From nucleus - autumn 2000 - News Review [pp6-13]
Junior doctors in the UK will have to wait between nine to twelve years for new EU legislation setting a maximum 48 hour week. However, the BMA has said that too many of the 35,000 junior doctors in the UK are working dangerously long hours: one in three work over 56 hours a week, or 72 hours if on-call time is included (BMJ 2000; 320:1081, 15 April), (BMJ 2000; 320:1423, 27 May).
However, a domestic pay and conditions agreement, under which the legal limit on doctors' weekly hours is set to fall to 56 within three years, has been accepted in the UK. Jobs will fall into one of four bands of pay, designed to reflect the amount and timing of out of hours' work, its intensity and antisocial nature. Currently doctors may be paid as little as £4.02 for each hour worked over 40 hours a week. The new scheme will see pre-registration house officers' pay rise to 100% of basic pay for out of hours work by December 2002 (BMJ 2000; 320: 826, 25 March), (BMJ 2000; 320: 1096, 22 April), (BMJ 2000;320:1494,3 June).
A national strike by the Republic of Ireland's junior doctors was deferred in late May the day before planned industrial action following an interim agreement which roughly doubles the overtime pay scale. However, the Irish Medical Association stressed that there was 'still a long way to go' to resolve the dispute (BMJ 2000;320:1494, 3 June).
The ban on the use of frozen eggs for in-vitro fertilisation (IVF) is expected to be lifted shortly. The Human Fertilisation and Embryology Authority (HFEA) that regulates IVF treatments in the UK recently granted the first licence to a clinic to thaw human eggs. Scientists have long suspected that using defrosted eggs can result in irreparable damage to the unborn child (Times 2000; 16 March), (Times 2000; 28 March).
Present legislation limiting research on human embryos is likely to be loosened following a report by an expert council representing the Nuffield Council on Bioethics. The panel recommended changes to the law to enable the use of cloned embryos to produce human tissue for transplant (Telegraph 2000; 6 April).
Currently the Human Fertilisation and Embryology Act 1990 permits the creation of embryos for specific research areas including infertility, contraception, congenital diseases and prenatal diagnosis. The Nuffield report states 'there are no grounds for making a moral distinction between research into diagnostic methods or reproduction, which is permitted under UK legislation, and research into potential therapies, which is not currently permitted'. However, it also emphasises the importance of resisting the inclusion of 'research donation' as a reason for abortion.
Furthermore, the Government's commissioned report on human cloning, headed up by Dr Liam Donaldson, is expected to recommend therapeutic cloning, arguing that potential benefits outweigh moral considerations. However, the Society for the Protection of the Unborn Child and other pro-life groups have criticised the composition of bioethics committees, and warn of the slippery slope from therapeutic to reproductive cloning. They are launching a nationwide petition to outlaw human cloning in Britain (Telegraph 2000; 3 April).
From September the UK government may allow insurance firms to ask people with a family history of illness such as Huntington's Chorea to undergo tests to see if they carry the gene responsible. Carriers would then face higher premiums for medical, life and travel insurance. Ministers had previously opposed testing on the grounds that it would leave a 'genetic underclass' unable to afford insurance. However, they are now reported to believe that if they do not regulate testing, insurers could insist on subjecting people to unchecked and potentially unreliable tests. Some employers in America are already using genetic tests in order to avoid the increased costs associated with workers who are genetically predisposed to particular ailments (Times 2000; 8 January), (Times 2000; 8 March), (Times 2000; 20 March).
The UK government has embarked on a £6 million campaign to cut the number of teenage pregnancies. There are an estimated 90,000 pregnancies in the UK each year, of which 8,000 are among girls under 16. This is the highest rate in Europe. In twenty pilot projects, among deprived areas, special advisors will give girls individual advice on abortion and contraception and help in parenthood (Guardian 2000; 26 April).
Through the 'Keep the Clause Campaign', public pressure has increased against the Scottish Parliament's decision in February to press ahead with the repeal of Section 28, which prevents public money from being spent on the promotion of homosexuality in schools and elsewhere. As a result, Donald Dewar, Scotland's First Minister, has announced that a new clause will be placed in the Ethical Standards in Public Life (Scotland) Bill, which will require local authorities to encourage 'stable family life' in all their services relating to children. Material to be used in schools will have to be appropriate to the age, understanding and stage of development of the child. Mr Dewar reported that 'stable family life' is an inclusive term and that the Scottish Parliament does not wish to be judgemental in its interpretation of the phrase. The bill could become law by the summer. However in a recent private referendum, 87% of one million Scottish respondents voted against repealing Section 28 (Guardian 2000; 28 April), (Times 2000; 2 March), (Times 2000; 31 May).
