From nucleus - spring 1998 - News Review [pp6-12]
The Liberal Democrats (at their Eastbourne party conference) voted for a review to look at the implications of changing the law to 'permit doctors to accede openly to repeated requests from suffering and terminally ill patients to die instead of having to help them secretly as at present'. The British government apparently has no plans to introduce legislation to legalise euthanasia.
The state of Oregon has just decided by referendum to uphold a 1994 Act making physician-assisted suicide legal.
Annie Lindsell, a sufferer of motor neurone disease, died on 2 December after being told that her GP would not be prosecuted for administering strong painkillers should her condition deteriorate. The court was satisfied that the principle purpose of treatment would be to relieve pain and not to shorten life. Ironically in the event no drugs were necessary. It seems a little confusing as to why the case went so far in the courts. The principle of 'double effect' is well accepted.
The Dutch Public Prosecutors Office has dropped a murder charge against staff at a nursing home who allegedly allowed a patient with Alzheimer's disease to dehydrate.
When relatives asked why Mr R Mulder, aged 62, was not being given fluids through a drip, they claimed to have been told that it was in line with the home's 'dehydration policy'. He regained consciousness hours later after transfer to a hospital. Since then claims have emerged that about 50% of deaths in Dutch nursing homes could be as a result of starvation.
The Royal College of Paediatrics and Child Health has recently defined five situations when it is appropriate to withhold or withdraw life saving treatment in children: brain death, PVS, no chance, no purpose and 'unbearable situation'.
Calls have been made to extend the UK 1967 Abortion Act to Northern Ireland, led by a group called the Alliance for Choice. They estimate that since the passing of the Act, over 60,000 women have travelled to the UK for abortions. An extension to the act would not be considered until a Northern Ireland MP calls for it. This is seen as unlikely at present by the advocates for change; reasons given are church opposition and all-male MPs.
On 31 October, the Supreme Court of Canada ruled against Manitoba's social services department for confining a pregnant woman with a solvent habit for the purpose of protecting her unborn child. Madam Justice Beverley McLachlin wrote that confinement would violate 'the most sacred sphere of personal liberty - the right of every person to live and move in freedom... A pregnant woman and her unborn child are one. To make orders protecting fetuses would radically impinge on the fundamental liberties of the mother'.
The Cancer Research Campaign has decided to cease supporting research bodies that receive funds from the tobacco industry. The announcement follows British American Tobacco's offer last year to provide £1.5m to fund a chair of international relations at Cambridge University.
Latest figures from the Office for National Statistics show that in 1996 in England 15% of girls and 11% of boys aged 11-15 smoked. In the UK 40% of smokers begin before they are 16 and virtually no-one over the age of 21 takes it up.
Already tobacco prematurely kills an estimated three million people world wide each year. This will rise to 8.4 million deaths annually by 2020. Delegates at the 10th world conference on 'tobacco or health' in Beijing in August were told that the ever rising number of deaths from tobacco will shift markedly from the developed to the developing world over the next three decades.
Japanese tobacco companies are to introduce a voluntary ban on advertising on radio, television, cinema and the internet from April 1998.
Increasing legislation on cigarette advertising in the USA and Western Europe has meant that tobacco companies have shifted their sights to sub-Saharan Africa. Its population of 850 million and limited regulatory measures make it an ideal target. In Kenya and Tanzania, rival companies are already vying for a bigger share of the market with aggressive advertising and sponsoring of events. Smoking has risen in the region, partly due to advertising and the availability of cheap brands. Farmers are tempted to become involved: tobacco fetches more than other cash crops. A WHO consultant said, 'Very soon a new global ash-tray will be in the tobacco-growing areas of Africa'.
A report encouraging the integration of therapies such as homeopathy, acupuncture and osteopathy into the NHS has been widely welcomed. The document (part of the Prince of Wales' 'Initiative on Integrated Medicine') is designed to stimulate debate before a conference next summer. It contains 28 specific proposals.
Edzard Ernst, professor of complementary medicine at the University of Exeter, is concerned that enthusiasm for alternative medicine may lead to its acceptance before we have evidence that the therapies actually work. The Welcome Trust and Medical Research Council have already shown interest in carrying out some research.
FACT, a journal from the Exeter Department, points to many flaws in published research on complementary therapies and urges readers to be more critical.
