl, M., Blakey, D. L., Francis, D. P. and Maynard, J. E. (1982). Interruption of hepatitis B transmission by modification of a gynaecologist's surgical technique. Lancet, 1, 731-733.

31. Lettau, L. A., Smith, J. D., Williams, D. ef al. (1986). Transmission of hepatitis B with resultant restriction of surgical practice. J A M A , 255, 934-937.

32. Kennedy, S. (1991). An elementary mistake? BY. Med. I., 302, 1614.

Against the proposition: Patrick Walker INTRODUCTION One individual however unhealthy, is unlikely to be in contact with a large number of doctors during their life. A doctor, however, by the nature of his profession, is likely to come into close contact with an exceedingly large number of patients, often unhealthy, through his professional career. In simple terms, therefore, when considering infec- tious or transmissable diseases, the risk to the doctor from patients is significantly higher than the risk for the patient from the doctor.

Although doctors no longer take the Hippocratic Oath, it is reasonable to believe that none would wish, know- ingly, to inflict harm on any patient. On the other hand, it would be arrogant in the extreme to believe that every action performed by doctors resulted in benefits for the patient. Indeed, one does not have to be unduly cynical to believe that the best a doctor can hope for is that by the end of his career he has on balance, done more good than harm to those who have sought his care and attention. For this reason, a balance is immediately struck between benefit and harm. It is not possible therefore, to argue that any phys- ician or surgeon who might be positive for any particular infectious agent should be prevented from practising medicine. In particular, there would have to be stringent arguments for saying that the area in which they were to practise should be curtailed.

For example, one could have a poor surgeon many of whose patients got wound infections, complications as a result of these infections leading to bedrest, immobility, venous thrombosis and embolism who, at the end of his surgical career, may have done much greater harm than a

proficient surgeon, operating within good tissue planes, with adequate haemostasis, whose patients rarely had complications as a result of his superior technique. Yet this particular surgeon might himself be a hepatitis B carrier and yet never have transmitted because of his surgical skill. Indeed, published accounts suggest that even when surgeons are discovered to be carriers, however distressing it is that any infection should be passed on to a patient, not only is the transmission rate low considering the number of operations performed, but the sequelae, although important, are rarely fatal.'z2 It follows that, while surgeons would undoubtedly have to submit to testing if an outbreak of hepatitis were to occur in their area of work, there would be no indication to screen practitioners unless such an outbreak occurred.

It may be thought irresponsible to let a surgeon continue to practise knowing that he was a carrier of hepatitis B. Yet, most surgeons are seropositive for Epstein-Barr virus and are probably excreting virus into their saliva on many occasions that they operate. EBV can cause B-cell lympho- mas and has been transmitted by means of donor organ yet, fortunately, there is no evidence that EBV is transmitted from surgeon to patient. This shows that patients can continue to benefit from the skills of EBV seropositive surgeons and that draconian restrictions on clinical practice should only be instituted once repeated transmission of disease has been proven.

HEPATITIS B IMMUNISATION Hepatitis B is an area which introduces a new concept, that of protecting the surgeon. It is now possible to offer

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medical and nursing staff immunisation against hepatitis B before they come into contact with patients from whom they might acquire the disease. As it appears that the vaccination process itself carries no risk to the medical or nursing practitioner, it should be encouraged.

There is, however, one area of difficulty. Once the sub- ject has been immunised it is the usual protocol to check the surgeon for antibodies at an interval, to be sure that the vaccination has worked. At first sight, this would seem common sense. However, there are two reasons why the doctor might not be antibody positive. The first situation would hopefully be that the vaccination had simply failed to take and another course was required. However, an alternative situation might be that the surgeon was a carrier of HBV.

Before an undergraduate medical student embarked upon a surgical career there would be some disappoint- ment if it was felt necessary to advise the undergraduate that his choice of future career should be limited to non- surgical specialties. This of course, begs the question as to the likelihood of transmission from a hepatitis B positive surgeon to a patient, but at this stage in the doctor's development, such recommendations might be thought reasonable.