Schoolgirls are being offered the morning-after-pill in pharmacies without a prescription. This pilot scheme, being run in Manchester, is the second stage of a study where the pill is being made available free of charge. Girls under the age of consent will be given the pill, but only if the chemist is satisfied that they understand the consequences of their request. The scheme is in response to demands by doctors, pharmacists and family planning groups, and could soon be spread nationwide (Times 2000; 8 January).
In what has been called the 'ultimate form of contraception', girls and boys aged thirteen were given babies to look after for a television programme designed to discourage under-age sex. The programme 'Borrow a baby' will be screened on Channel Four (Times 2000; 9 March), (Times 2000; 10 March).
The aftermath of the millennium celebrations has led to a record 20% rise in the number of abortions performed in the UK so far this year. The rise was blamed on the closure of many clinics and GP surgeries over the festive period, leading to a difficulty in obtaining emergency contraception. This news coincides with an all-party parliamentary pro-choice group report claiming that women face 'significant delays and obstacles' when seeking to end a pregnancy. The group found that three out of ten women got no help at all from their doctor when they asked for an abortion.
However, pro-life activists point to the example of an aborted 22-week baby which survived for 80 minutes while hospital staff waited for it to die in Darwin, Australia last month. Such incidents are by no means uncommon in the UK. Last year a normal baby was aborted at Birmingham City Hospital at just under twenty three weeks gestation, because tests had shown he might suffer from Down's Syndrome. He lived for two hours (Times 2000; 2 March), (Times 2000; 11 April).
Referring physicians and transplant centres are reluctant to consider an individual with Down's syndrome for heart or heart-and-lung transplantation. Currently referral rates do not reflect the high prevalence (40%) of surgically treatable cardiac problems in individuals with Down's syndrome. Physicians cite co-existing medical problems and high rates of infective and malignant complications of Down's syndrome as factors which could reduce the likelihood of a satisfactory outcome. They judge that because there is a limited supply of organs, it is ethically sound to use them preferentially for individuals without Down's syndrome. They also argue that it is difficult to obtain informed consent from individuals who are profoundly mentally handicapped. There is concern however that widely held beliefs are not supported by the evidence and that individuals with Down's syndrome are receiving sub-optimal care without justification (BMJ 2000;320:816-817, 25 March).
Controversy over the lack of worldwide regulation of baby surrogacy has arisen after twin girls were born without identifiable parents, either legally or biologically. Both the sperm and egg used to conceive Danielle and Emma in Greece were from anonymous donors, and when the Italian man and his Portuguese wife, who had taken out a contract with a British surrogate mother, Clare Austin, discovered that the children would be girls they demanded an abortion. Ms Austin, who was 21 weeks pregnant, said she would oblige, but instead travelled to California where she gave birth and handed the children over to a lesbian couple for adoption (Times 2000; 8 May).
A study published in the BMJ has found that physicians tend to overestimate the probable length of survival of terminally ill patients by a factor of five. Overly optimistic predictions were most likely to be given to cancer patients. The researchers report that the physician was least likely to make accurate predictions the longer the relationship with the patient had lasted. They conclude that 'undue optimism about survival prospects may contribute to late referral for hospice care, with negative implications for patients' (Reuters Health 2000; 18 February).
Ann Winterton's Medical Treatment (Prevention of Euthanasia) Bill is currently at report stage in the House of Commons. The bill would outlaw the withdrawal of medical treatment, nutrition or hydration from a patient with the intention of hastening a patient's death. On 8 May Ann Winterton put down an early day motion, noting with concern various recent developments towards euthanasia. The motion, signed by 41 other members of Parliament, invites the Government to reconsider its position and honour its stated opposition to euthanasia, as well as to allow her bill adequate time to complete its stages (BMJ 2000;320:1094, 22 April), (SPUC News Digest 2000; 17 May).
France's National Ethics Committee has released a report which states that euthanasia may be permissible in certain circumstances, and admits that it is already practised in the country's hospitals. The carefully worded document, which took three years to complete, avoids demanding any change in legislation and calls for a loophole in the law to save physicians from possible prosecution. A 1995 survey of 140 French anaesthetists found that 26% of them had deliberately injected patients with lethal drugs when they felt that the patients had no chance of recovery.
In 1999 a young nurse, Christine Malevre was charged with manslaughter after telling police that she had helped 30 patients to die at their request. In response to the case, then Health Minister Bernard Kouchner (now the United Nations administrator in Kosovo) called euphemistically for a 'different approach' to how one dies. Psychiatric reports found that Malevre had no true compassion but had a 'megalomaniacal desire' to be in a position of power. The charge against her was upgraded to murder (Reuters Health 2000; 6 March).
A survey conducted by the Mental Health Foundation has found that 44% of patients with mental health problems feel discriminated against by their GPs. Respondents reported that GPs made comments such as 'snap out of it' and 'I can only help you if you're suicidal'. Nurses, psychiatrists, consultants, accident and emergency staff and social workers were also specifically reported as being discriminatory towards mentally ill people (BMJ 2000;320:1163, 29 April).
