The 3rd International Conference on Injury Prevention and Control

The 3rd International Conference on Injury Prevention and Control

[NOTE: The official Web site for this conference, which was formerly located at www.nisu.flinders.edu.au, is no longer available. Links from this page have been removed accordingly. ]

The 3rd International Conference on Injury Prevention and Control was held in Melbourne, Australia from February 18-22 1996. For bicycle helmets, there was a poster session and an oral session.

Many of the world’s leading helmet activists were there: Michael Henderson (Australia); Diane Thompson, Robert Thompson and Frederick Rivara (HabourView/Puget Sound, Seattle); Philip Graitcer (head of the WHO Helmet Initiative); John Langley, Paul Scuffham (Otago, New Zealand); Stig Hakansson (Swedish Helmet Initiative); Peter Vulcan (Monash Accident Research Centre); and others. Representing “the other side” was Nigel Perry of New Zealand.

While a common theme which emerged was that “any helmet is better than no helmet”, this was rather contradictory to other issues raised, namely that bad fitting helmets can provide little or no protection; and that it is difficult for many people to find a helmet that fits properly. To add to that, from New Zealand we had an interesting new concept that people simply don’t know how to wear their helmets properly!

It was argued that real (i.e. anecdotal) cases should be used to promote helmets as this is very persuasive. Given that virtually all of the attendees were already completely sold on helmets as “the” solution, it was not considered an issue that this approach gives a misleading picture and over-emphasises helmet benefits while distorting the real scale of bicycle injuries. Someone was heard to state that “negative cases will always occur”. This is of course true, but it is no reason to dismiss them!

Moral, social, ethical and legal issues are not the concern of injury prevention professionals, or so they say. Never mind that the research studies they conduct are geared for one ultimate purpose: to provide the needed support for helmet legislation which they have already pre-determined as being “the way to go”. One researcher was heard to argue that it was their job to provide figures to politicians to make decisions on laws, and if they want these figures in context then they should ask. When asked shouldn’t these figures be provided in context it was simply argued that this wasn’t their job.

It was argued by one attendee that scientists have a responsibility to give a balanced view and that they were not doing so. By highlighting the benefits of helmets and ignoring the negative results, not putting cycle injuries into perspective, and ignoring the social impact of children being required to wear helmets virtually everywhere, it was argued that they had lost balance in injury control and that this was wrong.

The hypocrisy of it all. Head injury rates per time-exposure for car occupants and cyclists are about the same. Helmets can potentially benefit car occupants as much as cyclists. Injury prevention professionals know this but they see promoting such helmets as futile. Interestingly, this is largely due to the “dork factor” which they have systematically attacked and eroded for cyclists, but which poses a far greater obstacle with motorists. Add to that, most of the injury prevention professionals are probably not overly keen in having to wear helmets in their cars themselves. When it is put to them that they should wear a helmet in a car if they promote cycle helmets (and the corollary of bicycle helmet laws) they are at a loss. To them a cyclist is irresponsible if they don’t wear a helmet, and therefore must be forced to do so, but they are not irresponsible when they themselves ignore the dangers for motorists. The hypocrisy of this doesn’t seem to dawn on them.

In discussions on the Australian situation it was bemoaned by many that the Australian police now had little interest in enforcing the law. Action was called for to lobby the Government to start “re-emphasising helmet wearing” (Note: it is a fact that a fresh series of “wear your helmet” radio commercials emerged on Australian radio stations not long after the 3ICIPC conference). It was also commented that once the law had been passed the Government’s general attitude was that they had done all that was necessary for cyclists, so other measures were not needed. Representatives of cycling organisations have commented to similar effect, that it is difficult to “get anything done” these days.

Stig Hakansson gave a talk about helmet initiatives in Europe, but in particular the Swedish Helmet Initiative. They’ve been promoting various helmets for a long time, but everything was going fine until 1990 when the tragedies started – children dying from suffocation when their bike helmets got stuck in play equipment, trees and other objects – they’d hung themselves! A comment was made along the lines of “We knew we’d killed, but didn’t know we had saved anybody”. However their faith in the approach overcame all obstacles and they came up with the self-release buckle system so kids couldn’t get hanged. This system makes the helmets unsuitable for use in traffic. Nevertheless, someone was heard to suggest it was badly designed play equipment and a tree in the wrong place that caused the problems! It’s not as if the kids actually climb the trees on purpose, surely!

Thompson, Rivara and Thompson presented data from the latest of their emergency room case-control studies which this time found that helmets provide a 70% decrease in risk of head injury, but were reportedly at a loss to explain the negative results from New Zealand. Nothing was said of the similar failures shown by Australian data, possibly because Australian researchers have been slightly less than honest in ignoring the reduced cyclist numbers and generally safer roads after the law while readily quoting figures which showed less head injuries and high helmet wearing rates.

Rivara gave a five point plan or set of goals for increasing helmet use in their campaign in Washington State:

  • increase parent awareness
  • remove cost barriers
  • overcome the “nerd factor”
  • target 6-12 year olds
  • focus on helmets – not riding behaviourThe last point is interesting. Don’t address the cause just the symptoms. Just give them a helmet and point them towards heavy traffic. It was argued however that trying to improve behaviour doesn’t work. You have to wonder though if maybe they dismissed education too readily. Perhaps their idea of cyclist safety education is to tell people to wear a helmet; and if they still don’t wear a helmet then conclude that education has failed.

    Paul Scuffham of New Zealand presented the paper “Trends In Cycle Injury In New Zealand Under Voluntary Helmet Use”. This study concluded that “The percentage of serious head injury among cyclists has not shown the expected decline as cycle helmet wearing has increased”. This study also found that promotion of helmets (never mind legislation) had reduced cycling, something like a 27% drop in teenage cycling in the 5 years leading up to the law. The author was apparently given a hard time in his presentation, with some members of the audience attacking the results and saying they simply must be wrong, and yet it was reported that the New Zealand Land Transport Safety Authority (LTSA) had sent the research back “two or three times” to Otago for checking and further investigation – but the results stood. I have also heard that Peter Vulcan had stated that he had checked the New Zealand figures and couldn’t explain them, but insisted that helmets do work.

    The attacks on Mr Schuffham seemed a little unfair, as it seemed that he had obviously tried very hard to find a positive result which simply wasn’t there. While it is believed that Mr Schuffham is still in favour of helmets and helmet legislation, it was reported that he felt that, perhaps, the benefits of helmets were being oversold.

    “Regaining Balance In Injury Prevention”, presented by Nigel Perry of New Zealand. “This short presentation will highlight some of the ways in which New Zealand, a country held up as an example by the WHO Helmet Initiative, has erred and the absurdity of some of its actions. We will argue, that though the motives behind most pro-helmet campaigns might be commendable, that compulsory laws are a “step to far” and indicate a loss of balance in injury prevention. In introducing such laws we are building an undesirable environment for the next generation, and those that do exist should be abolished.”

    “Cycle Helmets: Fit To Buy Or Bought To Fit?”, presented by Judith McCool of New Zealand. In the wake of the other research from New Zealand which found that the risk of head injuries had not decreased with increased helmet wearing, Judith McCool visited all 53 shops in Christchurch which sell helmets and asked for help in purchasing one. In all 53 cases she argued that she had be given bad, poor, or wrong advice. Ironically, the paper was co-authored by John Langley, who was reported to have complained at a round-table discussion at the conference that he was unable to find a helmet that would fit him!

    So, wonderful lifesaving helmets aren’t protecting people from the big bad motor vehicles because people just aren’t strapping them on their heads the right way. Brilliant! It should also be pointed out that it takes “a good 10 to 15 minutes” to adjust your helmet properly. Many case-control emergency studies (such as the recent one from Seattle) have found very high protective benefits for helmets, but it seems that those studies must have been conducted in other parts of the world where people actually know how to wear a helmet properly.

    I should point out that most of the helmet legislation in Australia actually stipulates that the helmet must be “correctly fastened to the head” (or words to similar effect) so perhaps the solution is simply to get the police to start dishing out fines to offenders. After all, if your helmet isn’t properly fastened then you are breaking the law.

    “Efficacy Of Mandatory Bicycle Helmet Legislation In NSW”, by Merdyth-Ann Williams of NSW, Australia. This poster claimed that “Since legislation [in NSW] there has been a decrease in bicyclist fatalities of 60% and serious injury of 21%.” That is an impressive reduction in fatalities, until you look at the actual data:

        Number of Cyclists Killed in Road Traffic Accidents in NSW
                Year    Killed   Helmet  No Helmet  Unknown
                1989    19        3        13        3
                1990    20        1        18        1
                1991*   10        7         3        0
                1992     6        5         1        0
                1993     8        7         1        0
                1994    23       16         5        2
                1995     ?        ?         ?        ?
    
                * Helmets law introduced in NSW in 1991, on 1 January for 
                  cyclists 16 and over and on 1 July for children under 16.

    This table shows number of cyclists killed in NSW. Source: Roads and Traffic Authority of NSW, Road Traffic Accidents in NSW Annual Statistical Statements. CRAG does not at present have access to the statistical statements for 1995 and later.

    The 60% reduction was apparently derived by comparing 1990 (20 deaths) with the average for 1991-93 (8 deaths per year). There is no statistical significance in these figures, with such small numbers being subject to large variation due to random chance. However, two points are immediately obvious; one being the large increase in deaths in 1994 (the author may have been less than honest in ignoring the 1994 figures which she surely had no excuse for not being aware of), the other being the high representation of helmeted cyclists. In fact, helmeted cyclists accounted for 80% of the post-law deaths (excluding those where helmet wearing status was known), which matches the observed percentages of helmet wearing (85% for adults and 76% children, or 80% overall). This was noted by Robinson (Accident Analysis and Prevention, 1996): “excluding cases where wearing status was not known, 80% of cyclists in NSW from 1992-94 were wearing helmets when killed on the roads (RTA 1992-94)”.

