News Review

Standards and numbers falling in British medical schools?

British medical schools should increase their annual intake by 1,000 to meet future demand, according to a government committee. The Medical Workforce Standing Advisory Committee, which has just made its third annual report, recommends making the changes as soon as possible.[1]

Meanwhile there has been an overall drop of 4.2% in university applications; medicine is among the courses worst affected. The fall is most evident in mature students with a 13.4% fall in applicants aged between 21 and 24.[2] Against this, recent research has suggested that those who do best in A-level examinations are not by nature likely to become good doctors.[3]

One reason for application drops may be that this autumn's students will be the first to pay the £1,000-a-year tuition fee recently introduced by the government. Those who plan to avoid repaying their student debt after graduation will not be reassured by the news that doctors defaulting on loans in the US are having their names published on the internet and are being disqualified for payment by the Medicare and Medicaid programmes.[4] The issue of student debt was reviewed in the last edition of Nucleus.[5]

Moves to legalise cannabis?

The BMA has called for a change in licensing laws to allow controlled trials on cannabinoids. The report Therapeutic Uses of Cannabis recommends research on their use as antiemetic agents and in managing spasticity. Trials could point out possible therapeutic advantages in the management of chronic pain, epilepsy, stroke, immunocompromised states and glaucoma.[6]

Meanwhile, the House of Lords' Science and Technology Committee is conducting an inquiry into the wider issue of the legalisation of cannabis. Its report is expected in the autumn.[7]

Acupuncture: does it have a point?

Acupuncture is an effective treatment for nausea and vomiting induced by anaesthesia, pregnancy or chemotherapy, according to a consensus panel of the US National Institute of Health. The panel has no binding power over doctors.[8]

Selling prisoners' organs

Two Chinese people have been arrested in New York after allegedly supplying organs cut from executed prisoners. Pancreata, livers and lungs were among organs offered to FBI agents posing as buyers in a 'sting' operation.

China claims that body parts are only taken with prisoners' permission and are donated, rather than sold, to patients. But on a videotape one of the arrested men, a prosecutor from Hainan, said: 'Prisoners have no political rights, so we don't ask'.

In America it is illegal to sell or buy body parts and the two men could face more than ten years in jail.[9]

Abortion

United States
In a landmark ruling the Supreme Court of South Carolina has ruled that a viable fetus is a person and covered by state child abuse laws. The surprise judgement followed an appeal by Cornelia Whitner, now 33, to have a criminal child neglect conviction overthrown on the grounds that her fetus might not legally be considered a person. Whitner had been sentenced to eight years imprisonment in 1992 (though was released after 16 months) for giving birth to a baby who had traces of cocaine in his blood.

The president of the South Carolina Medical Association, Dr Nelson Weston, called the decision 'unfortunate' as it made 'a viable fetus the same as a person'. Ms Whitner is appealing to the US Supreme Court.[10]

Meanwhile, the US Senate has confirmed President Clinton's nominee, Dr David Satcher as Surgeon General. Dr Satcher, presently director of the Centers for Disease Control and Prevention (CDC), is a supporter of late term partial birth abortions.[11] In a rather ironic twist, the BMJ records the CDC as reporting the 1995 US abortion rate at 20 per 1,000 live births.[12] In fact the true level (one in five) is higher by a factor of ten!

Australia
Two Western Australian (WA) doctors have been charged over an abortion, in a move that will reignite the debate in that country. Abortion is strictly unlawful in all Australian jurisdictions, yet the body of case law allows certain provisions: serious danger to the mother's physical or mental health, as well as possible financial hardship, make abortion permissible. The WA Director of Public Prosecutions holds abortion to be legal only when the mother's life is in danger. No such prosecutions have been made for over 20 years, during which 80,000 abortions have been performed. Supporters of abortion have concern that similar prosecutions may be carried out in other states. A petition, signed by female parliamentarians, has labelled the ruling draconian and hostile.[13]

Medicalising execution?

Amnesty International has warned that increasing numbers of doctors will become involved in state ordered executions if the preference for lethal injection continues to grow. The report Lethal Injection: the Medical Technology of Execution states that medical expertise confers 'the imprimatur of respectability... and (legitimises) an illegal and unethical practice'.

In the last year, countries that have joined the US in using the method include Guatemala, the Philippines, Taiwan and China.[14] The World Medical Association (WMA) and the International Council of Nurses have explicitly rejected the practice. The WMA's recent Hamburg Declaration on torture has urged doctors to resist any pressure to act against their ethical principles.[15]

Age of Aquarius?

More people believe in ghosts than in God according to a Daily Mail ICM poll. 64% of 1,000 polled said they believed in psychic powers, 38% in ghosts, 34% in poltergeists and 29% in alien visitations. Paradoxically the number claiming to have had direct experience of 'weird phenomena' had decreased, suggesting that people are increasingly likely to take unusual testimony at face value.[16]

As G K Chesterton has said, 'When people cease to believe in God, they do not believe in nothing, they believe in anything'.