Competition in America against the popular, yet contentious, drug Viagra, recently grew when the FDA approved the use of apomorphine (Uprima) to treat impotence. Uprima works by stimulating dopamine release, which mediates the cerebral role in triggering erections. Already it has been predicted to be a strong competitor despite concerns over its safety profile and interactions with nitrates and alcohol. Nonetheless, the FDA believes that Uprima's benefits outweigh its risks. (BMJ 2000;320:1094, 22 April).
Market expansion could see women as future Viagra 'customers'. New Scientist has reported an American study showing Viagra to be effective in helping infertile women become pregnant. By dilating blood vessels and thus improving blood flow, Viagra helps the endometrium to thicken, aiding implantation. British experts have viewed the approach with cautious enthusiasm (Telegraph 2000; 6 April).
Last year's promises by the World Bank and IMF regarding debt cancellation are not being delivered. Only five countries met the requirements necessary to receive cancellation by April under the terms of the enhanced Highly Indebted Poor Countries initiative - six fewer than promised. Creditors are blamed for the slow progress. Jubilee 2000 is now concerned that significant debt relief for the world's 40 poorest countries will not be achieved by the end of this year. Given the acute social crises in the most heavily indebted countries, external observers believe all foreign debt must be totally cancelled as the first step towards poverty reduction (BMJ 2000;320:1095, 22 April).
The South African government has refused to supply AZT to pregnant women to prevent vertical transmission of HIV, or to women after rape. The South African president has questioned whether HIV causes AIDS or whether poverty is the actual cause of the opportunistic infections previously attributed to the virus. The debate comes in the midst of a governmental attack on GlaxoWellcome (manufacturer of AZT), which almost suggests the pharmaceutical industry invented HIV in order to profit from it (BMJ 2000;320:1016, 8 April).
Further dispute over the origin of AIDS has arisen through claims that the disease emerged in humans when the kidneys of chimpanzees infected with HIV were used to make polio vaccine in the 1950s. Proponents of a post-war origin of AIDS claim the oldest HIV specimen was found in blood from 1959. Those that challenge this link cite a New Mexico study which shows the last common ancestor of HIV appeared in about 1930 - before the vaccine was developed. Furthermore, the vaccine's manufacturers deny using chimpanzees to make it, claiming instead to have used Asian macaques which cannot support HIV. Either way, a Royal Society conference on the origins of AIDS has been delayed pending the results of independent tests looking for HIV in the vaccine's stocks and to find out which animals were actually used (Telegraph 2000; 26 April).
The incidence of HIV infection in Africans living in the UK is rising according to the Communicable Diseases Surveillance Centre. Unfortunately, research into specific factors is only just starting. This is despite the effectiveness of similar studies of the homosexual population in informing infection-reducing policies. Rising incidence is attributed to: increased testing (eg in antenatal clinics, in line with government policy), an increased number of individuals requesting testing and increased numbers becoming sick and seeking care. Alternatively there may be more infections actually occurring. It is presumed that most Africans with HIV were infected in Africa but new technology may enable the timing and hence place of infection to be defined (BMJ 2000;320:735, 18 March).
In Britain, German-owned supermarket chain Aldi has faced claims of sexual and disability discrimination from a homosexual employee. Mark Hedley, 34, was not allowed to resume his post following an absence for HIV treatment. Aldi said their decision was made because other staff felt uncomfortable working with Mr Hedley, and they feared store sales would suffer. On the day before the hearing, an out-of-court settlement of £250,000 was reached. The Terence Higgins Trust commented that employers concerned about HIV should seek advice before acting on any of their prejudices (Telegraph 2000; 11 April).
Californian voters have approved a measure prohibiting recognition of same-sex marriages, even if legally performed in another state. Proposition 22 amended the state's family code to say: 'Only marriage between a man and a woman is valid or recognised in California'. 60% of voters supported the prohibition. Meanwhile, the bill has split the religious community. Leaders of Mormon, Roman Catholic and Evangelical Christian churches support it, while three Southern California leaders - Episcopalian, Lutheran and Methodist - issued a joint statement opposing it, saying it could lead to discrimination (Telegraph 2000; 7 March), (Telegraph 2000; 9 March).
In March, St John's, USA, was brought to a standstill as emergency services descended on the town centre. They were responding to over twenty calls to '911' by local residents, who had seen a sign in a shop window saying 'help needed'. Emergency teams initially had no idea what was going on, as callers were too excited to speak rationally. Uncertain of the gravity of the situation, but fearing the worst, the local SWAT team was called in. City officials have asked merchants to advertise in the local paper whenever they have job openings (Boston Times 2000; 14 March).