News review

GP found guilty of 15 counts of murder

Harold Shipman, a Manchester GP, has been found guilty of the murder of 15 elderly women and sentenced to life in prison. Police have evidence for the possibility of many more murders and some reports suggest that his total death toll could be over 150. He was also found guilty of forging the £400,000 will of Mrs Grundy, one of his victims who died of 'old age'. Later exhumation revealed large quantities of morphine in her body.

The local Health Authority has urged the government to tighten up the system and make GPs more accountable. The General Medical Council will be encouraging the government to introduce many reforms.

Health authorities are to be made aware of any previous convictions for offences such as Shipman's (for stockpiling of pethidine), and will require any deaths in GPs' surgeries to be reported to the coroner. GPs who countersign death certificates will have to examine the body, check the medical notes and speak to the families themselves. More auditing of GPs' surgeries will be introduced and their computers will be configured so that backdating and falsification of reports is much harder. A new whistle-blowing hotline will be set up and the availability of controlled drugs will be tightened.

An independent inquiry has been set up, chaired by Lord Laming of Tewin. The main aim of the inquiry, which will report to the government in September, is to examine how patients can be safeguarded in the future (BMJ 1999; 319:1026, 16 October), (Telegraph 2000; 1 February), (Telegraph 2000; 2 February).

Belgium considers legalising euthanasia

Proposals to decriminalise euthanasia in Belgium have been met with anger from the medical community who feel they have not been properly consulted. Senators propose that doctors should be allowed to carry out voluntary euthanasia under certain conditions; the patient must be aware of his serious and incurable condition and of the alternative possibilities of palliative care, the patient must be a competent adult and make an explicit and repeated request. He must be in continuous and intolerable suffering that is not alleviated by medical care, with his condition confirmed by another doctor.

The Christian Democrat party is opposed to these proposals, saying they fear increasing liberality, even more than in Holland, and that there would be no effective control (BMJ 2000;320:137, 15 January).

Physician assisted suicide

Oregon's 1997 Death With Dignity Act allowed voluntary self-administration of lethal drugs prescribed by a doctor. But now, under the Pain Relief Promotion Act, federally controlled substances can no longer be used for physician assisted suicide in the US. If a doctor prescribes a drug with the purpose of ending life, he is now subject to criminal penalties which can be as high as 20 years in prison. (BMJ 1999;319:1312, 13 November).

In the UK, Age Concern has called for a Government enquiry into recent claims that elderly patients are being starved to death and into increasing allegations of involuntary euthanasia (withholding of food and drink from the not-terminally ill). The charity reports an increasing loss of confidence in the NHS among senior citizens and has received more than 1,000 complaints that the elderly are being fobbed off, undervalued or abused. A pressure group of concerned relatives called SOS-NHS Patients in Danger is considering going to the European Court of Human Rights with 50 examples of suspicious deaths under NHS care. The BMA says that tube-feeding is a medical treatment and can be withdrawn, but does not advocate the removal of oral feeding. (Independent 1999, 7 December).

The Winterton Bill

Ann Winterton's Medical Treatment (Prevention of Euthanasia) Bill, seeking to prevent doctors from taking any action which could be interpreted as deliberately shortening life, has passed its second reading in the House of Commons. The BMA, which is firmly opposed to euthanasia, is campaigning against the Bill, saying that it would override patient autonomy and would prevent patients from refusing further treatment. Current BMA guidelines allow doctors to agree to a request to withhold/withdraw treatment, and if the patient is incompetent, doctors are expected to act 'in the patient's best interests'. However, Ms Winterton says her bill does not require doctors to strive officiously to keep dying patients alive (BMJ 2000;320;319, 29 January), (Independent 2000; 24 January), (Telegraph 2000; 27 January).

Lords block Section 28 repeal

On the 7th of February the House of Lords threw out Government plans to repeal Section 28, which prevents public money from being spent on the promotion of homosexuality in schools and elsewhere. However, three days later, on the 10th of February, the Scottish Parliament voted to abolish Section 28 in Scotland.

