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ss nucleus - autumn 1998,  News Review

News Review

Perinatal AIDS prevention

Over the next five years between five and ten million children will contract HIV perinatally; most in the developing world. This number could be cut by more than 75% if known HIV-positive mothers were to receive drug therapy, undergo caesarean section and avoid breast feeding.[1]

The Joint United Nations Programme on HIV/AIDS has said that the prevention of mother to child transmission of the virus must now become a global health priority.[2] This follows research in Thailand by the Centres for Disease Control and Prevention, which has shown that oral zidovudine given in the last four weeks of pregnancy (at a cost of only $50 per patient) will reduce HIV transmission by 51%. GlaxoWellcome has further responded by announcing plans to make zidovudine available to women in developing countries at a quarter of the normal price.[3]

An intercollegiate working party in Britain has recently called for better access to antenatal HIV testing[4] after a BMJ editorial branded current UK practice 'shameful and negligent'.[5] Only 16% of pregnant women in London know their HIV status, while rates of 73% and 95% respectively have been achieved in France and Sweden.[6]

Without intervention, the rate of HIV transmission from mother to infant is between 18% and 24%.[7]

Living wills pave the way for euthanasia

Two out of three Britons favour making living wills legally binding on doctors, according to a recent MORI poll. The government is proposing to legislate to set up a statutory framework for living wills and submissions on its consultation document Who decides? closed at the end of March.

CMF is opposed to legally binding living wills, which we see as the beginning of a slippery slope. Although living wills could not force doctors to do anything unlawful (such as performing euthanasia), they would open the door to starvation of incompetent patients through withholding of food and fluids. Our own submission can be read here.

Advance directives (patients' advance refusal of treatment) are already binding on doctors under common law following a ruling by the High Court in 1993. The case concerned a schizophrenic man with a gangrenous leg living in Broadmoor Special Hospital who obtained an injunction banning doctors from amputating his limb at any time in the future.[8]

Legalised physician assisted suicide in the US

An 85 year old woman with metastatic breast cancer has become the first person to die under Oregon's Death with Dignity Act. Oregon is the only state in which physician assisted suicide is legal although Jack Kevorkian, a Michigan doctor, has made a career out of carrying out the procedure illegally.[9]

In a recent survey of 3,102 doctors in the New England Journal of Medicine, a third of respondents said they would comply if physician assisted suicide were legal, and a quarter said they would perform euthanasia.[10]

The US Supreme Court ruled last year that there was no constitutional right to physician assisted suicide, but the Oregon law, which had been held in abeyance by legal challenges, may well pave the way for similar legislation in other states.

Cloning

Human Factor IX has been produced at commercial concentrations in the milk of transgenic sheep. Conceivably, the world demand for the protein could be served by only 50 animals.[11]

A calf called Mr Jefferson has been produced by nuclear transfer, the same technique used to produce Dolly the sheep. The possibility of transgenic cattle producing large quantities of human therapeutic proteins is not far off.[12] Meanwhile Dolly has produced a lamb, Bonnie, at the Roslin Institute in Edinburgh.[13]

Calf and lamb clones from nuclear transfer have been produced in five countries so far. In New Zealand a Friesian-Hereford cross calf called Jill is being hailed as the beginning of an assembly-line of high-producing cattle; and two cloned rams called Thomas and James have fathered their first lambs.[14]

Concerns about gene therapy and screening

No useful gene therapy treatment has yet emerged for diseases such as cystic fibrosis, according to a recent editorial in Thorax. Despite this, many patients are pinning their hopes unrealistically on media reports that breakthroughs are near at hand.[15]

Exaggerated claims have also been made for genetic testing. In fact, the ability of genetic tests to predict disease accurately is limited by variable expressivity, incomplete penetrance and genetic heterogeneity even when single genes have a prominent role; and in many common disorders multiple genes are implicated.

Effective genetic testing requires accurate tests, pre-test and post-test education and counselling and protection of confidentiality; but commercial interests may mean that the technology is in wide use before proper protocols have been implemented.[16] The psychological impact of screening on individuals and their families needs careful study.[17]

The internet

The BMJ recently joined Nucleus, the Lancet and a host of specialist journals in making the full text of its paper journal available on the internet.