    The “reduction in serious injury of 21%” is apparently a measure of the reduction in head injuries compared with non-head injuries. This type of analysis is misleading. Firstly because various anti-speeding and measures and RBT had made NSW roads safer at the same time as the helmets law was introduced. Reducing motor vehicle speed and involvement in bicycle accidents has been shown to lead to significantly greater reductions in head injuries compared with reductions in other injuries. Secondly, because they assume that all other factors are equal (eg that riders forced to wear helmets aren’t taking more risks and suffering more overall injuries than before, with the protective benefit of their helmets cancelled out by increased risk taking).

    Williams states that “since legislation bicyclist head trauma has been significantly reduced”, but this should not be so quickly attributed to helmets. After the law, NSW saw a 39% decline in total head injuries to children under 16, but child cycling also declined by 39%. At the same time, head injuries to child pedestrians declined by 19%, and head injuries to children from all road accidents declined by 26%. After allowing for the decreased cyclist numbers and safer roads (shown by the decrease in pedestrian injuries), the relative risk of head injuries to cyclists actually increased!

    For adults, head injuries also declined by 32% while non-head injuries declined by only 4%, but there is no reliable data for the measure of change in the numbers of adult cyclists (although it is likely to be similar to that of children since “adult” is defined here as over 16 and the older teenagers represent a large proportion of bicycle users and are the most averse to helmet wearing).

    For a more detailed look at the NSW data, click here.

    Finally, the poster “The Effectiveness of Wearing Pedestrian Helmet While Walking From Home to School in Elementary School Children” by Tatushiro Yamanaka and Arata Ogihara was also of interest. “The principal of the school can decide whether helmet wearing should be a rule for pupils”. Yes, in Japan some kids have to wear helmets while walking! The paper concludes that it hasn’t reduced injury rates significantly (injury rates were 0.18%/0.22% and head injuries 0.012%/0.018% for helmeted/unhelmeted kids). What is frightening is that they introduced the rule in the first place, and how few people amongst all those present seemed to think that it had gone too far.

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    Compulsory Bicycle Helmets: Unfair Discrimination

    Wearing of helmets has been compulsory for cyclists in Australia for years, but how many people know that reports of the Federal Office of Road Safety, in 1987 and 1998, recommend them for occupants of motor vehicles too?

    Hoping that helmet wearing would reduce serious head injury and satisfied that the costs and inconvenience to bicycle riders were “more than balanced by the savings to the community”, Australian governments made it compulsory for cyclists. They have not applied this reasoning to vehicle occupants, whose head injuries cost $1.5 billion a year! Instead, FORS published the 1998 report “so that the community can make informed choices” and emphasised helmet wearing as a voluntary measure only – in contrast to giving cyclists no choice.

    As costs of helmets to motorists and cyclists would be the same, governments must be assumimg that helmet wearing would cause greater inconvenience to motorists. As shown below, the reverse is true.

    Important inconveniences of wearing a helmet are difficulty of secure storage, less protection from the sun than is provided by a normal hat and a restricted flow of air to keep the head cool.

    For cyclists, secure storage of helmets can be difficult. At places of work, storage may be easy, but at schools is likely to be difficult. In retail premises and public buildings it is usually not possible. For occupants of motor vehicles, secure storage would be easy.

    Medical research has found “for people outdoors in Australia, a hat with at least a 7.5 cm brim is necessary to provide reasonable protection around the nose and cheeks, those sites on which non- melanoma skin cancers commonly occur.” As helmets have narrower brims, a cyclist wearing one is not adequately protected, whereas the roofs of motor vehicles shade their occupants.

    Helmets restrict the flow of air needed to dissipate heat generated through the exertion of cycling, causing discomfort in hot weather. Occupants of motor vehicles do not exert themselves and would suffer less discomfort.

    It has been argued that some vehicles provide insufficient headroom to allow occupants to wear a helmet. The argument is spurious. Such vehicles would be rare, only tall people would be affected and could use a headband as an alternative – see media release below.

    Clearly, helmets cause much more inconvenience to cyclists than they would to occupants of motor vehicles, and bicycle helmet laws discriminate unfairly.

    The inconvenience of helmets to cyclists is of course borne out by the decline in cycling, by about a third, after the introduction of compulsory wearing. As rates of casualty to the remaining cyclists increased, this inconvenience was not balanced by savings to the community.


    Media Release

    COMMONWEALTH DEPARTMENT OF
    TRANSPORT AND REGIONAL
    DEVELOPMENT

    18 September 1998
    D2/98

    PROTECTIVE HEADWEAR FOR CAR OCCUPANTS

    Head injuries to car drivers and passengers could be reduced by as much as 25% if they wore light protective helmets or even padded headbands, according to a research report released today by the Federal Office of Road Safety (FORS).

    The report presents findings from a two-year study on head and brain injuries among car occupants. It was jointly conducted by the NHMRC Road Accident Research Unit (University of Adelaide) and the Monash University Accident Research Centre.

    The study found that bicycle-style helmets would be as effective as driver airbags in preventing head injuries, and would provide considerably greater head protection than many other in-vehicle options, such as improved interior padding, side-impact airbags or advanced seat-belt designs.

    Professor Jack McLean, head of the Road Accident Research Unit, said that use of protective headwear could be a particularly valuable safety option for people with older cars, but even drivers with airbags would benefit significantly from the added protection.

    While full helmets would provide the greatest safety benefits, Dr McLean’s detailed study of head injuries found that specially designed headbands could offer an innovative and practical alternative.

    The proposed headbands would apply padding to the front and sides of the head. where most impacts occur. They would be lighter, cooler and less bulky than a conventional helmet.

    A FORS spokesperson emphasised that protective headwear was being put forward as a voluntary measure only. “Car occupants are already better protected than cyclists or motorcyclists. But this research shows that safety could be improved quite a lot by using simple, low cost head protection. We are publishing these results so that the community can make informed choices.”

    Head injuries to vehicle occupants account for almost half of all injury costs from passenger car crashes. Beside the costs in human suffering, this represents a monetary cost to the community of about $1.5 billion per year.

    The research report will be given to Australian helmet designers and manufacturers.

    Copies of the report, Prevention of Head Injuries to Car Occupants: An Investigation of Interior Padding Options (CR 160), are available from the Federal Office of Road Safety by phoning (02) 6274 7185.


    Ms Pam Leicester, a behavioural scientist from the NRMA’s Road Safety Department, said the idea had merit, but it would not be easy to persuade motorists to wear helmets. – Sydney Morning Herald, 22 September 1998

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    Henderson Paper Reviewed

    The 1995 Henderson report can be found here.  It is another report exaggerating the benefits of helmets, funded by the NSW government.

    Another critique of this report can be found here.

    Individuals and organizations zealously pushing mandatory helmet use for cyclists are continuing to churn out reams of propaganda. One of the more voluminous efforts is Michael Henderson’s “The Effectiveness of Bicycle helmets: A Review” 1995, a politically motivated paper prepared on behalf of the Motor Accidents Authority of New South Wales, Australia apparently in a desperate effort to justify the State’s botched law outlawing cyclists who ride without a helmet.

    Henderson’s report recycles much of the same old material that’s been cited by others over the years. The studies he references fail to provide a real world context, and to show any particular understanding of cycling. Although presenting bicycle head injuries as a worldwide problem, Henderson neglects to provide us with any sense of the size or scope of it. Worldwatch Magazine in its Jan/Feb 1993 edition reported that bicycles outnumber cars globally two to one, but only 2% of the world’s traffic fatalities are cyclists. Mayer Hillman in “Cycle Helmets – the case for andagainst” states that only 2% of all cycling injuries are severe or critical head injuries. So why didn’t Henderson paint the background? Maybe it was fear of having his grand illusion exposed.

    Nowhere in the report does Henderson respond to other issues raised by Mayer Hillman in his authoritative 1993 review of available helmet research. Hillman identified deficiencies in the methods used by researchers. Ironically, Henderson relies heavily on many of the same researchers. It is inconceivable that Henderson was not aware of Hillman’s widely quoted study. We believe that he chose to ignore it because it completely undermines his own report. Such is the nature of those who are so obsessed by the means that they lose sight of the end, in Henderson’s case – his commitment to universal helmet use by legislated means causes him to ignore evidence of the negative effects such a measure has on community health.

    Here are some strong reasons why we should be concerned about Henderson’s paper.

    Henderson Ignores Safer Cycling Environment

    Henderson uses the growth worldwide of bicycle sales in comparison to car sales over the last 20 years and fatality rates to show that he believes there is a cycling problem. “The number of new bicycles produced is now three times the number of new cars” he says, and elsewhere “over the 20 years 1970 to 1990, bicyclist fatality rates per l00,000 people have fallen by an average of 1.0 per cent each year, but this is a rate of fall less than one-third of that shown by other road-user groups.” Although his point is unclear, he seems to be saying that the decline in the fatality rate of cyclists among the population should have matched the fatality rates of other road users. Such a comparison and any conclusion derived from it would be erroneous because it is based on rates among the population, not cycle usage. Besides a slower fall in the cyclist fatality rate is to be expected given that the number of cyclists among the population is increasing faster than other road user groups, and given that some groups may not be increasing at all, for example pedestrians. Evidence suggests that walking is declining as population switches to car use. In the 10 years ending in 1986, UK commuters reduced journeys on foot by 7%.

    Henderson’s interpretation of the statistics he presents conceals the much greater problem for society, which is the large number of head injury fatalities among motor vehicle users. In Ontario, Canada this number annually outstrips head injury fatalities among cyclists by a factor of over 10 to 1 (over 200 vs.20) among a population of 11 million of which more than half are cyclists. Laboratory tests show that a bicycle helmet provides protection to parts of the head in a narrow range of impact velocities. It matters little whether an impact in that range occurs when the helmet wearer is on a bicycle or in a motorvehicle. If Henderson’s case for universal helmet use for cyclists, based on a reduced fatalities, could be upheld, then there would be a better case by a factor of 10 to support universal helmet use for car users. It is not for us to pursue that one, but we are overjoyed that Henderson’s statistics reveal that cycling is increasing at the same time as cyclist fatality rate is falling. This suggests to us healthier populations and a safer environment for cyclists.