A more difficult situation arises in a practising surgeon who after graduating from medical school has undergone a perfectly satisfactory period of surgical training, may well have obtained specialised qualifications and has planned his future career in the surgical field. Indeed, this practitioner might be a particularly talented surgeon. If he reports for vaccination and is encouraged to have a post vaccination check up to ensure that he has seroconverted, he runs a significant risk, if he should be found to be a carrier of HBV. Indeed, in some areas one can see the situation arising where a doctor could be prevented from pursuing a career upon which he has embarked and into which he has put so much investment. With a surgeon in later life it might well be that he has a National Health Service and a private practice supporting a family and a mortgage dependant solely on his ability to perform surgical procedures. The implications for this individual if someone were to suggest they should not carry on in the surgical specialty could be literally devastating.

Furthermore, one would have to consider how well this surgeon could perfom in 'low risk areas if he were forced to change career. If he were given preference over col- leagues who had themselves trained in 'low risk' medical specialties, then they would feel disgruntled and patients would be denied the expert advice that their colleagues were being trained to give. For example, Occupational Health, Public Health Medicine and Medical Virology are 'low risk' specialties but surely deserve to be practised at a higher level than by a disgruntled ex-surgeon.

It is clear therefore, that, before advocating any method of screening, it would be necessary to adopt one of two policies. The first would be to say that anybody participat- ing in the scheme who was found to be HBeAg positive and prevented from practising would have full compen- sation commensurate with their position and salary, both inside and outside the National Health Service, if it were

the conventional wisdom that this was necessary. As it would be almost certain that such positivity had been acquired as part of their professional duties, the morality of this would be clear and a possible benefit to patients argued. The amounts of money involved, however, might be quite considerable if there were a significant number of surgeons involved and, returning to the earlier discussion, it might be that preventing the good surgeon who was HBeAg positive from practising allowed in his place a less proficient surgeon to do more damage to more people than the positive surgeon could ever have done. The second policy would be to offer hepatitis B vaccination to sur- geons without insisting on post-vaccination antibody check ups, certainly to those already established in training grades and at senior level. If a patient should acquire serum hepatitis soon after a surgical procedure on more than one occasion in the hands of one surgeon in any 6 month period it might at that point be necessary to suggest that the surgeon be screened and the compensation mechanism alluded to above, put into place.

CONCLUSION If there is to be cooperation between medical staff and the occupational health physicians in areas of screening, then there will have to be clear guidelines, probably by statute to ensure the following:

'If as a result of taking part in a screening exercise a medical practitioner should be found to be carrying hepatitis B which, on the balance of probabilities he has acquired during his professional practice, full complete and appropriate compensation should be payable by the State to the the practitioner, to cover all areas of his professional practice if restrictions on his ability to practise are deemed necessary'.

Unless such an undertaking is given it is highly unlikely that screening, even if one accepts it as a good idea (which is speculative), will meet with the necessary cooperation from the profession.

PROPOSALS On entering medical school, all undergraduates should be immunised against hepatitis B. All should be offered post-immunisation antibody screening and those found to be HBeAg positive (a small number reflecting preva- lence in the general population of that age) counselled about choice of medical or surgical career. All practitioners in training or trained should be offered immunisation. Those who elect to have antibody screening after immunisation and are found to be anti- gen negative and antibody negative can decide how they wish to proceed taking advantage of immuno- globulin prophylaxis after needle stick injuries in high risk cases. Those who elect for antigen screening and are found to be antigen positive can be handled in one of two ways depending on their prevalence in the surgical population, a figure that needs to be identified by a large truly anonymous screen: (i) If the prevalence of HBeAg positivity in the

practising surgical population is low, then full and

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commensurate compensation should be awarded to surgeons who decide or who are advised to change career direction as outlined above.

(ii) If the prevalence of antigen positivity in the surgical population proves to be high, the compensation should be directed towards those patients suffering morbidity themselves or in their families, as a result of acquired disease thought to be as a result of surgical transmission.

Perhaps it is worthwhile bearing in mind the image of the virus carrying proficient surgeon and the non-virus

carrying inefficient surgeon and comparing at the end of their professional career the balance of good and evil that each has performed.

Mr P. Walker

REFERENCES 1. Anonymous (1991). Surgeons who are hepatitis B

carriers. Br. Med. I., 303, 184-185. 2. Heptonstall, J. (1991). Outbreaks of hepatitis B

virus infection associated with infected surgical staff. Communicable Disease Report, I, R81-R85.