The number of internet websites has grown from 20,000 in May 1995 to 2.1m and there are now estimated to be 107m people on-line. With the introduction of webTV this may increase by another order of magnitude.

While the internet holds tremendous potential as an information source for those working in the developing world, we can expect an initial widening of the information gap. The cost of the technology coupled with poor telephone lines and unstable connections can make downloading material frustratingly difficult. There is a great need for making appropriate technology available at an affordable price.[18]

Screening for Down's syndrome

Pressure is being applied for earlier antenatal screening for Down's syndrome after a large US study identified 80% of affected babies in the first trimester.

Parameters measured in 4412 pregnancies included a -fetoprotein, free b-human chorionic gonadotrophin, oestriol, pregnancy associated protein A and nuchal translucency. High risk cases then proceeded to chorionic villus sampling or amniocentesis and abortion. The Leeds antenatal screening service reports similar 'success' with smaller numbers of patients.

Supporters claim that the earlier test will enable earlier termination, with fewer physical and psychological complications for the mother. About 2.5 million pregnant women are screened for Down's syndrome each year in the United States, but nearly all the testing is carried out in the second trimester.

Down's syndrome is the most common genetic disorder and its elimination through selective abortion will no doubt provide a pattern for other forms of 'chromosomal cleansing'.[19] Such screening is often done without consent.[20]

Therapeutic touch fails the test

Recently published research has demonstrated that practitioners of 'therapeutic touch' are unable to detect the 'human energy fields' they claim to rely on for diagnosis and treatment. In the study 21 practitioners detected the presence of a human hand behind a screen less than 50% of the time.

Proponents of the therapy, which involves passing hands a few inches above a patient's body to 'repattern energy flow', say that more than 100,000 people world-wide have been trained in the technique, including 43,000 healthcare professionals.[21]

Therapeutic touch is based on New Age Pantheism and is one of many alternative therapies receiving uncritical acceptance by healthcare workers and patients.

Cannabis as medicine?

British doctors have been unable to prescribe cannabis since 1971 under the Misuse of Drugs Act, but now a working party on the therapeutic uses of cannabinoids is being set up by the Royal Pharmaceutical Society of Great Britain.

This move follows last year's BMA Report Therapeutic Uses of Cannabis, which concluded that, while cannabis is unsuitable for medicinal use, cannabinoids should be considered. In a written submission to the House of Lords Science and Technology Committee inquiry into cannabis, the BMA further said that individual cannabinoids have a therapeutic potential in several medical conditions in which present drugs are not fully adequate.[22] Submissions to the inquiry closed on 12 May.[23]

Only a few of the 60 known cannabinoids have been so far studied. The strongest evidence relates to the effectiveness of d-9-tetrahydro-cannabinol and the synthetic cannabinoid nabilone in relieving nausea and vomiting secondary to cancer chemotherapy. Anecdotal reports and animal studies suggest that cannabis derivatives may also have application as muscle relaxants, analgesics, anti-inflammatories, anticonvulsants and bronchodilators, but the results of controlled trials in humans are still awaited.[24]

More pressure on the tobacco industry

Almost 75% of respondents in a British Market Research Bureau survey of 2757 smokers believe that the tobacco industry should fund specialist smoking clinics, and one in three think that the industry should be made liable for smoking related illness.[25] The tobacco industry makes £800 million profits each year but the government and health authorities spend only £22 million in helping smokers quit. 30% of the smokers believed doctors to be the greatest influence in helping them to stop and BMA Council Chairman Sandy Macara has labelled the tobacco industry 'public enemy number one'.[26]

Last year the American tobacco industry agreed restrictions including a payment of $368.5billion in instalments over the next 25 years in return for a limit of $5billion annual compensation claims and future immunity from future class action lawsuits. However, they recently pulled out of the deal when the Senate commerce committee drafted a bill with revised figures of $600billion and $6.5billion respectively. The industry ran adverts in national newspapers claiming: 'We agreed to change the way we do business...not to go out of business'. President Clinton has vowed to push ahead with or without the co-operation of the companies.[27]

Meanwhile, a huge number of confidential tobacco industry documents have come into the public domain after a US Supreme Court ruling. Apparently they show that the industry 'was aware of the addictive or habit forming nature of nicotine, experimented with 'dosages' of nicotine, and did not reveal to consumers the extent of their knowledge'.[28]

Milk marketing code transgressions continue

According to a report from the International Baby Food Action Network, companies are still violating the WHO's international code of marketing for breast milk substitutes.