    Merits of Helmet Legislation confused with Merits of Helmet Use

    Henderson states “There remains a proportion of the riding population who are opposed to legislation requiring the use of helmets on grounds of principle. They simply cannot accept that society has the right to make them do something that protects only them.”

    This is one of Henderson’s straw man arguments. The object of his supposition is false anyway. Western democracies have consistently upheld the rights of individuals to choose whether or not to accept preventive medical treatment which essentially is what forced helmet-use is.

    A more accurate comment would have been “They simply have not been convinced that there is a societal interest in helmet legislation.” They have good reason for this. There isn’t one. To date, all the evidence from Australia’s experience counters the claim of a societal interest. No one, and certainly not Henderson in his report, has demonstrated such an interest. To do that would require the issue to be studied from a broader perspective, as we explain in the next paragraph. And even if net benefits could be determined, democracies still have to deal with the discrimination inherent in a law which would select cyclists for special treatment as though they were the only road users to suffer head injuries.

    Henderson also makes the common error of equating the merits of helmet use with the merits of helmet legislation. In those jurisdictions which have already mandated, legislation has been justified solely on the effectiveness of helmets. The possible change in behaviour of cyclists from forced helmet use and the consequential negative impact on the health of a community has been ignored. The health and environmental benefits of cycling have been well documented by others. In compiling a British Medical Association report – Cycling to Health and Safety, the authors found a 20 to 1 advantage in life-years gained through cycling compared to those lost due to death and injury. Countries where cycling represents a significant form of transportation benefit from the added advantage of reduced pollution. Less automobile use results in lower levels of toxic emission.

    In the Canadian provinces of Ontario and British Columbia, governments ignored cyclists’ warnings about inevitable loss of such benefits and legislated anyway. Henderson’s report follows the same path by refusing to recognize that helmet performance is only one factor in the effect of legislation. Fortunately for Ontario cyclists, a new government rescinded the helmet law for adults before it went into effect. Count one victory for cyclists.

    Cited Source Disagrees with Henderson

    Henderson references a study by Dorsch, Woodward and Somers (1984) of 197 cyclists who had struck their heads or helmets. He calls the cyclists “enthusiasts” presumably to mask that they were drawn mostly from South Australian bicycle racing clubs. Henderson must have known that identifying them as such would expose the fact they were unrepresentative of the cycling population, and thus render any conclusions extremely suspect. Even one of the authors warned about interpretation of the findings. In evidence presented to the House of Representatives Standing Committee on Road Transport Safety inquiry (1985) on page 901(a) of evidence, Dr. Dorsch said

    “One has to be very careful in making estimates of how effective universal bicycle helmet usage would be in reducing deaths and serious injuries. … people who are wearing what we regarded as the good, hard helmet … had 19 times less risk of suffering a fatal head injury. That was a hypothetical procedure. ……. In our paper we did, sure, put estimates on it but as a very hypothetical procedure. I was a bit distressed by some of the reports I had seen that suggested that 75 per cent of deaths could be prevented by everyone wearing very good, hard helmets.”

    She later added: “When you read those [coroners’] reports … you start to have some doubt that even the best helmets available would be as effective as we might think.”

    Henderson Unable to Interpret Source Material

    Henderson should have been more sceptical of his own sources. In a section on crash studies, he reports that for helmeted cyclists, the average mean peak impact velocity was 14 km/h for no injuries, 20 km/h for head injuries, and higher than 20 km/h for fatally injured cyclists. Other medical studies have shown that head injury will start to occur at an impact velocity of around 6 km/h. This suggests that a helmet is generally effective in reducing injuries in a narrow range of impacts from 6 to 20 km/h. Any higher and the injury is usually so severe that the impact is lethal regardless of helmet use.

    Despite this, in a subsequent section on time-series analysis, Henderson cites the conclusions of the Sacks et al, 1991 report which claimed as many as 2,500 of 2,985 US head injury deaths from 1984 through 1988 could have been avoided through universal helmet use. This study based its estimates not on the fatal velocity data that he cited earlier, but on a helmet-effectiveness factor borrowed from a study of non-fatal cycle accidents! The Sacks report has been criticized by other researchers because the definition of head injury included facial injuries against which a helmet provides no protection.

    Straight Line Distortions

    In assessing the results of helmet legislation in the Australian states of Victoria and New South Wales, Henderson elects not to address the evidence of reductions in the number of cyclists in both jurisdictions following legislation. Despite immediate pre and post- law counts which showed large declines in child cycling in Victoria, he suggests that the higher 1991 count of adult cyclists compared to a 1987 count showed that cycling had INCREASED overall post-law. However, in the case of adult counts he neglected to point out that the counts were taken three and a half years apart and at different times of the year. Such discrepencies invalidate any comparisons. A valid comparison would have been between actual post-law counts and projected post-law numbers with pre-law trends of increased cycling factored in. Nonetheless, a likely conclusion from the Victoria data is that adult cycling post-law DECLINED from the immediate pre-law levels but still remained higher than in 1987 because of the strong pre-law growth in cycling. Although Henderson blatantly disregarded these probabilities, the authors of the Victoria study did not. They said in a 1994 workshop “.. because there was no adult survey in 1990, the direct effect on total bicycle use cannot be determined.”

    Conclusion

    The size of this report provides the hint to what is missing from it – a qualitative discussion of the pros and cons of universal bicycle helmet use. In substituting quantity for quality, Henderson exposes his bias in favour of forced helmet use, and his hatred for those who choose not to wear helmets. Henderson gave us a clue right up front. He started his report on the basis that cycling is a problem even though as he noted, the fatality rate among cyclists is declining. Yet those of us who know cycling and have practiced it for 30, 40, 50 years and more know it to be an extremely safe activity with or without a helmet. Persons who abide by the rules of the road and operate their bicycles as a vehicle have little to fear and much to gain. Had Henderson started with an open mind, he might have learned something and arrived at different conclusions. But he didn’t, and as a result, Henderson added nothing to the body of knowledge on safe cycling, but rather makes an extremely benign and beneficial activity falsely appear dangerous.

    References

    • British Medical Association (1992), Cycling towards Health and Safety, Oxford University Press
    • Cameron, M.H., Newstead, S.V., Vulcan, A.P. and Finch, C.F. (1994) Effects of the Compulsory Bicycle Helmet Wearing Law in Victoria during its First Three Years”, Australian Pedestrian and Bicyclist Safety and Travel Workshop
    • Curnow, B. (1993), submission to Select Committee on Road Safety, Parliament of Western Australia
    • Hillman, M. (1993), Cycle Helmets – the case for and against, Policy Studies Institute, London
    • Robinson, D., (1996) Head Injuries and Bicycle Helmet Laws, Accident Analysis Prevention, in press
    • Ontario Road Safety Annual Reports (1990, 1991 and 1992), Ministry of Transportation of Ontario

     

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    Medical Doctors, and the Compulsory Helmets Law

    Introduction

    by Peter van Schaik

    Medical Doctors have frequently claimed the right to enforce compulsory helmets on cyclists, to protect the public purse. For example in his review entitled “The Effectiveness of Bicycle Helmets: A Review” (1995), Dr. Michael Henderson says: “There remains a proportion of the riding population who are opposed to legislation requiring the use of helmets on grounds of principle. They simply cannot accept that society has the right to make them do something that protects only them.”

    Henderson is completely wrong. He has nothing to back up his claim that societal interest prevails. Society has in fact consistently protected the rights of individuals to choose whether or not to accept a medical treatment. Wearing a helmet is really just another form of medical treatment, and in the form of legislation it is a medical treatment which has been administered by doctors onto their patients against their will.

    Doctors tend to only see the end result of an accident, which they may reasonably feel a helmet would have prevented, from which they decide that all cyclists must wear helmets. Medical doctors and other medical staff are really just another minority group with extreme views. They have had an unreasonably large influence over the Government in the bicycle helmets issue. They have a lot to answer for! It could be said that if you can’t stand the sight of blood or human suffering, you shouldn’t become a doctor in the first place.

    Compulsory helmets considered as a medical treatment

    by Bill Curnow

    The Royal Australasian College of Surgeons, Victorian Branch, was the prime mover towards compulsory helmet wearing. The Federal Government then took action to bring it about. Announcing this, then Prime Minister Mr Hawke said:

    “I pay tribute in the development of this proposal to Sir Dennis Paterson, President of the International Society of Orthopaedics and Traumatology, whom I met earlier this year. As a result of his advocacy of the need for the Commonwealth to take the lead in this area, I asked Bob Brown and Neal Blewett to put together this package.”

    Who’s who in Australia notes Sir Dennis’s prominent role in the Royal Australasian College of Surgeons.

    In effect, then, surgeons, per medium of statute, are imposing upon cyclists a treatment intended to reduce head injury. This action runs counter to the common law governing medical treatment.

    Fetal welfare and the law, a report of an inquiry commissioned by the Australian Medical Association, provides a useful summary of relevant common law concerning the rights of the patient versus those of the surgeon and the duty owed by the surgeon to the patient.

    1. Rights of the patient

    Courts have consistently upheld the right of the individual to decide how to protect his or her own body from injury or death, and have rejected claims that the medical profession has a right to impose treatment.

    The report on fetal welfare says it is for the patient, not the doctor, to decide whether the treatment will be performed. In Canada, the Ontario Court of Appeal, in Malette and Shulman, awarded damages against a doctor who transfused blood into a patient who was unconscious as a result of a motor accident, but who carried a card saying that she would refuse blood transfusions. In delivering the court’s judgment, Justice Robins said at page 328, quote: ”

    “A competent adult is generally entitled to reject a specific treatment, or all treatment, or to select an alternate form of treatment, even if the decision may entail risks as serious as death and may appear mistaken in the eyes of the medical profession or of the community. Regardless of the doctor’s opinion, it is the patient who has the final say on whether to undergo the treatment. … The doctrine of informed consent is plainly intended to ensure the freedom of individuals to make choices concerning their medical care. For this freedom to be meaningful, people must have the right to make choices that accord with their own values regardless of how unwise or foolish those choices may appear to others.”.