Human rights organisations have criticised China for its use of transplant organs taken from executed prisoners. It is estimated that 2,000 to 3,000 organs are obtained yearly from such prisoners. They are often offered through newspaper advertisements and foreign customers can reportedly pay up to US$30,000 for the operation. Fears have been raised that this practice will lead to human rights abuses and over-enthusiastic capital punishment, especially as it is carried out with the blessing of government institutions which profit financially from it. A Chinese government official has called the accusations 'a slanderous attack on China's judicial system'.
Two further articles give concern that the means to reach the end of increased organ donation will become increasingly unethical. In the first, Dr Jack Kevorkian, the well-known euthanasia practitioner from Detroit, plans to offer organs from his suicide patients. He has said, 'Here's a situation where we can end the suffering of a patient and get organs back to save lives'.
In the second, calls have been made to kill certain PVS patients by lethal injection in order to harvest their organs. Once a decision has been made to stop treatment and withdraw food and water, death takes place over 10-12 days; their organs become dehydrated, damaged and are unsuitable for transplant. The International Forum for Transplant Ethics sees no moral distinction between allowing someone to die by starvation and actively ending life. The parents of Tony Bland, the PVS victim of the Hillsborough Disaster in 1989, have supported the call, saying that they would have preferred this option for their son even though it was not available at the time. A spokeswoman for the BMA, however, has said that, 'PVS patients are not suitable donors. There could be a risk of treatment decisions being muddied by the wish to use their organs'.
Thousands die each year waiting for allotransplants and waiting lists keep on growing. Recent estimates state that it would take just 100 breeding sows to negate the entire UK kidney shortfall. Recent advances have made xenotransplantation look far more likely. For instance, genetic engineering has virtually abolished the problems of hyperacute rejection when transplanting animal organs into humans. Transgenic pigs now express human complement-inhibiting protein that suppresses the immune response.
However, many hurdles still stand. Recent research found that pig retroviruses are transmitted through the germline so that proviral DNA is present in all pig cells. These viruses, related to HIV-1 and HTLV-1, are difficult or impossible to remove by breeding and have been shown to infect human tissue. The effect on humans is not yet known but similar viruses from mice have caused thymic leukaemia in macaque monkeys. Some researchers now hope for primate trials to investigate the effect of the viruses on immunosuppressed hosts. Meanwhile, a WHO meeting of experts said that, 'Xenotransplantation offers exciting opportunities but must be carefully monitored'. They stated that it is acceptable 'as long as the health of humans is protected and human dignity is respected'.
The 40-nation Council of Europe (CoE) has adopted a protocol which supports the banning of human cloning. Although not specifically mentioning the word 'cloning', the protocol prohibits creation of a human being genetically identical to another human being, whether living or dead. A CoE spokesman welcomed the 'clear, scientifically sound' wording as it bans the result, rather than the technique leading to the result.
A recent proposal has been made to undertake a world wide study of the genetic differences between different human populations. The project would entail collecting genome samples from all the major population groups on earth and creating a database to study genomic variations between populations. The purpose would be to learn about the origin and evolution of the human species and to provide data for biomedical research. A committee spokesman from the US National Research Council said that the project would provide enough information to answer questions about human evolution and history. It is seen as a platform from which more focused studies could be done. One question we must ask is whether the data is valuable enough to outweigh the dangers; it may well form the justification for modern-day eugenics programs built on 'clear, scientific data'.
A recent letter to the BMJ called upon the scientific community to combat media hype into genetic research by informing the public about 'the serious risks inherent in transgenic experimentation'. This was in response to accusations that current media disquiet about transgenic research is merely the product of a 'scientifically illiterate' society.
Fifty-five couples have now had pre-implantation genetic diagnosis at the Hammersmith Hospital and almost 100 babies have been born after the procedure world wide. This current rate of application is about to change with the granting of 'treatment' licenses to two other London Hospitals, University College London and Guy's & St Thomas's.
The procedure, which involves identification of potentially affected embryos after in vitro fertilisation, is most commonly used for cystic fibrosis. 'Success' has also been achieved with Tay Sachs disease, Rh D blood typing and X-linked disorders such as Duchenne muscular dystrophy and Lesch Nyhan syndrome. The new centres will offer identification of embryos with thalassemia and sickle cell disease.
