News Review

Dutch ship never intended to perform abortions

The staff of the Aurora, the Dutch floating reproductive health clinic previously reported in Nucleus have admitted that they never intended to perform abortions on the journey. The ship, which docked in Dublin earlier this year and carries a small clinic in a container strapped to the deck, did not have the necessary licence from authorities in the Netherlands.

The organisers were also not prepared for the level of response that the ship's visit engendered. More than 200 international journalists covered the ship's visit to Ireland - almost double the number of women who contacted the vessel seeking abortions. Many of whom later had the operation performed in England.

Dr Gunilla Kleiverda, a Dutch gynaecologist on board the Aurora, said: 'We didn't really expect to see more than two or three women. It is a pilot project to see if women were willing to come.' (Nucleus 2000; October:11, BMJ 2001;322:1507, 23 June)

Review ordered of abortion law in N Ireland

The Family Planning Association in Northern Ireland has been granted a judicial review of the medical practices in the province relating to abortion. The terms of the 1967 Abortion Act currently only apply in Great Britain and have never been extended to Northern Ireland. A High Court hearing in Belfast was told by the association that its application for review was not aimed at achieving a change in the law on abortion. Instead they hope to obtain an order requiring Northern Ireland's health minister to issue best practice guidelines for the medical profession as well as advice for women on the services available.

The association's director, Audrey Samson, said that, although just over 70 abortions were carried out in Northern Ireland in 1999 under a limited set of conditions permitting terminations, at least 1,500 women travelled to England each year for abortions. Pro-life groups are opposing the association's legal challenge. (BMJ 2001;322:1507, 23 June)

Cannabis legalised in Canada

Canada has become the first country to legalise the growth and use of cannabis for medicinal purposes. The new regulations passed at the end of July will allow three groups of patients to benefit. The first is patients with terminal illness and a life expectancy of less than twelve months. The second is chronic illnesses such as multiple sclerosis, cancer, HIV or AIDS, severe arthritis, and epilepsy. The last group are those who have obtained two medical opinions declaring that cannabis would be beneficial. The patient applies for permission to use cannabis by completing a form that must also be signed by their doctor. If approved, the doctor must also set the dose.

The government was keen to clarify that it was not supporting the widespread use of cannabis and would not be providing it. The Canadian Medical Association, however, said it did not support the move, pointing out the 'lack of adequate scientific support.' Peter Barrett, president of the association, said that, 'most physicians were reluctant to participate in the government's programme because they worry about recommending a drug that has not been subjected to rigorous testing and whose full side effects, interactions with other drugs and correct dosages are not known.' (BMJ 2001;323:68, 14 July; BMJ 2001;323:302, 11 August)

French health minister admits to mercy killing

Bernard Kouchner, the French Health Minister, has admitted to administering lethal doses of morphine to war casualties while working as a doctor in Lebanon and Vietnam.

The co-founder of medical aid charity Medicins Sans Frontiers said that ending someone's life was 'a delicate matter', in the revelations made to Dutch magazine Vrij Nederland. Asked what form of euthanasia he had administered, he replied: 'Both passive and active euthanasia...I have been in so many wars and also in hospitals. It happens on a daily basis that life-prolonging equipment is being switched off.'

When legalisation of euthanasia came into effect in the Netherlands Mr Kouchner said he would press for it to be legalised in France too. He says now that he does not favour euthanasia legislation in France. In 1998, a survey of British doctors by the British Medical Journal claimed that half the GPs in the country had in some way assisted terminally ill patients to die. Euthanasia is illegal in all forms in Britain. (Guardian 2001;25 July; Times 2001;25 July)

Woman moves forward in quest for 'right to die'

A terminally ill woman who wants assistance to end her own life, won the right to have her case reviewed in the high court on 31 August. Diane Pretty, 42, was diagnosed with motor neurone disease in 1999. She is now paralysed from the neck down, but is fully mentally competent. She wishes to take her own life but is physically unable to do so. The director of public prosecution had previously refused to guarantee that her husband would not be prosecuted under the 1961 Suicide Act if he helped to end his wife's life. After the ruling, Brian Pretty said that his wife was 'very pleased' with the outcome.

The Voluntary Euthanasia Society and the civil rights group Liberty are supporting her case. They claim that the exceptional circumstances mean that Mr Pretty should be exempt from the Suicide Act.

The judge, who described the case as 'tragic', said he wanted the full hearing to be held as soon as possible. It will almost certainly be held in front of a senior judge because of the ramifications for other seriously disabled people. It is expected to come to court on 10 October. Mrs Pretty's counsel, Philip Havers QC, said: 'if ever there was an individual who can demonstrate a well-settled wish on wholly rational grounds to terminate her life we suggest it is this claimant.'