Fertility treatments

While intracytoplasmic sperm injection has greatly increased hope for subfertile males, there is still debate over whether or not it increases the level of congenital malformations. Recent Australian and Belgian studies came to different conclusions and a BMJ editorial called for common definitions and further research.[17]

Meanwhile the Human Fertilisation and Embryology Authority (HFEA) has recommended setting up a national donor service for human eggs and sperm, similar to the one existing for blood.[18]

AIDS/HIV epidemic worsening

A report by UNAIDS and WHO has concluded that the global HIV epidemic is far worse than previously thought. Over 30 million adults and children are now believed to be living with HIV infection: one in every 100 sexually active adults world-wide. The predicted figure for the year 2000, given current rates, is 40 million.

The vast majority of those with HIV live in the developing world and nine out of ten HIV positive people have no idea that they are infected. It is estimated that 2.3 million people died of AIDS in 1997, a 50% increase on 1996. Nearly half of these deaths were women and 460,000 were children under 15.[19] More than half of the total infected are aged 15-24.[20]

While the advantages of ascertaining maternal HIV status before birth are clear (transmission is halved by avoiding breast feeding and reduced a further two thirds by the administration of zidovudine), antenatal testing is still not done well, even in Britain.[21]

New advances in drug therapy are prohibitively expensive in societies where total health spending per person is often only £3 per day. In such circumstances, prevention must remain the only hope for control.

Free sex?

Most women regret having sexual intercourse before age 16 according to a New Zealand study published in the BMJ.

More men than women said that both they and their partner were equally willing at first intercourse. Being forced at first intercourse was commonly reported by women, especially those who experienced it before the age of 14.

Early intercourse carries increased risks of sexually transmitted diseases and unwanted pregnancies, which may result in long term health and social disadvantages.[22]

Safe sex?

A recent review[23] highlighting the medical consequences of permissive behaviour reveals disturbing facts about homosexual longevity. Whilst the median age of death for married men whose obituaries were published in conventional newspapers was 75 (paralleling the US average), it was lower for gay men: 39 if AIDS-related and 42 if not.[24]

Genes and ageing

Ageing and the disorders of later life are separate entities but both are under genetic control. Whilst ageing involves defects in mitochondrial DNA leading to oxidative cell damage, age related disorders (such as cancer, dementia and vascular disease) are due to the effects of inherited risk factors.[25]

Scientists in the US have significantly extended the life span of cultured human cells by adding an enzyme called telomerase, fuelling speculation that the human life span could be extended beyond 120 years. Telomeres are highly conserved sequences of DNA present at the ends of chromosomes; they are shortened in the premature ageing condition progeria. Normal cell ageing is thought to be due to sloughing of telomeric DNA.

This work may have application in reversing blindness from macular degeneration, wound healing and skin grafting.[26] Interestingly, men lived much longer before the great flood, at which time God decreed a life span of...120 years. Was the mechanism genetic?

Prenatal selection

A massive review of antenatal screening for Down's syndrome has called for the establishment of 35 screening centres in Britain.[27] The authors suggest that the procedure should be offered to all pregnant women in the second trimester, using triple or quadruple serum tests to select women for amniocentesis.[28]

A programme offering testing for Fragile X syndrome in New South Wales has identified about 75% of affected families: all males with the full mutation were aborted.[29]

Like children with Down's syndrome, males with Fragile X need extra help at school and protected employment later; usually they are not able to live independently. Affected females have much milder learning difficulties.

The above studies provide further evidence that prenatal 'search and destroy' policies for those with special needs are passing without comment in the medical press.

Smoking

European Union health ministers have decided that all tobacco advertising will be scaled down from 2001 and banned completely by 2006. The WHO has confirmed that smoking is the single greatest cause of preventable disease and death. In the EU alone, 91% of lung cancers in men are caused by tobacco smoke and over 500,000 deaths annually are related to tobacco.[30]

Passive smoking kills 22,000 people in the EU, according to an authoritative study funded by the European Commission. Passive Smoking, The Health Impact suggests that each year 2,000 die from lung cancer and 20,000 from cardiovascular disease.[31]

Fifty British lung cancer patients are to go ahead with test cases for compensation against tobacco companies after an appeal court ruling. A leaked internal memo from British American Tobacco (BAT) allegedly shows that Britain's biggest tobacco company knew 20 years ago that the sale of their products depended on their addictiveness, a fact never admitted publicly by the industry.[32]

Euthanasia by the back door?

New government proposals for taking decisions on behalf of mentally incompetent people would put living wills on a statutory footing. The new consultation paper, issued along lines originally recommended in 1995 by the Law Commission, would also allow 'substitute decision makers' to make judgements about medical interventions when patients cease to be competent. The consultation period finishes on 31 March.

On the day Lord Irvine unveiled the paper, MPs voted against Joe Ashton's Doctor Assisted Dying Bill by 234 votes to 89. The bill would have allowed 'incurably ill patients' to be killed by a doctor.[33]

Oregon's decision to allow assisted suicide for terminally ill people has been threatened by a warning from the US Federal Drug Enforcement Administration. It stated that a doctor who writes a prescription for suicide would be violating the Controlled Substances Act.[34]

A vaccine for leprosy?

