The comments of An Orthopaedic Surgeon in his/her letter delivers some interesting insights into the prevailing paternalism of Malaysian medicine in some quarters.

To wit: 'I am the specialist doctor, so I should know what is best for Anwar Ibrahim, even though I have only 'done' (not necessarily operated successfully on) 25 possibly similar 'cases' (not 'people') but I am willing to categorically state, that I would not offer endoscopic surgery to Anwar even though I may not have examined him personally, or had a chance to analyse his current MRI scans.'

I would have thought that recommendations for treatment should never be made without being able to personally evaluate a certain quantum of medical information both clinically and radiologically.

Besides, if a surgeon has operated on only 25 cases, how can she/he project a statistically reliable disclosure of risk of such surgery in her/his hands?

Some doctors in Malaysia appear to need to improve their understanding of the concepts of patient autonomy and 'partnership with patients' in medical treatment decision-making. They should stop being so arrogantly prescriptive, particularly when risky surgery is involved.

Open de-compressive surgery may well end up being the 'right' medical answer for Anwar and for sure, such operations are performed routinely in Malaysia by suitably trained and experienced neuro and orthopedic surgeons.

However, I would not agree that these operations are always done 'without harm', anywhere in the world for that matter. There are a not insignificant number of unfortunate patients in Malaysia hobbling around partially paralysed, with incontinent bladders and disordered sexual function, who have had their spinal nerves irreparably damaged by inexperienced surgeons. Some of these surgical victims are even ortho-surgeons and general practitioners themselves.

Whatever the 'best' solution is (if there ever could be an unassailable entity as 'the best' in medicine) to Anwar's spinal problem, the final decision regarding treatment can only be made by the patient - not even his wife or lawyer - however illogical it may be. His doctors can only advise, not compel, as the patient obviously has capacity to consent.

The real issue is not what any doctor thinks is best for Anwar, or whether or not local doctors have adequate expertise for safe and effective endoscopic or other forms of spinal surgery.

What is contentious (it bears repeating) and is also a matter that requires urgent articulation is this: does Anwar, as a prisoner of the state, legally retain the right to choose the form of medical treatment he is to undergo?

If he does, the next question is how far that right extends and will it encompass overseas treatment?

So, it really appears that the decision to be made is not primarily a medical one any more. The patient has obviously been advised, and doctors must now stand back and allow Anwar's legal (and I daresay political) privileges to be defined by the persons who have the authority to do so.