    Justice Robins posed the question why Mrs Malette should be transfused against her will. Quoting him again, at page 333:

    “The appellant’s answer, in essence, is that the card cannot be effective when the doctor is unable to provide the patient with the information she would need before making a decision to withhold consent in this specific emergency situation.”

    The doctor’s emphasis on the need to take account of specific circumstances at the time contrasts strongly with a law that compels cyclists to wear helmets in all circumstances. Justice Robins continued:

    “In the absence of an informed refusal, the appellant submits that Mrs Malette’s right to protection against unwanted infringements of her bodily integrity must give way to contervailing societal interests which limit a person’s right to refuse medical treatment. The appellant identifies two such interests …” – end of quotation. He went on to say that the first was the interest of the state in preserving life, but declared that, quote:

    “The state’s interest in preserving life or health of a competent patient must generally give way to the patient’s stronger interest in directing the course of her own life.”

    On page 334, Justice Robins added:

    “Recognition of the right to reject medical treatment cannot be said to depreciate the interest of the state in life or in the sanctity of life. Individual free choice and self-determination are themselves fundamental constituents of life. To deny individuals freedom of choice with respect to their health care can only lessen, and not enhance, the value of life. This state interest cannot properly be invoked to prohibit Mrs Malette from choosing for herself whether or not to undergo blood transfusions.” At page 336 he said, “The right to determine what shall be done with one’s own body is a fundamental right in our society. The concepts inherent in this right are the bedrock upon which the principles of self determination and individual autonomy are based. Free individual choice in matters affecting this right should, in my opinion, be accorded very high priority.” – end of quotation.

    In England, in Re T (Adult: Refusal of medical treatment), the House of Lords has made it plain that the right to refuse medical treatment extends even to the point where refusal will result in the likely or certain death of the patient. In this case, at pages 652 to 653, Lord Donaldson acknowledged the “absolute right to choose whether to consent to medical treatment, to refuse it or to choose one rather than another of the treatments being offered … notwithstanding that the reasons for making the choice are irrational, unknown or even non- existent.” At page 661, he said:

    “This situation gives rise to a conflict between two interests, that of the patient and that of the society in which he lives. The patient’s interest consists of his right to self-determination – his right to live his own life how he wishes, even if it will damage his health or lead to his premature death. Society’s interest is in upholding the concept that all human life is sacred and that it should be preserved if at all possible. It is well established that in the ultimate the right of the individual is paramount.” – end of quotation.

    In Australia, the same doctrine has been affirmed by superior courts. In F against R (1993) 33 SASR 189, the Supreme Court of South Australia considered a surgeon’s duty to inform the patient of the risk that an operation will not succeed in its aim. Chief Justice King remarked at pages 192/193, quote:

    “The governing consideration is the right of every human being to make the decisions which affect his own life and welfare and to determine the risks which he is willing to undertake.” He also referred to, quote, “the paramount consideration that a person is entitled to make his own decisions about his life”, a passage which the High Court of Australia cited in Rogers and Whitaker (1992) 175 CLR 479, at page 487.

    In summary, superior courts have upheld the right of the individual to decide how to protect his or her own body from injury or death and have rejected claims that the medical profession has a right to impose treatment. As the report on fetal welfare puts it, “Consent is the crucial concept”.

    Against this background of common law, it would be reasonable to expect that governments and legislators would give careful consideration to the principles developed in the common law before abrogating them by statute. In fact, the reports of the introduction of and debate on the Traffic (Amendment) Bill 1992, Hansard 9 April 1992 pages 143 to 145 and Hansard 19 May 1992 pages 568 to 586, make no mention of its effect of overriding common law applicable to medical treatment. Similarly, there is no mention of it in documents received from the Department of Urban Services in response to a wide- ranging request of 4 October 1994 under the Freedom of Information Act 1989.

    2. Duty of the surgeons

    (a) The applicable law

    The applicable law is summarised in the report on fetal welfare. It says on page 69, that, in broad terms the law imposes on a medical practitioner a duty to exercise reasonable care and skill in the provision of professional advice and treatment. In the past, identification of the appropriate standard of skill and care has been greatly infuenced by the views of the profession. This test was known as the Bolam standard. It is derived from the direction given to the jury in Bolam v Friern Hospital Management Committee (1957) 2 All ER 118. It was explained in the following way by Lord Scarman, in Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital (1985) AC 871 at 881:

    The Bolam principle may be formulated as a rule that a doctor is not negligent if he acts in accordance with a practice accepted at the time as proper by a responsible body of medical opinion even though other doctors adopt a different practice. In short, the law imposes the duty of care; but the standard of care is a matter of medical judgment.

    In Australia, in Rogers v Whitaker, Chief Justice Mason and Justices Brennan, Dawson, Toohey and McHugh of the High Court said at page 487, quote, “the Bolam principle has been discarded and the courts have adopted the principle that, while evidence of acceptable medical practice is a useful guide for the courts, it is for the courts to adjudicate on what is the appropriate standard of care after giving weight to the paramount consideration that a person is entitled to make his own decisions about his life” – end of quotation.

    The duty of care of the common law would require that those responsible for imposing upon cyclists the medical treatment of helmet wearing, surgeons in particular, should have certain knowledge of the efficacy of helmets in mitigating injury and should draw attention to any uncertainties or adverse effects.

    (b) Evidence relevant to standard of care

    (i) Evidence of surgeons

    There is evidence that the care taken by those responsible for imposing the medical treatment of helmet wearing falls short of an appropriate standard.

    The Hansard record of the evidence which the Royal Australasian College of Surgeons, per Drs Dooley and Trinca, submitted to the House of Representatives Standing Committee on Road Safety in the course of its inquiry on motorcycle and bicycle safety in 1978, shows that they had no evidence of efficacy, merely of numbers of cyclists killed and injured.

    Evidence given by Dr Trinca shows that he was negligent about establishing the efficacy of helmet wearing with certainty before taking action towards it. He said, “If we could perhaps worry a little less about and take a little less time in proving what is precisely right according to all standards and get something that protects and get it agreed to by that particular group, at least we would be getting somewhere. I have a feeling that it is in much of our research work that a lot of delay happens. As doctors we are impatient. We cannot wait for 2 or 3 years’ evaluation.”

    (ii) Evidence adduced by parliamentary committees

    Following the impetus of the surgeons, public authorities took up the task of imposing upon cyclists the medical treatment of helmet wearing, starting with recommendations by parliamentary committees.

    Recommendations by parliamentary committees in New South Wales in 1988 and Victoria in 1986 were influential in forming the Federal Government’s policy of compulsory helmets. The House of Representatives Standing Committee on Transport Safety also recommended compulsory helmets in its 1985 report. The evidence of efficacy of helmets that these committees adduced is examined in a paper by Bill Curnow entitled “Review of evidence on the efficacy of helmets”. The paper concludes that the Federal Government’s policy on compulsory helmets was decided without sufficient knowledge of the efficacy of helmets in reducing injury to cyclists.

    (iii) Evidence used by Commonwealth and ACT Governments

    The ACT introduced the helmets law in response to a financial inducement from the Commonwealth Government. An FOI request made by CRAG to the Department of Urban Services on 6 January 1992 requested, among other things, the rationale which the Commonwealth provided to ACT authorities. We expected that it would at least describe the social ill requiring a legislative remedy, provide evidence that helmets are efficaceous, and discuss possible adverse effects of helmet wearing. Concerning the matter of a social ill, one would expect evidence of a sharp increase in casualties to cyclists, but deaths to cyclists had actually been declining.

    The response received shows that neither the rationale nor the written advice to the then Minister included any of these matters. This shows that both the Commonwealth and the ACT authorities exercised a less than acceptable standard of care.

    Further, in our FOI request of 4 October 1994 to the Department of Urban Services we sought documents concerning any consultations with, or requests for advice from health authorities and any advice received. No such documents were provided in the Department’s response of 2 February 1995. Again, the ACT authorities exercised a less than acceptable standard of care.

    Other evidence of ACT authorities’ lack of care is evident in the matter of exemptions for medical reasons. In a letter of 4 May 1993, the then Minister for Urban Services said that he did not intend allowing exemptions under any medical circumstances. He said that this view had been supported by the Australian Medical Association and the National Road Trauma Advisory Council – NRTAC. Through FOI, CRAG requested from the Department documents showing the terms in which the organisations which had advised their support for compulsory helmets had expressed it. The letter from NTRAC merely says that it supports the advice of the Royal Australasian College of Surgeons, but the Department did not obtain that advice. The Minister’s claim of support from the AMA is false, as is shown in another document. Again, ACT authorities exercised a less than acceptable standard of care.

    The ACT Government’s 1992 information bulletin, “Compulsory wearing of helmets for bicyclists in the ACT”, which is currently being promulgated through official outlets, says helmets are extremely effective in reducing injuries to the head. Although the Minister for Urban Services was advised by letter of 6 April 1995 of the NHMRC’s warning of possible increase in brain injury from wearing a helmet, the bulletin makes no mention of it – a less than acceptable standard of care.


    Other Considerations

    by Peter van Schaik

    Henderson says: “When protection can be proven by good science- -as is the case for helmets and seat belts–then even those who hold most firmly to civil libertarian principles must concede that to compel protection for a few does bring benefit to many”.

    Henderson makes these claims of helmets being proven by good science, but doctors pushed for compulsory helmets before any scientific evidence even existed. As for those studies that have since appeared in the world literature, the tag “good science” is a very questionable one. Nevertheless, Why are these same principles not extended to other areas? Why is it just cyclists who must wear helmets?