A vaccine for leprosy has been approved by India's drug control agency and is to be used as an adjunct to standard multidrug therapy. The vaccine, developed at the National Institute of Immunology in New Delhi, is said to be the first in the world that stimulates the immune system to kill Mycobacterium leprae. It should become commercially available at six rupees (10p) per dose by June 1998.

The vaccine (which will help reduce duration of treatment by more than six months) may also provide immunoprophylaxis; results of trials are not expected for another three years.[35]

Genetics

'In the last eight years...about 30 major gene therapy companies have been launched, three major gene therapy journals have been established, more than 200 human gene therapy protocols have been approved and over 2,000 patients have received gene therapy. As yet, however, only a handful of patients with rare conditions have benefited....' So began a major review of the status of gene therapy in the BMJ.[36] While the future holds promise, there is a very long way to go, and the inevitable result is that more and more effort will be directed towards prenatal search and destroy strategies.

The US Task Force on Genetic Testing is concerned that, as the human genome project progresses, the number of genetic tests being developed could overwhelm institutional review boards.[37] In the meantime, the Human Genetics Advisory Forum (HGAC) has recommended a two year moratorium on insurers asking clients for genetic test results. A new code for the industry states that existing results should be given.[38] Part of the problem is that genetic epidemiology is still in its infancy. The HGAC has concluded: 'It is unlikely that actuarially important genetic predictions of common causes of adult death will be available and validated for some time'.[39]

Meanwhile the presses are kept rolling with the latest genetic advances. Two of the most recent are the sequencing of the genome of Mycobacterium tuberculosis and the cloning of transgenic sheep capable of producing human factor IX.[40]

Contraception

The Department of Health has advised GPs that the contraceptive device Persona may have an unacceptably high failure rate for some couples. After an investigation, the Medical Devices Agency stated: 'Persona is basically a test-based form of the rhythm method of contraception'.[41] Persona, which has been bought by 100,000 British women, is being blamed for 60 abortions (following failed contraception) each month.[42]

The Contraceptive Service's Emergency Contraceptive Pack was launched on 11 February. The poster, leaflet and 'credit card' campaign is advocating emergency 'contraception' up to 72 hours after unprotected intercourse, and the IUD up to five days after.[43] Obviously the later the intervention, the more likely that the mechanism of action will be prevention of implantation (ie abortifacient) rather than prevention of conception.

Meanwhile the medical director of the International Planned Parenthood Federation of America, Dr Jerry Edwards, has devised a hand-held syringe technique that will enable women to have abortions as early as eight days after conception.[44]

Austrian Nazi past examined

A two day symposium has been held in Vienna to examine the role of its psychiatric establishment during the Nazi era. Significant evidence was presented to suggest that the Steinhof hospital was a Nazi killing centre. Although this was a first in that it was organised by a jurisdiction, the City of Vienna, it was seen by many as evidence that Austria has not truly faced up to its history. Only one of the contributors was an Austrian and he himself believed that his past research had made him unpopular in Austria.[45]

Illegal sterilisations in Australia

A recent report states that Australian doctors have carried out more than 1000 illegal sterilisations of intellectually disabled girls since 1992. A High Court ruling at this time made such sterilisations unlawful without the permission of a court or tribunal. However, this permission has been granted only 17 times in 1045 documented cases. The authors of the report state that the data used did not include operations done in public hospitals. They estimate that the true figure may be three times higher.[46]

Euthanasia

A Canadian court has ruled that a mandatory life sentence would be a cruel and unusual punishment for a farmer convicted of killing his child, a twelve year old girl with cerebral palsy. He apparently did it to relieve her of a lifetime of unremitting pain. Spokesmen for disabled groups said that the ruling was essentially 'open season' on the disabled, but the case judge said that the homicide was committed for 'caring and altruistic reasons'. The defendant received a one year jail sentence plus one year house arrest.[47]

An AIDS specialist from Toronto, Canada, has been convicted on two counts of physician-assisted suicide. He pleaded guilty to supplying lethal doses of barbiturates to two patients, one of whom survived after spending days in a coma. Maurice Genereux was portrayed by the surviving patient as a doctor who freely dispensed tranquilisers to suicidal patients without making efforts to dissuade them. He was suspended from practising medicine in 1994 on charges of sexual harassment but reinstated early due to a shortage of AIDS doctors.[48]

Egypt condemns female genital mutilation

Egypt's highest court has upheld an earlier ban on female genital mutilation (FGM). This is the latest stage in a controversy that began when the government tried to stop the procedure in public hospitals. FGM is not thought to be justified by many Islamic scholars and there is division over whether it should form part of Islamic practice. It should be noted that it also occurs among the country's Coptic Christian community. Polls suggest that 70 - 90% of Egyptian women have been genitally cut in some way. Government clinics and private practitioners have been teaching staff and patients about the dangers of FGM. However, it is still supported by many women in Egypt and therefore its elimination will not be a simple thing.[49]