News Review

Physician assisted suicide

At its annual conference the BMA has called for a full and frank debate into physician-assisted suicide (PAS). Most doctors opposed the concept, saying that better palliative care was more important.[1] Yet, some junior doctors now see a greater moral acceptability in PAS compared with euthanasia, which are both illegal.[2] The conference also rejected a motion that doctors are 'obliged to accede to clear requests by patients that their life should be allowed to end'. It said that this is too broad and dangerous a statement, which would be open to misunderstanding and place doctors in jeopardy.[3]

Abortion

The US House of Representatives voted in June to ban the testing, development or approval of any drug that chemically induces abortion. The House is also considering legislation to make it illegal to take an underage girl across state lines for an abortion if her home state has a law requiring parental consent.[4]

Misoprostol, the prostaglandin analogue for treating peptic ulcers, is being used by three-quarters of Brazilian women to terminate their pregnancies. It is available over the counter, and children who survive misoprostol use seem to have a high rate of congenital abnormalities. [5]

Five Miami abortion clinics were attacked recently with butyric acid poured through letterboxes. Three patients required treatment of injuries sustained. These attacks came after Florida pro-lifers were banned from bearing 'Choose Life' licence tags on their cars.[6]

The Wellcome Trust and the Population Council have called for an increase in the use of medical abortions to reduce the 70,000 deaths a year caused by surgical abortions performed in unsafe conditions.[7]

Western Australia now has the most liberal abortion law in the country after a new bill was passed allowing abortions to be performed up to 20 weeks' gestation. The mother's informed consent is required, and the abortion can be performed if serious personal, family or social consequences will ensue if the pregnancy continues, or if there is a serious danger to the mother's physical or mental health. Abortion after 20 weeks is permissible but only if a panel of six (including two doctors) agree that a severe medical condition of mother or child justifies the procedure.[8]

The Scottish Parliament wants the power to set its own abortion law. Currently, Westminster determines the UK abortion law and government ministers are attempting to avoid conflict with the Catholic Church of Scotland. Ministers are afraid that the Scottish Parliament would pass a more restrictive law, leading to 'abortion fugitives' across the border.[9]

Smoking

The US Senate Republicans have killed a bill aiming to deter young smokers because it was too costly; they hope to produce a cheaper version.[10] The bill intended to raise the price of cigarettes, establish regulations on advertising and penalise tobacco companies for every year the rate of smoking among young people did not decline.[11]

An American study has shown that 54% of the 10-13 year olds studied had tried smoking, with a substantial number continuing to smoke. Parental and peer smoking were the strongest influences; many children were not properly supervised by their parents and had easy access to cigarettes.[12]

The UK pressure group ASH (Action on Smoking and Health) has shown that tobacco companies were aware of the link between smoking and cancer since the 1950s. They have also known of tobacco's addictive nature since the 1960s. Since 1975, the companies have been targeting young people, the cigarette smokers of the future. They have been taking advantage of teenagers' 'fragile developing self-image, which needs all the support and encouragement it can get'.[13]

British doctors are fighting for a ban on smoking in all public places, saying that passive smoking increases the risk of lung cancer by 20-30%.[14]

Three quarters of articles denying a risk due to passive smoking have been written by authors affiliated to the tobacco industry, casting doubt on the validity of their conclusions.[15]

Gene therapy used to treat HIV-1

Two genes from healthy CD4 lymphocytes have been used to produce a molecule that inhibits viral replication and a defective viral protein that interferes with RNA nuclear export. These two molecules cannot stop HIV-1 infecting cells, but may prolong the lives of these cells by reducing viral replication and cell lysis. A trial is now underway in America.[16]

AIDS vaccines

Phase III of a candidate HIV-1 vaccine (AIDSVAX) has been approved in America. 5,000 healthy US volunteers will take part in the placebo-controlled trial, followed by a further trial in Thailand. Some scientists are unconvinced of the efficacy of AIDSVAX, and concern has been expressed over the ethical responsibilities of the drug companies. Trial sponsors must provide treatment for participants who become infected, make successful vaccines available cheaply to participating countries and include programmes for the prevention of HIV infection. Participants who are intravenous drug users must have access to clean needles, and there are concerns about double standards of treatment for seroconverters in the developed versus the developing world.[17]

AIDS epidemic

In southern Africa and Cambodia, more than 20% of antenatal attendees are HIV positive.[18] In sub-Saharan Africa, at least 10% of all adults are infected, and many capital cities have a prevalence of 35% or more. Botswana and Zimbabwe have reached a prevalence of 25%, a new world high.[19]

By 2010, AIDS may increase infant mortality by 75% and under-five mortality by more than 100% in some areas. Giving multivitamins to HIV-positive pregnant women seems to improve the babies' health after birth and help prevent pre-term deliveries.[20]

Tuberculosis is the leading cause of death worldwide among HIV sufferers. In Africa the death rate could be almost halved if cotrimoxazole plus standard treatment was fully available. Death rates from STDs after contracting AIDS are also very high, but little is being done to combat this.[21]