While most companies in the developing world have stopped direct media advertising of infant formula, they have switched their efforts to promoting other products such as follow-on formula and formula milk for mothers, in order to keep the brand name in the public domain. Most code violations occur in hospitals and clinics.[29]

Fetuses can remember music

Babies in the womb can hear and remember music as early as 20 weeks' gestation according to research at Keele University. Babies responded to familiar music after birth by becoming calm and relaxed while unfamiliar music produced no reaction.

Research at Queen's University, Belfast, has shown that fetuses exhibit right or left-handedness as early as ten weeks' gestation.[30]

This new evidence calls further into question the claim of the recent RCOG report that fetuses cannot feel pain before 26 weeks.[31]

Interestingly, the study received little attention in the medical press, in keeping with the general policy of selective reporting in this field. The question of whether or not fetuses are sentient was recently discussed in Nucleus.[32]

Bishop blames 'homophobic' Bible

The leader of the Anglican church in Scotland has accused the churches of 'homophobia' and has called the Bible 'our greatest danger'.

The Right Rev Richard Holloway, in an address to the Lesbian and Gay Christian Movement in London, called the Bible 'flawed and fallible' and predicted that 'soon we'll abandon its ignorant misunderstanding of homosexuality'.

By contrast, Dr John Stott, Rector Emeritus of All Souls Langham Place, Central London, has said that homosexual relationships are 'incompatible with true love because they are incompatible with God's Law'.[33]

Meanwhile, Peter Tatchell, the leader of the homosexual activist group 'Outrage', is standing trial for invading the Canterbury Cathedral pulpit on Easter Sunday, to preach a sermon of his own. The Archbishop of Canterbury, George Carey, was giving his Easter address at the time.

New treatment for Parkinson's disease?

Transplantation of dopaminergic neurones from aborted human fetuses as a treatment for Parkinson's disease has been under trial for some years, but the approach raises ethical dilemmas and results are thus far variable.[34]

Recently, researchers at the University of Colorado have transplanted dopamine producing neuronal cells from cloned cow embryos into parkinsonian rats and produced a significant improvement in motor function.

If problems of rejection could be overcome by genetic modification, the process may well work in humans. Ultimately it may be possible to convert human fibroblasts into dopamine producing cells and obviate any call for embryonic tissue.[35]

Preventing burnout in doctors

Burnout is characterised by 'a progressive loss of idealism, energy, purpose and concern as a result of conditions at work'. According to an article on the management of sick doctors in Advances in Psychiatric Treatment (1997;3:250-311), the best protection against it is to ensure that the most enjoyable components of a job are not sacrificed to meet clinical or administrative demands.[36]

Chinese doctors condemn forced organ donation

The Chinese Medical Association has said that it regards the involuntary or forced removal and sale of organs as illegal and ethically unacceptable.[37] The statement followed a meeting with the World Medical Association to discuss allegations that Chinese doctors have been involved in trading organs from executed prisoners.[38]

Preventing teen pregnancies

More than 80% of hospital doctors believe that the contraceptive pill should be available to girls below the legal age of consent. 49% say doctors should consult the girls' parents beforehand and 55% say doctors should take the opportunity to give moral advice.

These were the central findings of a BMA News Review survey of 150 hospital doctors on the subject of under age prescribing. The equivalent figures for GPs were 94%, 67% and 38% respectively.[39]

The number of conceptions in girls aged under 16 has risen for the third consecutive year in England and Wales to 9.4 per 1,000.[40]

But is contraception really the answer? There is substantial evidence that contraceptive failure is a major factor in unplanned pregnancy;[41] 80% of teenagers with unplanned pregnancy in one study claimed to have been using contraception at the time of conception.[42] 87% of teenage mothers in Britain are unmarried; the highest level anywhere in the world.

Refugee children

There are 23 million refugees in the world, of whom about 40% are children under the age of 18. US studies indicate that serious psychiatric disorder is present in 40-50% of these.