The Netherlands and the state of Oregon in the USA are currently the only two places in the world that allow voluntary euthanasia. (Guardian 2001;31 August; BMJ 2001;323:531, 8 September)

Kidney shopping

Between 30-50 Canadians travel abroad each year for kidney transplant operations due to waiting lists of up to six years at home. Buying and selling organs is illegal throughout Canada. No law, however, prevents Canadians going abroad for organs. The International Transplant Society and the World Health Organization have condemned this practice, and some health officials want the criminal code changed to make it illegal.

The practice has risks too. Some patients return with scars, but without kidneys despite having paid for them. Investigative journalists Lisa Priest and Estanislao Oziewicz reported in the Toronto Globe & Mail newspaper that a Vancouver businessman, Walter Klak, was acting as a middleman. Mr Klak had more than 100 patients on his waiting list and was frequently negotiating between patients and suppliers of kidney operations. They were awaiting operations at a Shanghai hospital where accident victims were taken.

Medical experts interviewed by the journalists estimated that Canadians paid between £35,700 and £103,600 ($50,000 and $145,000) for transplants in developing countries. Some return without any medical documents describing the operation or donor. This leaves doctors in Canada in the dark about donor screening for infections such as HIV or hepatitis. (BMJ 2001;322:1446, 16 June)

UK fares badly in WHO league table

A league table produced by World Health Organisation officials listed the UK 24th globally in terms of healthcare efficiency. Oman came first and Andorra and Saudi Arabia are in the top ten. Among the 191 countries on the list, Italy is third, France fourth, and Spain sixth whilst HIV/AIDS-hit African nations cluster at the bottom of the table, with South Africa at 182 and Zimbabwe last.

In June last year, the WHO published a report, analysing the healthcare performance of the 191 nations that took into account a range of issues, such as equal access to healthcare, the responsiveness of the service and the amount of money populations could contribute. In that table, France came first and the UK 18th. However, in the new table, which looks solely at efficiency - how much healthcare a country provides for the resources invested - both countries slipped several notches. Efficiency was related to the amount spent on health per head of the population, they found, with a benchmark at around $80 (£56), below which it was difficult to be efficient.

The Department of Health said the paper was 'very interesting research', but noted it was based on estimated figures from 1993 to 1997. 'The government is committed to the largest ever sustained increase in expenditure for the NHS - but it is also committed to ensuring that investment is spent wisely and effectively on improving health,' a spokesman said. (Guardian 2001;10 August)

Government announces draft sex strategy

The government has issued its long awaited draft proposals aimed at modernising sexual health and HIV services in England. The national strategy for sexual health and HIV will also tackle the rising prevalence of sexually transmitted infections. It will be accompanied by a new national safer sex information campaign in 2002 and spending of £47.5m over the next two years. The move coincides with publication of the latest figures from the Public Health Laboratory Service, which show that the upward trend in sexually transmitted infections since 1995 continues unabated.

The strategy will focus on more integrated care, including piloting 'one-stop shops' for young people. A key element is a reduction in the number of newly acquired HIV and gonorrhoea infections by 25% before the end of 2007, including increasing the uptake of HIV testing to 60% of people offered it. Screening for chlamydia will begin in 2002, but initially only among selected groups of women. All gay and bisexual men attending genitourinary clinics will be offered hepatitis B vaccination at their first visit.

Cases of gonorrhoea in England and Wales rose by 27% from 1999 to 2000 and are now at their highest level for over a decade. Attendances at genitourinary clinics have doubled over the past ten years to more than one million. New diagnoses of HIV were the highest on record last year.

Speaking at the launch last week, the deputy chief medical officer, Sheila Adam, acknowledged the strategy as 'ambitious'. But she said, 'This is the first comprehensive look at a range of measures aimed at reducing sexually transmitted infections.' (BMJ 2001;323:250, 4 August)

AIDS campaigners challenge South African government

About 100 paediatricians in the Treatment Action Campaign, which campaigns for access to treatment for HIV and AIDS, are to take legal action against the South African health ministry. They have denounced its continuing refusal to supply antiretroviral drugs for the prevention of transmission of the virus from HIV positive pregnant mothers to their babies.

The government announced last year that it would set up limited sites to test the effects of the antiretroviral nevirapine. At the time this was registered in South Africa for use in adult and paediatric HIV infection but not for the prevention of transmission from mother to child. However, previous trials have found nevirapine to be effective, safe, and inexpensive in reducing the incidence of vertical transmission. It was subsequently registered by South Africa's Medicines Control Council and is being widely used in the private sector. Yet the government has refused to make it widely available in the public sector, where it is needed most. This has been widely attributed to President Thabo Mbeki's eccentric views on AIDS.