    Pedestrians suffer many more head injuries than cyclists, and most of these are resultant from a collision with a motor vehicle, much the same as the accidents Henderson describes: “The predominant collision was between a cyclist and the front of a car” (Otte, 1989). According to the UK Govt yearly digest of statistics published by HMSO, called “Social Trends”, the deaths per billion kilometers travelled are: bicyclists (53), pedestrians (71). Using data derived from fatality rates per million hours (Vicroads, 1990), percentages of deaths from head injury (FORS, 1992), and ratio of hospital admission for head injury (HI) to death from HI (Queensland Health Department Statistics), it is possible to estimate the risks of serious HI and death by HI per million hours of activity. These are: cyclists (2.39), pedestrians (2.34), motor vehicle occupants (1.77), motor cyclists (20.9). Pedestrians are at about the same risk as cyclists.

    Motor vehicle occupants are at a slightly lower risk, but they account for 17 times as many head injuries as cyclists. The mechanics of their head injuries are not necessarily the same, but a great many result from their head striking the door frame (despite wearing a seatbelt) – surely a helmet would help there. At least one researcher has stated that bicycle helmets would be suitable, and a standard for car helmets is now available.

    Bicycle helmets first became popular amongst racing cyclists, then spread to other cyclists. In the form of helmet laws, the standards of the professional and ‘more serious’ cyclists have been forced upon the general cycling public. Professional motor racing drivers wear helmets, so by the same reasoning, if it is good enough for them it’s good enough for the general motoring population, the same as with cycle helmets.

    Given his great concern about head injury, I could fully expect Dr. Henderson to be wearing a helmet if I met him on the street, or saw him driving a car.

    And what about people who use stairs? They account for a great many head injuries of a preventable nature, and their risk per time factor or risk per kilometre must be absolutely overwhelming!

    There are many other areas where protection has been proven by “good science”. Here in Australia, many people die from skin cancer each year. In NSW in 1992, skin cancer claimed the lives of 226 men and 141 women, but 1990 (the last pre-helmet law year) saw only 20 cyclists killed. Why not compulsory shirts and wide brimmed hats whilst outdoors? Acceptance is already high so surely this legislation would be easy to implement. Then there are those other activities where compulsory abstenance would certainly be beneficial to the societal purse: smoking, drinking, overeating, growing old. Why stop at bicycle helmets?

    Although compulsory bicycle helmets may not be of much concern to most people at this time, the real concern should be: what will the ‘Safety Nazis’ be legislating for in 10 or 20 years time?

    Almost everything we do has some risk attached and it’s a question of how we estimate the situation. For many people, for whatever reason, it is just not worth the inconvenience of wearing a helmet, as evidenced by the huge declines in cycling recorded after introduction of the law. Cycling without a helmet is really little different from other potentially harmful activities such as smoking and drinking. The difference is that cycling in itself is healthy, the chance of serious head injury is actually very small, whereas the loss in health and subsequent cost to the health system from those other activities (or from not exercising and becoming sedentary) is virtually guaranteed. The main effect of the helmet law has been to discourage a healthy activity.

    Bicycle helmet laws remove freedom of choice. The aim may well be to preserve life but the secondary effect is to restrict freedom. In supporting the helmet laws, doctors often talk about the loss of freedom and quality of life in head injury victims as if they own the book on the subject. But without personal freedom of choice the quality of life is diminished. It is wrong for doctors to have the final say over what form an individual’s freedom should take. It would seem that Medicare has been a sinister tool for removing individual freedom, since it has made it possible for doctors to make the claim of “it being for the greater good” in protecting the investments of others, thereby bypassing the long-standing principles of common law and abrogating individual freedom.

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    Civil Liberties Considerations

    A. AUSTRALIA

    1. Lionel Murphy, address to ALP National Conference, 1967

    Every generation has to fight over and over again the battle for our fundamental rights and liberties and this generation has to do that also. We Australians tend to think that our civil rights are beyond question. In recent times, almost every one of our fundamental rights and liberties has been either trampled on, whittled away, challenged or ignored in Australia.

    2. Constitutional Commission, Report of the Advisory Committee on Individual and Democratic Rights under the Constitution, Canberra, Commonwealth of Australia, 1987

    Deprivation of Liberty of Property (pages 45/46)

    Perhaps the most fundamental principle of English law is that embodied in Magna Carta, which states the basic rule that no persons may be arbitrarily deprived of their liberty.

    The committee recommended that a new subsection 80(ii) be inserted in the Constitution in the following terms:

    80. The Commonwealth or State shall not

    ***
    (ii) deprive any person of liberty or property except in accordance with a procedure prescribed by law which complies with the principles of fairness and natural justice.

    Chapter 8 Australians And Equality Rights

    Stemming from Magna Carta, the notion that everyone should be treated equally before the law found its way through the English legal system into the general body of Australian law.

    The committee then noted that the Aborigines and other races were not included in the concept of “equal rights to all persons”, and discriminatory Federal and State laws founded on race continued to operate in Australia until relatively recent times. … “The committee considered that a general restatement of the ancient principle of equality embodied in Magna Carta should be stated in general terms which make it clear that any unfair discrimination between Australians should be placed beyond the powers of governments.

    “Of course it is clear the governments should not be prevented from making appropriate distinctions between different Australians, founded on a rational basis. Ultimately it is only those who are unfairly discriminated against who are being denied equality before the law. It is clearly appropriate for a discrimination on the basis of age to be implemented, so that governments can enact laws which require that children must attend school, or which provide for the age at which children obtain full legal capacity.”

    Other examples of justifiable discrimination were cited.

    The committee recommended that in substitution for the existing non- discrimination provisions of section 117, there should be proposed the following:

    117. The Commonwealth or a State shall not deny equality before the law to all the citizens and to all of the permanent residents of Australia and in particular the Commonwealth or a State shall not unfairly discriminate between any of them on any grounds.

    B. INTERNATIONAL AND HISTORICAL

    3. J.M. Kelly, A Short History Of Western Legal Theory, Oxford University Press, 1992

    Plato suggested that the dominant element in a state tends to make laws benefiting itself. He assigned to law not merely the regulation of conditions … but also the deliberate training (in the gardener’s quite as much as the teacher’s sense) of that society towards an ideal state of perfection. Thus he visualised law in an extra dimension which, although various regimes have tried to make it a reality, the West has on the whole rejected. Sparta is thought to have been his inspiration. This city enforced its manners by education and training on the young, and maintained them among them as adults. These manners had no basis in what we might recognize as a religious morality, but were geared to the production and constant renewal of a militarist and irresistible state.

    Aristotle: Justice is of two kinds: `distributive’ and `corrective’. By distributive justice he meant `that which is exercised in the distribution of honour, wealth and other divisible assets of the community, which may be allotted among its members in equal or unequal shares. Allowing for the far greater range of material regulation characteristic of the modern state, we might say this definition corresponds evidently with `legislative justice’, the kind we expect to see displayed in statutes or other governmental measures which distribute benefits or impose burdens in patterns and proportions which we can accept as fair or rational having regard to the subject matter; the kind which is free of invidious discrimination. Aristotle’s meaning emerges from some general propositions, for example, that equals are to be treated equally, unequals unequally; that justice is proportion, injustice is disproportion.

    Cicero the philosopher assigned to the positive laws of humans an altogether subordinate place by comparison with the law of nature. The mere fact that a measure has been enacted by a commonly accepted method does not of itself entitle it to respect as being just, or perhaps even to the title of `law’ at all if it defies higher principles.

    St Thomas Aquinas insisted on the connection of law with reason, the channel through which the law of nature could be apprehended by human intelligence: `Human law has the quality of law only in so far as it proceeds according to right reason; and in this respect it is clear that it derives from the eternal law. In so far as it deviates from reason it is called an unjust law, and has the quality not of law but of violence. … Laws may be unjust … if the burdens, even though they are concerned with the common welfare, are distributed in an inequitable manner throughout the community. Laws of this sort have more in common with violence than with legality.’

    Laws that are rightly enacted prove deficient where to observe them would be to offend against natural right. In such cases judgement should be delivered, not according to the letter of the law, but by recourse to equity, this being what the lawgiver aimed at.

    `Now human law is enacted on behalf of the mass of men, the majority of whom are far from perfect in virtue. For this reason human law does not prohibit every vice from which virtuous men abstain; but only the graver vices from which the majority can abstain; and particularly those vices which are damaging to others.’ This emphasis on the element of `harm to others’ appears in another passage in briefer form, where St Thomas derives the law against murder from the natural- law precept, `Do harm to no man’. It will be noticed that this theoretical basis for punishment, though St Thomas did not expressly declare it the only legitimate one, will not stretch far enough to cover the punishment of acts of moral turpitude not impinging on others – a curious premonition of the views of J.S. Mill.

    English lawyer Christopher St German (c.1460-1540) stated the criteria for legislative justice in terms which come straight from St Thomas: `A human law is called just, by the standard of its end, its author, and its form. Its end: when it is designed for the common good. Its author: when it does not exceed the powers of him who enacts it. Its form: when its burdens are laid upon the subjects in a due proportion, with the common good in view. And if its burdens are laid upon people in an unfair way, even if its purpose be the common good, it does not bind him in conscience.’

    Locke `A man … having, in the state of Nature, … only so much [power] as the law of Nature gave him for the preservation of himself and the rest of mankind, this is all he doth, or can give up to the commonwealth, and by it to the legislative power, so that the legislative (sic) can have no more than this. Their power in the utmost bounds of it is limited to the public good of the society.’

    The French Declaration of the Rights of Man and the Citizen, made by the National Convention in 1789, identified as the object of all political association the conservation of `the natural and imprescriptible rights of man: liberty, property, security and resistance to oppression’; and defined liberty as the freedom to do whatever does not injure others, who also enjoy the same freedom.

    Montesquieu perceived that political liberty could not exist where any two of the three powers – legislative, executive and judicial – were in the hands of the same organ of the state.

