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ss nucleus - summer 2006,  News Review

News Review

HFEA widens PGD criteria

The Human Fertilisation and Embryology Authority (HFEA) has widened its criteria for preimplantation genetic diagnosis (PGD) by giving the go ahead for screening embryos for the breast and ovarian cancer 'susceptibility' genes BRCA1 and BRCA2, and the colon cancer gene HNPCC.

The HFEA, who had previously permitted embryo screening for inherited diseases such as cystic fibrosis, retinoblastoma and familial adenomatous polyposis, denied that the decision was a further step along the slippery slope to 'designer babies'. In a statement issued by the HFEA, chairwoman Suzi Leather said they had approved the extension because of the 'aggressive nature of the cancers, and the impact of treatment, and the extreme anxiety that carriers of the gene can experience'.

Around 5% of breast cancers are due to inheriting BRCA1 or BRCA2 genes and mutations in these genes carry an 80% risk of breast cancer, with the BRCA1 gene also carrying a 40% chance of ovarian cancer. Carriers of the hereditary non-polyposis colorectal cancer (HNPCC) gene have an 80% risk of developing colon cancer. All the diseases are also treatable and likely to develop much later in life.

The decision was received with mixed responses. The BMA's head of ethics and science, Dr Vivienne Nathanson, welcomed the extension, saying that it is right to use advances in medical technology to reduce suffering and impairment. Josephine Quintavalle, director of Comment on Reproductive Ethics (CORE), said that PGD is currently being used as a 'destruction weapon' aiming to eliminate 'any embryo which does not conform to eugenic concepts of perfection'.

In another development, a group of researchers from Guys Hospital, London, have announced their success at screening embryos using a new test – preimplantation genetic haplotyping (PGH). PGH enables doctors to check for many more potential illnesses, as it looks at the whole DNA of a cell, rather than just testing for a single gene defect. The method involves testing parents and any existing children or relations who exhibit, or are carriers of, a genetic condition. Once the faulty units of DNA are located, IVF embryos can be screened in the lab.

The team have so far treated five couples with the method, using it to test for Duchenne muscular dystrophy (DMD), cystic fibrosis (CF), and to help a woman with a hydatidiform mole. Simone Apsis, of the British Council of Disabled People commented, 'Who is going to make the decisions about who should and should not live? We believe all babies have an equal right to life.' (BMJ 2006; 20 May, 2006; 10 May, 19 June)

Migrant doctors' job crisis

A new initiative from the Department of Health (DoH), which aims to address the jobs crisis facing junior doctors, has met with widespread confusion and dismay. The new visa rules, which are already in force, centre on restricting job access for International Medical Graduates (IMGs). IMGs currently comprise 30% of the NHS workforce.

The unexpected announcement in March by Health Minister Lord Warner requires that overseas doctors must have a work permit to train or work in the NHS and that medics can only be recruited to the UK where there is a skills shortage. This does not affect those from the European Economic Area (EEA) or refugee doctors, rather it is other IMGs who have been thrown into a state of turmoil - many of whom will already have expended significant time and money on passing the Professional Linguistic Assessment Board (PLAB) exam they need to work in the UK.

There is particular controversy about the decision not to exempt IMGs currently in training posts, many of whom will now have to return home with incomplete training. Some face financial difficulties as well as the uncertainty of being able to continue their training overseas. As one doctor, Lebanese Joseph El-Khoury, commented, 'All the work I have put into developing my skills has gone to waste. It is unrealistic for me to return to my country without completing my training as a psychiatrist and a degree to certify it.'

The DoH decision seeks to address the oversupply of junior doctors caused by an increase in UK medical graduates, unrestricted entry to the PLAB exam and migration of EEA doctors. Although the new measures should reduce UK medical unemployment, some argue that a more considered policy could have avoided jettisoning doctors in training, and the possibility of their being replaced by someone less able. There was no consultation with doctors' representatives before the controversial announcement. The BMA is calling for a delay of up to a year, to allow people to adjust to the new rules. It is also hoped that discussions between the DoH, the BMA, ethnic minority groups and others in the NHS will result in an improved policy. (DoH press release 2006; 7 March, BMA News 2006; 29 April, BMJ Careers 2006; 3 June)

NHS & alternative medicine

A group of Britain's leading scientists and doctors have expressed their concern and disapproval about the use of complementary medicine in the NHS in an open letter, issued on 23 May, sent to each of the directors of the service's 472 trusts.

The letter - organised by cancer specialist Professor Michael Baum, of University College London - objects to the widespread use of these therapies without sufficient emphasis on the evidence that is necessary for other therapies. Professor Edzard Ernst, the UK's first professor of complementary medicine and one of the signatories on the letter, commented: 'The wholesale integration of complementary medicine, simply because it's alternative, and people may want it, and feel satisfied with it, is not a good reason for integration. I believe we need one single standard in medicine and that is the standard of evidence based medicine.' By way of example, the signatories criticised the 'overt promotion of homeopathy in parts of the NHS' citing it as 'an implausible treatment for which over a dozen systematic reviews have failed to produce convincing evidence of effectiveness'.

