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ss nucleus - winter 1997,  News Review

News Review

Latest attempts to legalise euthanasia

The Supreme Court of the United States made unanimous rulings in June that there is no fundamental right to assistance in committing suicide. The rulings invalidated the decisions in March and April 1996 of the Ninth and Second Circuit Appeals Courts which had effectively lifted bans on physician- assisted suicide in 16 US states. In making his ruling Chief Justice Rehnquist said that there was an 'important and logical' distinction between refusal of unwanted treatment by a competent patient and receiving assistance in actively terminating life.[1]

So far Oregon is the only state to succeed in making physician-assisted suicide legal but the Act, which was passed by public referendum in 1994, is still held in abeyance by legal challenges.

In the Netherlands, although euthanasia remains a criminal act, doctors are not prosecuted provided they follow established guidelines. The July 1996 Rights of the Terminally Ill Act of the Northern Territory of Australia, which permitted the practice, was overturned by the Australian Senate on 24 March this year. Colombia, however, passed a law allowing euthanasia in late May[2] and the Philippines[3] and South Africa[4] have also been considering legislation.

Recently the UK debate blew up again when two doctors confessed to giving lethal doses of drugs to hasten the deaths of terminally ill patients. Michael Irwin, chairman of the Voluntary Euthanasia Society, and David Moor, a Newcastle GP, have not been prosecuted.[5] The British Medical Association overwhelmingly rejected calls to legalise euthanasia at its summer conference, as did the House of Lords Select Committee on Medical Ethics, which reported in 1994.

Moves to enable 'late' and 'lunchtime' abortions

US federal funding may be restricted on Medicaid programs which include abortion as a covered benefit. This will not affect other managed-care plans.[6] In May, the Senate defeated a proposed ban on all abortions after fetal viability.[7]

In 1994 there were 94 terminations after 24 weeks gestation in Britain. According to retired obstetrician and gynaecologist, David Paintin, late termination is sometimes necessary 'to enable the woman to avoid the considerable long-term burden of providing care for a severely handicapped child'.[8] Paintin recently co-authored a strongly worded letter to the BMJ defending legal abortion in Britain and insisting that British doctors were not 'acting like Nazis' by ending the lives of four million unborn children since 1968.[9]

Meanwhile a new 'lunchtime abortion service' for busy women is being launched by Marie Stopes International in London, Leeds and Manchester. Private patients will pay £285 for the ten minute procedure.[10]

New developments in the treatment and diagnosis of HIV/AIDS

Recent studies have suggested that 2-3 years of anti-retroviral therapy may completely eradicate HIV. A first phase of rapid decrease in viral load is due to eradication of cells with high turnover including lymphoid cells. A second, slower phase, corresponds to a decrease in infected longer-lived cells including macrophages. However, these results must be treated cautiously as it is always possible that there may be a third phase. Virions could remain in immunologically privileged sites such as the brain and rekindle infection.[11]

South Africa is revolutionising its HIV/AIDS control strategy. Part of the scheme aims to target long-distance truckers and prostitutes, a major factor in disease spread, with education and increased condom use. A study done in Tanzania showed that simple management of STDs can reduce HIV seroprevalence significantly.[12] It is estimated that 45% of the children in Zimbabwe will be orphaned by AIDS within the next decade.[13]

Western Countries introduce smoking bans and restrict tobacco advertising

The US Food and Drug Administration (FDA) has upheld its decision to control tobacco sales and advertising due to a scientific consensus on the addictive and other properties of nicotine.[14] President Clinton has declared a smoking ban in all US federal buildings.[15] Heavy restrictions on tobacco advertising have been introduced in Belgium[16] and Hong Kong[17] and are being planned also in the UK.[18] Romania, where 45% of men smoke, plans tough anti-smoking laws[19] whilst Israel plans to be the first country outside the US to sue tobacco companies. In the 50-year history of the state, more Israelis have died from smoking-related illness than from terrorism, road accidents and five wars combined.[20]