A French study has shown that the most effective way of preventing perinatal HIV transmission is to give the mother AZT and perform an elective caesarean section, reducing the transmission rate to 0.8%, compared to untreated rates of 17.2%, treated vaginal delivery rates of 6.6% and treated emergency caesarean rates of 11.4%.[22 ]However, caesarean section for the prevention of HIV transmission is not feasible and even dangerous in many developing countries. Strategy therefore aims to reduce perinatal transmission by ensuring the availability of AZT during pregnancy and delivery, along with adequate antenatal care, counselling and HIV testing.[23]

Female genital mutilation

The practice of genital mutilation is slowly decreasing in come countries, such as Kenya and the Sudan. However, it is still very widely practised and it has been estimated that 100 million women have been mutilated in Africa and parts of Asia, with another two million being mutilated each year.

The 97% rate of mutilation in Egypt recorded in 1996 seems unchanged, even though the practice is now officially prohibited, largely because of tradition and the lack of effective education in rural areas.

An alternative approach to stop female genital mutilation involves a week of counselling and training for young women. It has benefited about 300 women in Kenya since it began in 1996. The programme is called 'Ntanira Na Mugambo', or 'circumcision through words'.

It teaches the community about the negative effects of mutilation and encourages men not to require that their future wives and daughters be circumcised. The girls also learn the basics of reproductive anatomy and health, hygiene and gender issues and are given a certificate at the end of the week. It is hoped this approach will become widely used, thus improving women's health and quality of life on a large scale.[24]

Medical students & cannabis

A study has shown that the number of medical students regularly using cannabis has doubled over the last 14 years. Studies suggest that impairment of memory may persist for up to 48 hours after one joint. 46% of students have used cannabis at least once, while 10% claim to use it regularly. A similar proportion of newly qualified doctors take cannabis, and it is not known if cannabis use is likely to affect academic performance.[25]

Cloning

An international team in Hawaii has produced more than 50 cloned mice. They injected differentiated cell nuclei into enucleated mouse oocytes, using strontium to activate them. Clones have also been created from clones, indicating that the process does not introduce significant mutations. The new technique could be used to produce herds of transgenic clones whose milk contains human proteins or whose organs are compatible with humans for xenotransplantation.[26]

Infertility treatments

Italy has drafted a bill in which infertility is defined as a disease. The bill permits free treatment for couples and the use of donated gametes for IVF. However, the legislation bans human cloning research, as well as experiments and commerce with human embryos and gametes. It forbids surrogate pregnancies and assisted pregnancies in single women (including widows) or those over 52 years.[27]

Two widows have become pregnant by their dead husbands' sperm. In July 1995 sperm was taken from Bruce Vernoff of California 24 hours after his death; his wife Gaby is now four months pregnant. In the UK, sperm was extracted from Diane Blood's husband while he was in a coma.[28] She had infertility treatment in Belgium and is now pregnant. In Britain she was denied treatment with her husband's sperm, as he had not given his 'informed consent'.[29]

Sterilisation

In Spain a recently passed law allows 'voluntary' sterilisation for mentally disabled people, but forbids sterilisation for eugenic reasons. The law requires a plea to be made by the individual's legal representative, and two specialists (not necessarily medically qualified) must consider the case before the judge makes a ruling. This revised legislation is intended to protect people with mental disabilities from sexual abuse.[30]

Alternative medicine

On 28 May the Foundation for Integrated Medicine held its first scientific conference, entitled 'Integrated Healthcare: A Way Forward For The Next Five Years?' Concern was expressed about the double standards that apparently operate when judging both orthodox and complementary medicine. The Prince of Wales, president of the Foundation, called for 'rigorous but open minded evaluation of practice in all aspects of healthcare'. The government has allocated a further £25,000 towards the development of a regulatory framework for practitioners of complementary and alternative medicine.[31]

The popularity of alternative medicine in the West continues to increase. A recent American survey said that devotees are not generally dissatisfied with their conventional doctors, but take a more holistic approach to their health.[32]

Developing world: debt and aid

The BMA council has joined the Jubilee 2000 coalition to campaign for the cancellation of developing world debt. Three times more money is paid in debt interest than is spent on healthcare in the developing world.[33] At the Annual World Economic Summit in May, students and doctors from MedSIN(UK) and MEDACT were among more than 50,000 protesters linked in a chain around the International Convention Centre in Birmingham. Germany and Japan have indicated that they are strongly opposed to cancelling the debt. MEDACT is seeking to persuade a sister organisation in Germany to lobby their government.[34]

Clare Short, the minister responsible for overseas aid, has criticised aid agencies and the media for focusing on humanitarian disaster appeals instead of on long-term development.[35]

The United Nations Children's Fund has reported that by early next century eight million children are unlikely to receive lifesaving new vaccines that are coming onto the market.[36]

Intraocular lenses have been found to be an effective method of treating people who are blind owing to cataracts in the developing world. However, only patients who can afford to pay for the surgery are likely to receive this form of treatment.[37]