About 120,000 refugees live in Britain, and their mental health needs have so far received little attention. War and persecution are the cause of most migrations.[43]

Abortion

Two thirds of Irish women with unwanted pregnancies opt to keep their children with only a third (who are mainly unmarried) having their pregnancies terminated in Britain. Overall the Irish abortion rate in 1995 was 8.5% of all pregnancies (25% of pregnancies in unmarried women and 2% in married women).[44]

A group of pro-abortion MPs have backed the Voice for Choice campaign for abortion on request under 14 weeks. A Commons motion put down by Gareth Thomas, Labour MP for Harrow West, demanded that 'doctors with an ethical objection should be obliged to declare it'.

Dr Vivienne Nathanson, head of the BMA's policy research department which covers ethics, said in response that 'Doctors are already under an ethical obligation to make it clear to patients if they have an objection to abortion and they must refer women to someone else'.[45]

There is, however, no legal obligation currently to refer. The issue of conscientious objection has been previously dealt with in Nucleus.[46]

Being open with patients

Doctors are to face sanctions from the General Medical Council (GMC) if they are not open with patients and do not routinely give them full information. The GMC has said in the second edition of its booklet Good Medical Practice that it will be more stringent with doctors who failed to meet the new standards.

But even the GMC has evidence that changing medical culture will be very difficult. It found that 36% of doctors did not believe that a requirement to treat every patient 'politely and considerately' and that failing to give patients information in a way that they understood were proper matters for disciplinary proceedings. Only 50% of doctors have read the new document on standards and behaviour which had been sent to all of them.

The Chairman of the GMC says that the preoccupation with technology and science has led to doctors leaving behind the arts of listening to patients and explaining in a way that they can understand, adding that patients have every right to expect that doctors will explain things fully and honestly.[47]

References
  1. BMJ 1998;316:645 (28 February)
  2. BMJ 1998;316:1038 (4 April)
  3. BMJ 1998;316:798 (14 March)
  4. BMJ 1998;316:1333 (2 May)
  5. BMJ 1998;316:241-2 (24 January)
  6. BMJ 1998;316:1030 (28 March)
  7. BMJ 1998;316:645 (28 February)
  8. BMJ 1998;316:959 (28 March)
  9. BMJ 1998;316:1037 (4 April)
  10. BMJ 1998;316:1334 (2 May)
  11. BMJ 1998;316:798 (14 March)
  12. BMJ 1998;316:646 (28 February)
  13. BMJ 1998;316:1335 (2 May)
  14. New Zealand Herald 1998;16 April
  15. BMJ 1998;316:1030 (28 March)
  16. BMJ 1998;316:852-6 (14 March)
  17. BMJ 1998;316:693-6 (28 February)
  18. BMJ 1998;316:1116 (11 April)
  19. BMJ 1998;316:1111 (11 April)
  20. BMJ 1998;316:1027 (28 March)
  21. BMJ 1998;316:1042 (4 April)
  22. BMJ 1998;316:1335 (2 May)
  23. BMJ 1998;316:802 (14 March)
  24. BMJ 1998;316:1033-4 (4 April)
  25. BMJ 1998;316:802 (14 March)
  26. BMA News Review 1998; March:13
  27. BMJ 1998;316:1185 (18 April)
  28. BMJ 1998;316:1186 (18 April)
  29. BMJ 1998;316:1115 (11 April)
  30. The Times 1998; 30 March:6
  31. BMJ 1997;315:1112 (1 November)
  32. Nucleus 1998; January:2,3
  33. The Times 1998; 18 April:2
  34. Nucleus 1996; July:16-20
  35. BMJ 1998;316:1407 (9 May)
  36. Student BMJ 1997;5:484 (December)
  37. BMJ 1998;316:956 (28 March)
  38. BMJ 1998;316:725 (7 March)
  39. BMA News Review 1998; April:14
  40. BMJ 1998;316:882 (21 March)
  41. BMJ 1995;311:807 (23 September)
  42. BMJ 1995;310:1644 (24 June)
  43. BMJ 1998;316:793-4 (14 March)
  44. BMJ 1998;316:882 (21 March)
  45. Hospital Doctor 1998; 7 May:5
  46. Nucleus 1996; January:9-14
  47. The Telegraph 1998;20
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