However, smoking bans in the West are leading tobacco firms to target the East aggressively. In the Philippines, 75% of adults smoke.[21] A recently-leaked memo shows that tobacco companies have heavily funded amenable scientists to carry out biased research into the effects of passive smoking.[22] Huge fines on tobacco companies will in fact be paid over 25 years by raising the price of cigarettes. It seems that the huge revenues which governments receive from the tobacco industry make them less than enthusiastic to crack down on smoking.[23]

Moves to regulate acupuncture and homeopathy

Calls have been made for the regulation of acupuncturists including standard training. Practitioners would be trained in basic mainstream medicine. Acupuncture may be the first port of call for a patient in the early stages of major disease which must be recognised. When practitioners have little conventional medical training, medical complications of acupuncture are no doubt increased. These include serious infections, pneumothoraces and nerve injuries.[24]

A recent German law means that health insurance may have to cover many more forms of alternative medicine. Instead of being examined 'according to the current state of scientific knowledge', therapies will be assessed by those in the relevant branch of alternative medicine, regardless of the opinion of conventional doctors.[25] In the European Parliament in May, however, members thwarted an effort to begin integrating the policies of different member states with regard to alternative therapies.[26]

Lambeth, Southwark and Lewisham Health Authority in London has decided to end funding for homeopathy as public health physicians found no convincing evidence of clinical benefit.[27]

Japan and Italy aim to smooth organ transplantation

Although Japan's recent ruling on brain death (see last Nucleus) passed the Lower House of Parliament, stronger resistance is expected in the Upper House.[28] Italy is considering legislation which would assume consent to organ donation in the absence of explicit dissent. This would take Italy from the bottom to the top of western organ-transplantation statistics.[29]

New techniques for neonatal surgery

Neonatal corrective surgery of congenital defects faces problems as babies have very little spare tissue to use in repair. A Harvard researcher has pioneered a technique whereby small tissue samples were removed from a lamb in utero and cultured. The engineered tissue was then used for surgery after birth, resulting in faster healing and maturing than with artificial materials. Human trials could begin in the next five years.[30]

New developments in genetic research

After Dolly the cloned sheep, comes Polly, a lamb who has been cloned but also carries a human gene. Researchers say that the gene manufactures an undisclosed protein which could be extracted from milk to treat human disease.[31]

A researcher claims to have cultured pluripotent human stem cells taken from aborted fetuses. Similar cell-lines in mice have resulted in unprecedented precision in genetic manipulations, producing 'chimeric mice' in which a proportion of the cells carry the altered genes.[32]

A Canadian religious cult has set up a private company to sponsor research into human cloning. The Raelian movement believes that life on earth was created by aliens who also achieved the resurrection of Jesus by cloning. Although their chances are not highly-rated, the episode underlines the dangers of present legislation in the US and elsewhere; federal-backed research is banned but not that in the private sector.[33]

The entire genetic sequence of Escherichia coli has now been reported by US researchers[34] and work is well underway in locating genes contributing to enuresis[35] and febrile convulsions.[36]

Infertility treatment controversies

A child has been born after donation of oocyte cytoplasm to a previously infertile woman. Oocyte cytoplasm transfer has been successfully performed in animals before now.[37]

An independent review of UK surrogacy law will be carried out after recent controversies. Most recently, a potential surrogate mother decided to keep the baby. Current legislation outlaws commercialisation of surrogacy and does not force surrogate mothers to give up the child.[38]

Denmark has passed its first ever comprehensive bill on assisted fertilisation. Included in the bill are free treatment and an upper age limit of 45 years. Single women and lesbians do not qualify for treatment, despite many politicians being in favour and heavy protests from the lesbian community.[39]

The United Nations Population Fund (UNFPA) has recently stated, 'Shortfalls in promised assistance to developing countries will result in at least 120 million additional pregnancies, 49 million abortions... and 65,000 maternal deaths over the period 1995-2000'. This is blamed on developed countries failing to keep promises made at the International Conference on Population and Development in Cairo in 1994.[40]