Proponents of alternative therapies abound - perhaps most visibly the Prince of Wales. In a speech to the World Health Assembly in Geneva – also on 23 May - he advocated the 'proper mix of proven complementary, traditional and modern remedies,' with an 'emphasis on the active participation of the patient' to create a 'powerful healing force'. Prince Charles also commissioned the Smallwood Report in 2002 which looked at three trusts in England and found that the majority of referrals to complementary therapists 'registered clinically significant improvements'.

Chairman of the British Complementary Medicine Association, Terry Cullen, commented on the letter, saying, 'It's very frustrating that senior responsible people dismiss complementary medicine for the sole reason that it doesn't have the definitive scientific proof that other drugs have. There is so much anecdotal evidence that thousands of people gain benefit from using complementary medicines. We shouldn't dismiss that.' ( 2006; 23 May, Sunday Times 2006; 28 May; Times 2006; 23 May)

Early medical abortion - a success for the NHS?

The British Pregnancy Advisory Service (BPAS) has announced that 10,000 terminations in 2005 were carried out before nine weeks of pregnancy using early medical abortion (EMA). Demand for the so-called 'bedroom abortion' are at their greatest ever and advocated by BPAS and the UK government's sexual health strategy as 'the best option for women needing abortion'.

EMA consists of a dose of mifepristone followed 48 hours later by misoprostol, a prostaglandin to induce uterine contraction, which results in expulsion of the fetus within hours. Women are released to go home after the misoprostol is given. Advocates suggest that EMA reduces the stigma attached to abortion as it is more easily accessible, reduces clinic stay and allows a woman to be in the privacy of her own home at the time of fetal expulsion.

Some, however, question these supposed benefits of EMA. Clinic stay allows for women to be counselled before and after a termination. There is also concern about the safety of EMA, which is currently being re-evaluated by the US Food and Drug Administration (FDA). The deaths of ten women have been linked to EMA and pro-life charity Life has branded EMA 'a dangerous cocktail of drugs'.

Annual UK figures for abortion continue to rise annually, reaching 185,400 in 2004. 77% of BPAS custom comes from the NHS, making them our leading NHS abortion provider. The development of EMA use is one method to deal with increasing demand on abortion services. BPAS Director Ann Furedi described the increase in EMA usage as 'a success for BPAS and for the government's sexual health strategy'. Comment on Reproductive Ethics labelled BPAS' 'trumpeting' of its role in 10,000 abortions as 'deeply insensitive self-promotion'. (BPAS Press Release 2006; 8 May, 29 May; 2006; 29 May; Times 2006; 29 May)

Oldest UK mum

A 63-year old psychiatrist is set to become Britain's oldest mother after undergoing treatment at the hands of controversial Italian fertility doctor Severino Antinori.

Dr Patricia Rashbrook went with her husband – John Farrant - to see Dr Antinori at his clinic in Rome. The actual treatment was carried out in an unknown European country, Italy's fertility laws having been restricted significantly in 2005. Antinori has defended his actions: 'When the couple love each other they naturally want to have a baby. Age isn't important in this decision – what's important is the physical condition of the mother... she fits all the criteria for maternity. She should live for at least 20 to 25 years - we are not giving birth to an orphan'. Dr Antinori first made news with an over-60s pregnancy in 1994. He has since helped numerous older women become pregnant such that the Italian press have nicknamed him 'the father of impossible children'.

The couple issued a statement to emphasise 'that this has not been an endeavour undertaken lightly or without courage… a great deal of thought has been given to… providing for the child's present and future wellbeing, medically, socially and materially.' Josephine Quintavalle of Comment on Reproductive Ethics said: 'She is being selfish and sometimes greater love is saying no. It is extremely difficult for a child to have a mother who is as old as a grandmother would be.' ( 2006; 4, 5 May, Guardian 2006; 4 May)

And finally… motivational deficiency disorder

The British Medical Journal's spoof 1 April news story describing motivational deficiency disorder (MoDeD) was taken too seriously, with New Zealand's Dominion Post berating the BMJ for 'damaging your [credibility] and ours as a result' after they reported the story as serious research.

MoDeD was reported as being characterised by 'overwhelming and debilitating apathy' which can even be fatal due to 'reduced motivation to breathe'. Professor Leth Argos told how the disorder is 'poorly understood, underdiagnosed and undertreated'. The report also told of a new drug, 'Indolebant', developed to treat MoDeD: 'One young man who could not leave his sofa is now working as an investment adviser in Sydney', reported Professor Argos.

MoDeD's creators, Professor David Henry and journalist Ray Moynihan, were surprised at the serious reporting of their spoof. At the Inaugural Conference on Disease Mongering, held in Newcastle, Australia, April 11-13, Professor Henry commented, 'it shows that it is relatively easy to get out the concept of a disease that doesn't exist and a treatment that doesn't exist' adding that 'when it comes to health, people suspend the scepticism they use in other areas of life'. The conference explored 'disease mongering', where drug companies 'create' new diseases for which treatments can be developed and promoted. (BMJ 2006; 1, 15, 22 April,

Tijesunimi Abiola, Clare Cooper, Jacky Engel and Kingsley Osei-Tutu
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