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When we hear about a person’s ill fortune, the essence of good communication is for both parties to feel that they are connecting—that is, ‘on the same wavelength’. The way we act is underpinned by our attitudes and reflects our personality. Sometimes, especially when faced with unfamiliar circumstances, we are unsure of how to respond. After all, attitudes are complex, being influenced by diverse factors including life experiences, our inherent idiosyncrasies and prevalent societal values. They are therefore vulnerable to criticism when we fail to connect. With my experience of permanent paralysis from a spinal injury sustained a few years ago I have had an opportunity to reflect on these matters. One way of responding to a person’s bad news may be to express empathy. But what is empathy all about? When is it appropriate to empathize and is this something that we can learn to do? Is empathy an innate quality or does it stem from acquired notions of how we should behave towards others? First and foremost, we need to find out how the person has been affected by events. Having gauged their perspective, we need to form our own perspective of events and, in order to empathize, feel touched by what has happened to them. This is inevitably coloured by our own previous experiences; disruptions to our own ‘normal life’ can give insight into the hardships of others. However, it is less the extent of our own hardship than how we have coped with it that affects our behaviour towards others. And, of course, we can learn much from the ways other people react to our misfortune. Those who communicate well—with that magical gift of acting comfortably and saying the right things at the right time—can teach us a great deal. So can those who get it wrong. After becoming paralysed, I was among patients who, although proceeding through a rehabilitation programme aimed at similar skills for independence, were reacting in very different ways. Some patients were deeply angry, others were resigned. Observing the responses of those around me, I could see the futility of anger and bitterness. A phase of grieving for what has been lost is unavoidable, but my own adaptation was to concentrate on the capabilities that remained. Moreover, returning to medical practice, I found myself in some ways stronger. I have learned from my own experience and those of others that growth through hardship is possible, and that the worst fate is to acquire the destructive baggage of a hard-done-by victim. People rarely come to terms with extreme hardships; they simply adapt and find different ways of living. In this process health professionals, I can testify, can provide crucial support that goes far beyond their technical skills. The key is empathy. When a person’s hardships seem beyond verbal communication, a simple acknowledgment of the inadequacy of words can be the most powerful statement of caring and support.

Four years ago, when giving a talk about living wills, I stressed that such wills could express the wish to stay alive with life-prolonging measures for as long as possible. In 1999, I was the Vice-Chairman of the Voluntary Euthanasia Society, and, since then, VES has been gradually developing this idea of a living will that offers a choice. The term living will was first used in 1969 by an American lawyer, Louis Kutner. The document is a ‘will’ in that it states a person's wishes. And, it is ‘living’ because it takes effect before death. In the past, the typical living will (also known as an advance directive, an advance refusal, or an advance statement) has only allowed patients to refuse medical interventions or treatments which were aimed at prolonging or sustaining life. Opponents of living wills have condemned such documents as ‘suicidally motivated refusals of medical treatment’. The VES has now produced a new living will that can be used equally well by those who want medical treatment to be given to prolong their lives for as long as possible. This new document (www.ves.org.uk) demonstrates just how concerned VES is to ensure that all citizens should be able to choose the right treatment options in the event that they lose the mental capacity to be involved, with their physicians, in making such medical decisions about themselves. The essential section of this new living will is the following, in which two specific circumstances are described. One is an ‘Imminently life threatening physical illness from which there is little or no prospect of recovery’, and the other is a ‘Very serious mental impairment with no prospect of recovery together with a physical need for life sustaining treatment’. For both situations, an individual has to choose between ‘I wish to be kept alive for as long as reasonably possible and consent to all appropriate medical treatment’ or ‘I refuse medical treatment aimed at prolonging or artificially sustaining my life. I consent only to medical treatment whose aim is to keep me comfortable and, so far as possible, free from pain. I refuse all other medical treatment’. Another important section of this new variant of the living will allows for the naming of a ‘health care proxy’, where this individual has to sign that he/she agrees to assume this role. In Scotland, health care proxies are known as welfare attorneys and these people are recognized under the Adults with Incapacity (Scotland) Act 2000 as having the legal power to make decisions on someone's behalf in accordance with what that person's specific wishes would have been. In England and Wales, proposals are being discussed that should clarify the legal status of a health care proxy. Who benefits from a person writing a living will? Mainly, of course, it is the patient and we are all patients sooner or later. Then, doctors benefit since they no longer have to guess what a patient would have wanted. And, thirdly, family and friends have documentary evidence of a person's wishes. This living will can generate useful discussions between the person making the will, the general practitioner and the family. Various authorities can be cited in support of living wills, ranging from the Lord Chancellor, Lord Irvine (in 1998, writing that they have ‘full effect in common law’) to the BMA (in 1999, stating that ‘where a patient has lost the capacity to make a decision but has a valid advance directive refusing life-prolonging treatment, this must be respected’). Then, in 2002, the General Medical Council noted ‘Adult patients who have the capacity to make their own decision can express their wishes about future treatment in an advance statement’. In the United States a federal law stipulates that, upon admission to any hospital receiving federal funds, a patient must be asked if a living will has been signed. In Denmark, a centralized computer records the details of everyone who has signed such documents. And, in Israel last year, the Health Ministry accepted a recommendation to have a similar computerized database established in that country. All responsible adults should have made a regular will stating exactly where their financial assets and possessions will go. And, I believe, all medical and nursing personnel should make a living will, setting an example for others to follow, because this could be of great assistance someday to their personal doctors, family and friends.

Mental health care is a complex activity. Those involved include patients, carers, clinicians, purchasers and the public, and these groups have different perspectives and viewpoints on mental healthcare. These viewpoints can be conflicting, and an understanding of their differences is vital for planning. One example is the contrast between the ideas behind evidence-based medicine and user empowerment, which can reflect the differences between a modern and a postmodern view of the world1. Here we discuss the potential impact of postmodern philosophical and cultural change.

I have probably heard them all—the often weird and wonderful arguments against applying the principles of science to complementary/alternative medicine (CAM)1. Specifically, the arguments against testing the efficacy of therapeutic approaches in CAM have worried me frequently and profoundly. Here I address eight arguments, all of which find expression in many different ways. I hope that the views expressed, even though doubtless biased, will stimulate constructive debate.