Apologies for medical misdemeanors during Nazi holocaust

The University of Vienna has issued an official apology and agreed to investigate the origin of cadavers used in a WWII German anatomy textbook. It has been alleged that Dr Eduard Pernkopf used body parts of people executed by the Nazis. Although it is not thought that concentration camp victims were among those used, Dr Pernkopf expelled Jewish faculty from the University under the Nazi Nuremberg Race Laws.[41]

Mounting medical student debt in Britain

The Dearing Report into Higher Education concluded that graduating British medical students could have a £20,000 debt. It also recommended that the government charge university students for part of their tuition fees. Universities are now desperate for money because of the increase in student numbers (currently 1.6 million) and insufficient funding. In future, students will be charged approximately £1,000 annually. This represents about one quarter of average tuition costs; some lower-income families will be excused. In addition, the already shrinking maintenance grants will be completely abolished; student loans will continue to be offered. The BMA objected to these plans, stating that the proposals 'will further deter all but the richest students from entering medicine'.

The Dearing Report acknowledges that extra help (in the form of bursaries or scholarships) may be needed for medical students because of the length of medical studies. The BMA warned, 'If [bursaries] are just an occult form of loan or a patchy hardship fund, they will be a complete non-starter'. As yet, no details of the bursary plans are available. The average medical student owes more than £4,500 on graduating.[42]

Meanwhile, the Policy Studies Institute and St George's Hospital Medical School are proposing that potential medical students should be selected on their potential to care for people. 'There is a need to ensure people do not enter the medical profession just because they are good at science.' Imperial College School of Medicine called for the lowering of A level acceptance grades into medical schools.[43]

Australian Medics Suicide Hotline

Australian doctors are 50% more likely to commit suicide than the rest of the population. Female medics and younger doctors are the most at risk. The Australian Medical Association reported on 21 known suicides since 1992; a report stated that these cases were only the 'tip of the iceberg'. The report highlighted stress sources including the 'authoritarian hierarchies' of hospitals, threats of litigation, more patients' rights, isolation and uncertain career options. Doctors are much less likely to ask for help than other people and most don't have a GP. Professor Raphael, chair of the doctors' mental health working group said, 'They are afraid someone will know about it, and they feel they are letting the side down'.[44]

References
  1. BMJ 1997; 315:137-8
  2. BMJ 1997; 314:1852
  3. BMJ 1997; 314:1644
  4. Daily Dispatch, 11 April 1997
  5. Student BMJ 1997; 5:272
  6. Lancet 1997; 314:1362
  7. Lancet 1997; 349:1528
  8. Br J Obs and Gynae 1997; 104:398-400
  9. BMJ 1997; 314:1623
  10. The Times, 28 June1997, p1
  11. Lancet 1997; 349:1371
  12. Lancet 1997; 349:1377
  13. AIDS Newsletter 11(12) 1996
  14. Lancet 1997; 349:1305
  15. BMJ 1997; 315:384
  16. BMJ 1997; 314:169
  17. BMJ 1997; 315:8
  18. BMJ 1997; 314:1502
  19. BMJ 1997; 314:1506
  20. BMJ 1997; 314:1711
  21. BMJ 1997; 315:209
  22. BMJ 1997; 314:1569
  23. New Scientist 1997; 2092:3
  24. BMJ 1997; 314:1362
  25. New Scientist 1997; 2088:9
  26. Lancet 1997; 349:1679
  27. BMJ 1997; 314:1574
  28. Lancet 1997; 349:1304
  29. Lancet 1997; 349:1821
  30. New Scientist 1997; 2092:13
  31. New Scientist 1997; 2093:5
  32. New Scientist 1997; 2091:4
  33. New Scientist 1997; 2084:12
  34. Science 1997; 277:1453-81
  35. J Med Genetics 1997; 34:360-5
  36. Dev Med and Child Neurology 1997; 39:79-84
  37. Lancet 1997; 350:186
  38. BMJ 1997; 314:1782
  39. Lancet 1997; 349:1678
  40. Lancet 1997; 349:1530
  41. BMJ 1997; 314:536
  42. Lancet 1997; 350:348
  43. BMJ 1997; 314:1786
  44. BMJ 1997; 314:1711
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