Although the diagnosis of dominant disorders is more difficult; Marfan's syndrome and familial polyposis coli have been identified. In principle, providing the basis of a molecular disorder is known, mutation detection is possible. Only normal embryos are implanted.
An interesting associated finding has been that 30% of normally developing cleavage stage embryos are chromosomally mosaic, perhaps explaining the high rates of embryo attrition occurring naturally and with IVF.
A new technique which could save thousands of lives and reduce disability could be introduced in Britain within five years. Tandem mass spectrometry could enable 17 congenital metabolic diseases to be identified and treated at birth. Presently we can only test for phenylketonuria and hypothyroidism.
Meanwhile a new book by the Birth Control Trust (which encourages prenatal screening and abortion for fetal abnormality) has been extolled with a half page review in the British Medical Journal. While handicapped neonates are viewed as patients to be treated, those still in the womb are managed with 'search and destroy'. As the author notes, 'Birth is the defining feature of becoming a person in English law'.
Cost-effectiveness analyses raise further cause for concern about eugenic policies. In a recent Dutch article, the authors compared the cost of DNA diagnosis and abortion for muscular dystrophy with the lifetime costs (£0.5-£2m) of caring for the handicapped person.
The Human Fertilisation and Embryology Authority have reported that over 21,000 'test-tube' babies have been born in the UK using the methods pioneered in Cambridge in 1978. A quarter of the total have been born in the last two years. Multiple birth rates are higher than ever with 1,774 twins, triplets or quadruplets (a third of all births) in the last 15 months. While mortality is ten times higher for triplet pregnancies, the live birth rate is 21.4% for pregnancies with three embryos transferred and only 6.8% for those with one. Overall 18.5% of IVF patients become pregnant and 15% have live babies.
The Bishop of Oxford, the Right Rev Richard Harries, has called for the age of homosexual consent to lowered from 18 to 16. He is the chairman of the Church of England bishops' group on homosexuality and a leading adviser to the Archbishop of Canterbury, Dr George Carey. Bishop Harries once held the view that sexuality was fluid between 16 and 18. However, he has changed his mind in light of 'recent evidence' suggesting that sexuality is well formed by 16. This issue was partly dealt with in the last issue of Nucleus. He does not support homosexual marriages or blessings, yet calls for the abolishment of a clause prohibiting local authorities from promoting homosexuality. This would seem to be clear support for promiscuity.
There is, however, encouraging news on this subject. The vicar and congregation of Jesmond Parish Church, the largest parish church in Newcastle, has rejected the authority of their new bishop-elect because of his views on homosexuality. The Right Rev Martin Wharton said on his appointment that 'homosexuality within a loving permanent relationship is no sin'. Rev David Holloway, vicar of Jesmond said, 'I have a legal duty under church ordinals to drive away erroneous and strange doctrines...We have to be faithful to the gospel'. In a 22-page open letter to the Archbishop of York, Rev Holloway asked that a new bishop be appointed to lead them pastorally.
Bromley council in London has banned homosexual couples and single people from adopting children in its care. A spokesman said, 'We feel that such children should be placed in as normal and natural a home as possible and not have to deal with the stress of being in the care of a homosexual or a single person'.
A Unicef report estimates that almost 3 billion people live in 'medieval squalor', unable to dispose safely of their own bodily waste. This is obviously a huge cause of disease, as can be seen from the West where sanitation has made much more difference to health than antibiotics. The report blames a lack of political will in developing countries as well as repayment of foreign debt for the decrease in investment in sanitation. 
The World Bank has for some time instituted stern measures of economic reform on thirld world countries, ostensibly to enable them to pay back their huge debts to the developed world. This policy has come under fire in India where several health experts and social scientists are saying that Indian poverty and subsequent ill health have increased as a result. The World Bank has denied these claims, stating that poverty is declining. It is a sad situation where 'to make the rich work harder we pay them more; to make the poor work harder we pay them less'.
Divorce has adverse effects on the physical and psychiatric health of those directly involved but how does it affect children? A British study of more than 11,400 children born in 1958 has found that children who grew up with both parents were on average better qualified and found better jobs. Other studies have shown that the children of divorced parents have a higher risk of ill health from the time of parental separation until adult life. They are also much more susceptible to subsequent psychiatric illness.