Mark Heywood of the Treatment Action Campaign said a lawyer's letter had been sent to the health minister, Dr Manto Tshabalala-Msimang, asking her immediately to supply the drug to all doctors in the public health system that wanted to provide it for their patients or to give good reasons why this should not happen. According to Heywood, about 75,000 babies are born HIV positive in South Africa every year. If nevirapine was supplied immediately at least 20,000 of those babies' lives could be saved.

The health minister replied without addressing the specific questions asked. Instead, her five page letter recounted the history of research and attempts by the department of health to establish guidelines to minimise the transmission of HIV/AIDS from mother to child. The letter raised several potential problems with the drug, all of which have been raised in the past. Mr Heywood said he found the letter disappointing and that the matter seemed certain to have to be resolved in court. (BMJ 2001;323:301, 11 August)

Indian doctors in anticancer drug row

Indian doctors have been accused of breaching ethics in trials of a candidate drug against cancer. The Indian health ministry and Johns Hopkins University in Baltimore, USA, are investigating charges that the doctors breached ethics when they tested the drug, developed at Johns Hopkins, on Indian patients with oral cancer. Johns Hopkins is already at the centre of concerns over its use of inhaled hexamethonium in trials of drugs for asthma.

The investigation into the trials comes after a doctor at the publicly funded Regional Cancer Centre in Trivandrum, Kerala, alleged that his colleagues injected the drug into at least 20 patients without the appropriate approval from health authorities. Dr V Narayan Bhattathiri, associate professor and head of clinical radiobiology at the centre, complained to the State Human Rights Commission that the study violated Indian health ministry guidelines that drugs developed abroad should not be trialled exclusively on Indian patients.

However, the doctors at the centre of the inquiry have defended their actions and insist that the study was done with the consent of patients, hospital ethics panels, and government officials. 'The drug also did not harm any patient and it did not interfere with standard therapy, whether surgery or radiation,' said Dr M Krishnan Nair, director of the centre. He said approval for the study was obtained through 'discussions' with the drugs controller's office and the patients had been informed that the drug was experimental.

Concerns have been raised that India is emerging as an attractive testing ground for experimental drugs. (BMJ 2001;323:299, 11 August)

G8 summit makes no decision on world debt

At the recent summit in Genoa, Italy, G8 leaders announced plans for a global health fund to tackle infectious diseases, but were only prepared to commit $1.3bn (£916m) to the fund - a big cut from initial plans for $10bn.

Despite the violent protests and chaos in the city during which one protestor was shot dead, the summit made no new commitments to cutting the debt of the world's poorest countries. In 2000, aid from the G8 countries fell to an all-time low. Campaigners from Drop the Debt, the successor organisation to the Jubilee 2000 coalition against third world debt, denounced the failure of the G8 countries to use their great wealth and power to attack poverty in developing countries.

Aid agencies have warned that the global health fund should not simply be used for isolated disease control programmes. They pointed out that health systems needed to be boosted in the poorest countries and that the causes of disease outside the direct control of the health sector also need to be tackled. (BMJ 2001;323:186, 28 July)

62 year old gives birth to her brother's baby

A 62 year old woman who circumvented a French ban on fertility treatment for older women by visiting a clinic in California, sparked moral outrage when it was disclosed that she had given birth to her brother's baby. (Times 2001;21 June)

UK clinic to help another woman conceive her brother's child

Another infertile woman could also have a child fathered by her brother via artificial insemination at a London clinic. The 47 year old woman, believed to be a doctor, has undergone assessment at the Bridge Centre in London. Her brother's sperm has already been frozen and would be used to fertilise a donor egg.

The Human Fertilisation and Embryology Authority, which regulates fertility treatments in the UK, says that the procedure is permissible under British law. A spokesperson said: 'There is nothing in the Human Fertilisation and Embryology Act nor in British law that would prevent this treatment. The decision of whether or not to proceed with treatment would be up to the clinic. They would have to offer counselling and take into account the welfare of the child.'

Gedis Grudzinskas, director of the Bridge Centre, said: 'What's the difference between this and a woman having a baby for her sister? I don't believe the word incest is an appropriate term and it's certainly not the case here.'

However, the case has provoked widespread criticism. A spokesperson for Comment on Reproductive Ethics said that the HFEA was 'rapidly turning into a rubber stamp organisation, incapable of saying no.' She added: 'In granting a licence for fraternal fertilisation, a procedure considered incestuous throughout human history, once again the HFEA shows itself to be an organisation without willpower or clout.' (Telegraph 2001;27 August)