    In France, in the 1760s, a group of Enlightenment authors known as Physiocrats contended that judges, before enforcing the laws, ought to satisfy themselves that the laws they were being called on to apply actually conformed with the dictates of the `natural laws of the social order’ and of justice.
    `It is clear that any judge who took it upon himself to inflict penalties on his fellows by virtue of obviously unjust laws would be guilty of fault. Judges, therefore, should measure the ordinances of positive law against the laws of essential justice which govern the rights and duties of all men … before taking it upon themselves to give judgement according to those ordinances.’

    Beccaria (1764): `Every individual would choose to put into the public stock the smallest possible portion of his own liberty; as much only as was sufficient to engage others to defend it. The aggregate of these, the smallest portions possible, forms the right of punishment; all that extends beyond this is abuse, not justice.’

    A core belief of the Benthamites was the sacredness of individual freedom, including freedom to contract, on the grounds that the individual must know best for himself what was most conducive to his own welfare.

    J.S Mill, Utilitarianism, ed. H. Acton (London, 1972):
    `All persons are deemed to have a right to equality of treatment, except when some recognised social experience requires the reverse. And hence all social inequalities which have ceased to be considered expedient, assume the character not of simple inexpediency, but of injustice, and appear so tyrannical, that people are apt to wonder how they ever could have been tolerated; forgetful that they themselves perhaps tolerate other inequalities under an equally mistaken notion of expediency, the correction of which would make that which they approve seem quite as monstrous as what they have at last learnt to condemn. The entire history of social improvement has been a series of transitions, by which one custom or institution after another, from being a supposed primary necessity of social existence, has passed into the rank of a universally stigmatised injustice and tyranny. So it has been with the distinctions of slaves and freemen, nobles and serfs, patricians and plebeians; and so it will be, and in part already is, with the aristocracies of colour, race and sex.’

    Herbert Spencer: `Only one essential rule bound men, namely, that while each may do what he likes, he may not injure the equal freedom of others’ – a kind of restatement of Kant’s formula.

    German jurist Gustav Radbruch: As for positivism, the doctrine that law was whatever a statute said, had rendered German justice helpless when confronted with cruelty and injustice once these wore statutory vesture. Post-war decrees invalidating Nazi laws, even though not in force, `their content was already binding before those deeds were committed; and in their content such laws correspond to a law which is above statute, however one might like to describe it: the law of God, the law of nature, the law of reason’. … Radbruch saw a revival of belief in a transcendent law by which evil positive laws may be condemned as `legal injustice’.

    A much stronger recognition now exists that the rights of a majority, while they must include the determination of the state’s general policy, cannot extend to invading a range of irreducible individual and hence also minority rights. This is reflected in the European Convention on Human Rights and Fundamental Freedoms (1950).

    Radbruch: When laws deliberately defy the instinct for justice, then they are void, `the people owe them no obedience, and lawyers, too, must find the courage to deny them the character of law.’ Another German jurist, Helmut Coing, (1985): `Deliberate violations [of natural law] must be met with passive resistance.’

    Dworkin (1978): `Justice as fairness rests on the assumption of a natural right of all men and women to equality of concern and respect, a right they possess not by virtue of birth or characteristic or merit or excellence but simply as human beings with the capacity to make plans and give justice.’

    4. Henry E. StrakoschState absolutism and the rule of law, Sydney University Press, 1967. (a history of the codification of civil law in Austria)

    The author argues that codification, not only in Austria but also elsewhere, was an essential step in the creation of the modern state. In both France and Austria the new codes preserved the rule of law and (in an age when the state was arrogating to itself a monopoly of government) they safeguarded individual freedom. Indeed the author argues that codification of civil law provided the legal basis of European liberalism.

    “It is necessary to make a clear distinction between civil law and public law and ‘the ordinances arising from the latter. … If administrative ordinances are being confused with laws as such the latter will soon be regarded as unstable, because dependent from the whims of the supreme power. That cannot fail to have a deleterious influence on the confidence in the administration of justice, because justice means always a fixed norm, of equal validity for all.” (author’s translation of Ofner, Vienna 1889)

    “The fact that there is a nexus between the positive law of the state and universally binding norms of human behaviour, in other words, between the coercive and the normative aspect of law, has always been recognized.”

    “Legal rationalism aimed at a concordance of the normative and the positive function of law, at an agreement between them which left to each its specific function. It was developed by the great scholastic masters of the thirteenth century in the doctrine of natural law. … Law was an instrument of government, directed towards a rationally conceived common good. Its purpose was rational and so was its content. Precisely for that reason the relation between law as a norm and law as a command, or between the moral and legal order, was real, without being one of identity. Each of them retained its specific character and yet they formed an indivisible whole.

    Positive laws had to fit into the more universal framework of the moral order: that alone gave them their character as laws. But it was never postulated that every positive law expressed a moral norm. The content of many laws was morally neutral (traffic laws are a modern example) and such laws were morally obligatory simply because they belonged to a morally valid legal order. Any law made by public authority was valid so long as it did not offend against the more universal norm of the moral law.” [The law for compulsory wearing of helmets is not a traffic law. Traffic laws deal with competing claims and correlative rights and obligations of road users. Helmet laws regulate individual behaviour irrespective of other road users, or, indeed, any other persons, and questions of competing claims and the rights and obligations of others do not arise.]

    “The French Revolution seemed to mark the final victory of an ineluctable trend towards the subjection of the law to the sovereign will of the legislating power and all attempts to preserve a rule of law alongside effective government by a centralized and absolutist state seemed doomed to failure. … Kant cut that Gordian knot … . First, he denied the existence of a direct nexus between the moral and the legal order. … But at the same time Kant preserved fully the objective nature of the law. The law, though divorced from the moral order, did not become an instrument in the hands of the state, in whatever lofty metaphysical terms the latter might be conceived”

    P. 206 “The means by which the Kantian critique of natural law was applied to the codification of civil law was the creation of the concept of `strict law’ … which could be fully expressed by way of positive laws. … Strict law was also restricted law: it could not operate throughout the whole realm of social and political relations. … It was a law whose formal character confined it to the production of the autonomy of the person; it was a law of freedom. … Strict law led, by the logic of its formal character, to the division of law into a zone of private law where `any action is lawful whose maxim allows the arbitrary freedom of each to co-exist with the freedom of everyone according to the a general law’, and a zone of public law.”

    P. 208 Zeiller, honoured in 1811 as `the creator of the civil code’ in Austria – still in force – stated in 1801: “The primary rule of legal obligations is therefore: Abstain from all actions which restrict the free and legal activity of others.”

    P.210 “Any preface to the code on the nature of law would have to be couched in approximately the following terms: `Law is the limitation of freedom to actions compatible with the freedom of others’. … The rights due to every man, in so far as he was a rational being, had been known to him by the creator of nature through reason and through a natural feeling for right and wrong. Justice had to be the basis of the positive law of the state if government were not to degenerate into arbitrary rule.”

    “The Kantian doctrine, while removing the immediate obstacles on the way of a creation of a civil law, had therefore also destroyed any possibility of limiting the positive legislative power of the state by a set of norms of greater universality and inherent strength.”

    Function of law to seek a balance in the socio-political order between anarchic individualism and totalitarian collectivism. … The law which evolved in Western Christendom established a point of balance in European history. It was able to perform that function because it expressed the two basic principles of Western Christendom: a belief in the rational and organic nature of society, and a belief in the transcendent value of the human person. … It gave rise to a form of political organization which became typical of European civilization, that of `lawful government’ which means the containment of the power of public authority within the framework of the law.

    “The nadir of lawlessness in internal government was reached with Hitler’s doctrine of `Law is what benefits the people.’ (See Heinrich Mitteis, Uber das Naturrecht, Deutsche Akademie der Wissenschaften zu Berlin, Berlin 1948, p. 37.) This doctrine of a `common good’, which destroyed the last vestige of a balance between the rights of the person and the rights of the community, was carried by the totalitarian powers … into international relations. … Japan, Italy, Germany … flouting of the public law of the world. … the peoples of Britain and the USA rallied to the defence of what they again understood to be the basic law of civilized life: the preservation of personal freedom in the state.”

    After referring to international institutions which influence on national policies, “the very existence of a forum where an international tension … is subjected to public debate … tends towards the establishment of the universal category of the law as the standard of action. But … international law is still confined to relations between sovereign states; individuals may become increasingly the objects, but they are not yet the subjects of international law. (Within the sovereign state the positive law of its making continues to hold sway.) The struggle between the obsolescent category of the absolute sovereignty of the state and the newly emerging fact of the international community is still far from being resolved; it is, in fact, the characteristic feature of the second half of the twentieth century. And it is also the struggle for peace and for the survival of civilization.

    “If we apply the findings of historical analysis … we must conclude that only a state whose sovereignty is not absolute, that is, a state recognizing the obligatory force of law as arising ultimately from principles lying beyond and above the positive legislative power of government, can be integrated through the due process of law into an international community. … The restoration of a dualism of government, the restoration of an equality of status between the law and the state, is therefore the presupposition of the solution of the most urgent problem of modern civilization, the problem of an international order based on law. But that is the same as saying that the restoration of a balance between the autonomy of the person and the rights of the community which is the gravest problem of modern government, will come to pass by way of a new impact of international law on the internal law of the state.”

    5. Justice BrandeisOlmstead v United States, 1928

    Experience should teach us to be more on our guard to protect liberty when the Government’s purposes are beneficent. The greatest dangers to liberty lurk in the insidious encroachments by men of zeal, well meaning but without understanding.

    6. Universal Declaration of Human Rights, 1949, as proclaimed by the General Assembly of the United Nations; the following are some extracts.

    Preamble

    … Whereas it is essential … that human rights should be protected by the rule of law, …

    Article 2

    Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, … or other status”.

    Article 7

    All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.

    Article 12

    No one shall be subjected to arbitrary interference with his privacy … Everyone has the right to the protection of the law against such interference or attacks.

    Article 29:

    1. …

    2. In the exercise of his rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedom of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society.

    Azzopardi’s summary: Freedoms to be limited only as necessary to safeguard rights of others.

    7. International Covenant on Civil and Political Rights, 1976

    Article 17

    1. No one shall be subjected to arbitrary or unlawful interference with his privacy, family, home … .

    Article 26

    All persons are equal before the law and are entitled without any distinction to the equal protection of the law. In this respect, the law shall prohibit any discrimination and guarantee to all persons equal and effective protection against discrimination on any ground such as race, colour, sex, … or other status.

    On 25 September 1991, Australia acceded to the First Optional Protocol to the Covenant, making it possible for any individuals within Australia who considered that any of their human rights as set out in the Covenant had been violated to take their case to the United Nations Human Rights Committee.

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    Review of Evidence of the Efficacy of Helmets for Cyclists

    Introduction

    That the wearing of a helmet can protect cyclists from head injury might seem obvious. Measurements in laboratories have shown that helmets have the potential to do this, but, as Davis (1993) noted, the issue is what happens when the devices promoted by such research are used and adapted by real people. Research into actual use of helmets shows that the efficacy of helmets in reducing head injury is far from clear.

    Interested bodies have tended to place undue credence on research findings that appear to support their own premature conclusions that helmet wearing is efficaceous. The House of Representatives Committee on Transport Safety noted in its 1985 report, hereunder HORSCOTS 1985 report, that research in which Dorsch and others found …. , see below, “has received almost universal acceptance by bicycle groups who have been working for many years to have bicycle helmets widely accepted on the basis of their effectiveness in reducing head injuries”. Similarly, despite evidence that the evidence that the efficacy of helmets was unproved, see below, the committee itself declared early in its inquiry that, “It is this committee’s belief that all cyclists should wear a helmet to increase cycling safety both on and off roads.”

    An examination is made here of the evidence of the efficacy of helmet wearing which the Federal Government relied upon for its 1989 policy of compulsory helmet wearing and of evidence from later research and experience of the policy in effect. The states relied in varying degrees on the Federal Government for evidence; the Government of the ACT relied on it entirely.

    1. Evidence cited

    In a letter of 24 June 1992, copy attached, the Federal Office of Road Safety cited several reports as the basis for the compulsory helmets policy. Four of them argue that wearing helmets reduces head injury. They are:

    1. report of the inquiry into child pedestrian and bicycle safety, Social Development Committee of the Parliament of Victoria, 1986, 1987, (the Victoria report);

    2. Staysafe 12, Parliament of New South Wales, Joint Standing Committee on Road Safety, 1988 (the NSW report);

    3. FORS report CR 47, Helmets for child bicyclists, some biomedical considerations, by J.C. Lane, 1986

    4. FORS report CR 36, Children and road accidents, an analysis of the problems and some suggested solutions, by Barry Elliott, 1985.

    Hereunder, the original research papers upon which the four reports in turn relied are listed and commented upon.

    1. The Victoria report

    (a) McDermott and Klug (1982) and McDermott (1984)

    From statistics for Victoria, they showed that head injuries were proportionately more frequent in injured bicyclists (few of whom wore helmets) than in motorcyclists (most of whom wore helmets) despite the more severe body injuries and presumed more severe impact sustained by motorcyclists. That the benefit of helmet wearing would transfer from motorcyclists to cyclists was merely assumed, however (McDermott et al, 1993).

    Comment: The second researchers listed, Dorsch et al, said “… it is of little help to compare the nature and frequency of head injuries between helmeted motorcyclists and unhelmeted bicyclists, as was done in a recent Australian study. In such a study, a host of differences between pre-crash, within-crash and post-crash factors in the two groups could contribute to erroneous conclusions about the potential protective effects of bicycle helmets.”

    The submission by the Government of Victoria to the HORSCOT 1985 inquiry commented on the Dorsch study, but did not even mention McDermott or Klug.

    (b) Dorsch et al (1984, 1987)

    The Victoria report cited the unpublished 1984 paper. The authors introduced their published paper of 1987 with the words, “In the past, evaluation of helmet efficacy has been based on laboratory tests of limited relevance to real crashes. … Helmets for bicyclists could do much to reduce deaths and injuries among crash-involved riders. While few people would doubt this assertion, there are currently no quantitative data demonstrating the efficacy of bicycle helmets in real crashes.”

    The authors sent 1321 questionnaires to members of bicycling clubs in South Australia, seeking information about their most recent crash. Out of 866 usable responses, “197 bicyclists reported a crash within the last five years in which they had struck their head or helmet. … it was estimated that the risk of death from head injury was considerably reduced for helmeted relative to unhelmeted bicyclists. … Further research is needed to confirm and refine our findings.”

    Comments:

    1. The authors note the popular assumption that helmets are efficaceous … “While few people would doubt this assertion“.

    2. The authors themselves acknowledged limitations of their findings and the need for further research to confirm them.

    3. The sample was mainly drawn from members of bicycle racing clubs, and therefore was not representative of the mostly younger and slower- moving general population of cyclists. Indeed, Dr Dorsch said in evidence to the House of Representatives Standing Committee on Road Transport Safety (HORSCOTS) inquiry (1985) on page 901(a) of evidence “One has to be very careful in making estimates of how effective universal bicycle helmet usage would be in reducing deaths and serious injuries. … people who are wearing what we regarded as the good, hard helmet … had 19 times less risk of suffering a fatal head injury. That was a hypothetical procedure. … it was based largely on an adult group of cyclists and because we went through a rather hypothetical statistical procedure to arrive at those numbers, I think one would have to be very careful in generalising those findings perhaps to very young bicyclists. … one has to be very careful in making estimates of how effective universal bicycle helmet usage would be in reducing deaths and serious injuries. In our paper we did, sure, put estimates on it but as a very hypothetical procedure. I was a bit distressed by some of the reports I had seen that suggested that 75 per cent of deaths could be prevented by everyone wearing very good, hard helmets.” She later added: “When you read those [coroners’] reports … you start to have some doubt that even the best helmets available would be as effective as we might think.”

    4. In its submission to the HORSCOTS 1985 inquiry, the Government of Victoria said:

    “The incidence of bicycle helmet use has not yet reached a sufficiently high level anywhere in the world for a scientific examination of helmet effectiveness in injury reduction to be undertaken. One study has examined the effectiveness of helmets on a self-reported accident basis for a small sample of users and concluded that the better hard shell helmets give greater levels of protection than inferior hard shell helmets, soft helmets or no helmet (Dorsch et al 1983) (NHMRC Road Accident Research Unit, University of Adelaide, Adelaide, 1984).” McDermott and Klug, 1982 was not even cited.

    A new Australian standard, AS2063.2 adopted in 19??, after the Dorsch study, “allowed for the introduction of light-weight, well-ventilated, soft-shell helmets” (Connolly, 1991). The findings of Dorsch would not be applicable to such helmets.

    5. The later researchers, Thompson et al (1989), noted the findings of Dorsch et al and added, “Because of methodologic limitations, none of the available studies have produced compelling evidence of the effectiveness of bicycle helmets.” Hillman (1993) – see below – made comments to similar effect. Wood and Milne (1986) noted that the findings of McDermott and Klug and Dorsch et al had indicated significant gains from helmet use, but pointed out that “the benefits of bicycle helmet wearing have not been proven yet using mass accident data.”

    The Victoria report also says, “In an extensive analysis of children and road accidents, Elliott (1985) states that `The value and importance of pedal cyclists wearing helmets appears beyond question at this point in time'”, but Elliott relies on McDermott and Dorsch et al.

    Ms C. Boughton of FORS cited Dorsch: “helmets meeting the current standard of AS2063 decrease the chance of death by a factor of 19 when compared to a person who is not wearing a helmet at all.” … “need promotion and public education campaigns to get the usage rates up to any acceptable level.”

    [Following paragraph added by Peter van Schaik]
    6. Another interesting point about the Dorsch study is that it found 62 per cent of cyclists who reported hitting their heads were wearing helmets at the time, but the percentage of helmet wearers would have been low. This suggests that helmeted cyclists are more likely to have an accident and/or strike their head.

    2. The NSW report

    The discussion of helmets in the NSW report began with the statement, “The Committee received compelling information about the need for helmets to be worn by bicyclists”, but the only evidence it cited was a finding by Healy (1985) of a 21 per cent drop in head injuries following increases in helmet wearing in Victoria.

    Healy (1985): Healy merely used data from Wood and Milne. The data comprise statistics for head and other injuries to cyclists and rates of helmet wearing in Victoria in 1981-85. The numbers are small and show much year-to-year variation, and Wood and Milne denied that these data constitute proof of the benefits of helmet wearing – see their comment above.

    3. FORS report CR 47

    The main concern of this report, by Lane (1986), was the technical characteristics of helmets. It relied for its evaluation of efficacy on Dorsch et al and a study by Wood (1986) of bicyclist casualties in Victoria over the period 1983-86, when the use of helmets was increasing. Lane cited Wood’s data showing bicyclist casualties with head injuries declined, but there was little change in the number of other injuries. Lane concluded this was very suggestive that the observed reduction in casualties with head injuries is a consequence of increased helmet wearing. He noted, however, that it did not constitute a formal evaluation.

    4. FORS report CR 36

    As noted above under the Victoria report, this report by Elliott (1985) relies on McDermott and Dorsch et al.

    Hillman (1993) in his report Cycle helmets, the case for and against makes a comprehensive review, in chapter 3, of research on helmet wearing and head injuries. He draws attention to difficulties and causes of uncertainty in estimating the efficacy of helmets, and shows that findings of research have varied widely. In chapter 4, Hillman questions the benefits of helmet wearing. He describes the benefits attributed to helmets as at best highly exaggerated, and says that wearing a helmet only marginally reduces the extent of head injuries following collision with a motor vehicle. (In Australia, a moving motor vehicle was involved in 92 per cent of fatal bicycle crashes in 1988 (Attewell and Dowse, 1992)).

    Summary of evidence cited in support of Federal policy

    Clearly, the evidence that supported the Federal Government adopting its compulsory helmets policy was flimsy. Far from being adequate to justify governments overriding individual decisions, it is hardly strong enough to support governments promoting the wearing of helmets.

    2. Evidence from other studies pre-law

    Wasserman et al (1986): These researchers noted that several authorities had suggested that bicyclists wear helmets but added: “few data are available to either support or refute this recommendation.” They interviewed 516 bicyclists in the USA regarding helmet use and head injuries. They expressed their findings in very cautious terms: “The findings suggest that helmets may be effective in preventing head injuries”, adding qualifications that “unmeasured variables might account for the apparent association between helmet use and protection from head injury … the results were somewhat fragile statistically … relied entirely on the interview.”

    Thompson et al (1989): Their conclusions that cyclists with helmets had an 85 per cent reduction in their risk of head injury and an 88 per cent reduction in their risk of brain injury are often cited. Their case-control study, at Seattle in the USA, comprised the following, with percentages wearing helmets in brackets: 235 “case patients” with head injuries received while bicycling (7%), a control group of 433 persons with bicycling injuries not involving the head (24%) and a second control group of 558 people who had had bicycling accidents during the previous year (23%).

    The authors acknowledged two sources of uncertainty: statistical error due to the fairly small sample, and bias in the sample: “We cannot completely rule out the possibility that more cautious cyclists may have chosen to wear helmets and also had less severe accidents.” Also, for the case patients a much higher proportion of crashes (22.6 per cent) was caused by contact with a moving motor vehicle than for the control groups (12.5 and 3.9 per cent respectively). Such crashes typically result in more serious injuries than crashes where no moving motor vehicle is involved.

    [Following paragraph added by Peter van Schaik]
    Dr. R.S.Thompson et al wrote in 1989 that bike helmets are highly effective, 85% for their group, in preventing head injuries, added that “Safety helmets are widely recommended for cyclists, but convincing evidence of their effectiveness is lacking.”

    [Following paragraph added by Peter van Schaik]
    McDermott et al in a Journal of Trauma report noted that Thompson’s 85% result reduces to 61% by excluding facial head injuries that a helmet would not prevent. It further notes that Thompson’s study had ten cyclists wearing helmets in the adjusted counts, a number too small to draw such a statistical conclusion. McDermott found that about 40% of bicyclist’s head injuries were reduced when using approved helmets, though injury rates increased for the neck, extremities and the pelvic region.

    [Following paragraph added by Peter van Schaik]
    Robinson (Head Injuries and Bicycle Helmet Laws, in press) says: “The 85% reduction in head injuries from helmet wearing in Seattle was derived mainly from a comparison of a 21.1% helmet wearing rate in a control group of children from families in a healthcare cooperative who had cycling accidents and a wearing rate of 2.1% in head injured child cyclists. However, in Seattle in May and September 1987, the same time as the investigation into helmet effectiveness at the five major teaching hospitals, the observational study (DiGuisseppi et al., 1989) found helmet wearing rates of only 3.1 and 3.3% in samples of 1957 and 2544 child cyclists. If cyclists riding around Seattle had been considered the control population, rather than those who had accidents, a rather different conclusion might have been reached about the effectiveness of helmets.”

    [Following paragraph added by Peter van Schaik]
    Thompson found that helmets reduce the risk of head injury by 85%, but by using the same methodology on other data in the study, it can be concluded that helmet use also reduces the risk of injury to other parts of the body by 72%.

    Rodgers (1988): To examine claims that growth in the use of hard shell bicycle helmets had been successful in reducing bicycle- related head injuries and deaths, Rodgers studied over 8 million cases of injury and death to cyclists over 15 years in the USA. He concluded as follows: “There is no evidence that hard shell helmets have reduced the head injury and fatality rates. The most surprising finding is that the bicycle-related fatality rate is positively and significantly correlated with increased helmet use.” To our knowledge, Rodgers’s findings have never been challenged.

    Travers Morgan (1987): Data from a questionnaire survey of bicycle crashes in Western Australia 1985-86 did “not include enough helmet wearers to assess with certainty whether head injuries are less common or less serious when a helmet is worn. … there is an indication that severe overall injuries are actually slightly more common among helmet wearers. Whilst this may not be significant, it does suggest that further research could be worthwhile” – page 35. Despite this finding, the authors recommended, on page 55, “greater initiatives should be taken to promote use of safety helmets.”

    Corner et al (1987): This study of technical requirements for helmets noted that “the most life-threatening crash situation is collision with another vehicle. Other crash situations, e.g. falling from the bicycle and the like, are usually significantly less severe and require only minimal head protection.” The study recommended that helmets should be extended to protect the temporal area of the head.

    Williams (1991): Helmets made to the Australian standard may fail to provide protection from 63 per cent of impacts to the head, those occurring to the temples and elsewhere below the test line for helmets. Also, where impact occurred on the ear pieces of the retention system or the rim of the helmet near the ear, wearers have suffered lacerations from the sharp edges of the ear pieces and rims.

    Comment by the British Medical Association: The British Medical Association (1993) reviewed the studies of Dorsch et al, and Thompson, Rivara and Thompson and a survey in the UK by Mills (1989). The BMA’s comment was: “Although these studies provide useful preliminary data, further research is required in order that more authoritative recommendations can be made.”

    [Following paragraph added by Peter van Schaik]
    North et al (1993): noted in South Australia that “We have recently observed an apparent fall in the number of patients suffering from head injury due to road trauma. … The largest drop in patient numbers was observed in motor cyclists, falling from an average of 24 per year previously, to only five in 1992.” This shows that whilst head injuries to bicyclists declined dramatically after the helmets law, so did those to other road users.

    [Following paragraph added by Peter van Schaik]
    Pitt et al. (1994): Commented “the reason for the decrease in bicycle related head injuries is more complex than just increased wearing of helmets”.

    [Following paragraph added by Peter van Schaik]
    Cameron et al (1994): Interpreted the decline in percentage of head injuries in Victorian accident claims for cyclists to be purely as a consequence of increased helmet wearing. Robinson (Head Injuries and Bicycle Helmet Laws, in press) observed a similar trend for child pedestrians and cyclists in data from 1980-85, when few cyclists wore helmets. The correlation between the head injury percentages was 0.94, with P < 0.02. It is suggested that the common trend may be related to impact speed of motor vehicles. Janssen amd Wismans (1985) found that reductions in impact speeds result in greater reductions in head accelerations than for other parts of the body. The introduction of the helmets law in Victoria coincided with the introduction of major initiatives directed at drink-driving and speeding in December 1989 and March 1990, as noted by Cameron. From this it could be expected that average impact speeds in bicycle accidents would be less, and thus the percentage of head injuries would also be reduced.

    Conclusion

    The Federal Government’s policy on compulsory helmets was decided without sufficient knowledge of the efficacy of helmets in reducing injury to cyclists.

    References

    Attewell, R.G. and Dowse, M.J., Fatal crash types. Analysis of 1988 fatality file, Federal Office of Road Safety report no. CR 105, Canberra 1992

    British Medical Association, Cycling towards health and safety, Oxford University Press, Oxford, New York, 1993

    Corner, J.P., Whitney, C.W., O’Rourke, N. and Morgan, D.E., Motorcycle and bicycle protective helmets: requirements resulting from a post crash study and experimental research, Federal Office of Road Safety report no. CR 55, Canberra 1987

    Davis, R, Death on the streets, Leading Edge Press and Publishing Ltd, Hawes, North Yorkshire, 1992

    Elliott, B., Children and road accidents, FORS report CR 36, Federal Office of Road Safety, Canberra, 1985

    Dorsch, M.M., evidence given to the House of Representatives Standing Committee on Transport Safety inquiry on motorcycle and bicycle helmet safety, 1985, at pages 901A and 902A

    Dorsch, M.M., Wodward, A.J. and Somers, R.L., Do bicycle helmets reduce severity of head injury in real crashes?, Acc. Anal. & Prev. 19, 3, pp. 183-190, 1987

    Government of Victoria: submission to the House of Representatives Standing Committee on Transport Safety inquiry on motorcycle and bicycle helmet safety, 1985, at page 1031

    Healy, D., Trends in helmet usage rates and bicyclist numbers sustaining head injury – Victoria, Road Traffic Authority report 86/6, Melbourne, 1985

    Hillman, M., Cycle helmets, the case for and against, Blackmore Press, Longmead, Shaftesbury, Dorset, 1993

    Lane, J.C, Helmets for child bicyclists, some biomedical considerations, FORS report CR 47, Federal Office of Road Safety, Canberra, 1986

    McDermott, F.T., Why pedal cyclists should wear safety helmets, Australian Family Physician, 13, 4, pp. 284-285, 1984

    McDermott, F.T. and Klug, G.L., Differences in head injuries of pedal cyclists and motorcyclist casualties in Victoria, Med. J. Aust. 2:30, 1982

    McDermott, F.T., Lane, J.C., Brazenor, G.A. and Debney, E.A., The effectiveness of bicyclist helmets: a study of 1710 casualties, The Journal of Trauma, 34, 6, pp. 834-845, 1993

    Rodgers, G.B., Reducing bicycle accidents: a reevaluation of the impacts of the CPSC bicycle standard and helmet use, Journal of Products Liability, 11, pp. 307-317, 1988

    Thompson, R.S., Rivara, F.P. and Thompson, D.C., A case-control study of the effectiveness of bicycle safety helmets, The New England Journal of Medicine, 320: 21, 1989

    Travers Morgan Pty Ltd, Bicycle crashes in Western Australia 1985- 86, Federal Office of Road Safety, Canberra, 1987

    Wasserman, R.C., Waller, J.A., Monty, M.J., Emery, A.B. and Robinson, D.R., Bicyclists, helmets and head injuries: a rider-based study of helmet use and effectiveness, American Journal of Public Health, 78, 9, pp. 1220-1221, 1988

    Wood, T., Bicycle safety in Victoria, Proceedings Bikesafe 86 conference, Federal Office of Road Safety, Canberra, 1986

    Wood, T. and Milne, P., Head injuries to pedal cyclists and the promotion of helmet use in Victoria, Australia, Acc. Anal. & Prev. 20, 3, pp. 177-185, 1988

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