Also on the 10th of February, the House of Commons approved legislation to lower the age of consent for male homosexuals from 18 to 16. This ruling cannot now be changed by the Lords, and it will therefore become law automatically in England, Wales and Scotland later this year. (Telegraph 2000; 11 February)

Developing world debt to be cancelled

The British Treasury is holding talks over the course of this year with the aim of cancelling debts owed to the UK by 25 impoverished nations. Debts will only be cancelled if there is a guarantee that the money will go to education, health or anti-poverty programmes. Uganda, Mozambique, Bolivia and Mauritania have so far qualified for relief and by August, ten other countries should see their UK debt wiped out. The aim is to cancel all debt in the 25 candidate countries by the end of the year. Jubilee 2000 is backing the Chancellor, and the US and Canada have also committed themselves to writing off debts in a similar way. According to Christian Aid, 19,000 children are dying every day in Africa as a result of poor health care, 'the grim harvest of the loan-shark policies of the G7, the IMF and the World Bank'. The charity has been encouraging Mr Brown to redouble his efforts to persuade other wealthy nations to follow suit (Independent 1999; 18 December).

Majority of HIV carriers are unaware of their status

The latest world estimates by the Joint UN Programme on HIV and AIDS show that 95% of the 33.5 million people thought to be carrying the virus are unaware of their status. In Britain, about 10,000 people do not know they are infected. This is almost a third of all HIV infected people in this country; and they are consequently oblivious to the risks taken by their sexual partners.

Globally, 50 million people have been infected with HIV and 33.6 million are still alive. The fastest growing epidemic is in Eastern Europe and the former Soviet Union, where HIV cases have doubled in the last two years. Over 23 million people are infected in Sub-Saharan Africa, and for the first time, more women have been found to be infected than men (Independent 1999; 24 November).

New HIV test discovered

A new test for the activity of the HIV virus has been developed and is being hailed as an important step in improving current treatment for HIV. The test detects and tracks loops of viral DNA that are the waste products of viral replication and can thus detect hidden viruses in the body once the blood has been cleared. The virus hides in tissues such as brain, eyes and testicles and appears not to be replicating. However, when patients come off the triple therapy, they relapse. Current drugs merely curb, rather than cure the disease and it is hoped that this discovery will bring a cure closer to reality (Independent 1999; 24 November).

However, one sixth of new cases of HIV are new drug-resistant strains, due to new mutations, according to two new studies published in the Journal of the American Medical Association. Current anti-retroviral therapy is ineffective against these strains; one mutation is a thousand times less sensitive than normal (BMJ 1999;319:870, 2 October).

Cancer and genetics

Scientists have discovered a defective gene on the X chromosome that increases the risk of testicular cancer by up to 50 times in men who carry it. About 20% of cases are inherited, and up to a third of these are thought to be due to this gene, TGCT1. Identifying this gene will now allow doctors to start treating patients earlier, increase the cure rates and possibly use the technology to help research into breast, lung and bowel cancer. The researchers are reluctantly patenting the gene, saying that this is the only way to safeguard patients against predators who will patent and exploit it (Independent 2000; 1 February).

Another team of scientists from the Johns Hopkins Hospital in the US have created a genetically engineered vaccine to treat prostate cancer in men. The vaccine is made from the patient's own prostate cancer cells which are grown in a dish, and then inserted with a gene that produces an immune-system-activating protein.

The recombinant cells were X-rayed to kill off any malignant potential and given to a patient. Within four weeks there was an increased circulation of B cells producing antibodies against the cancer cells and also an increased number of T cells attacking the prostate tumour itself. It seems that the patient's immune system was re-educated to recognise the prostate cancer cells as a potential infection and attack them and also attack the main tumour. Work is now underway to produce a non-personalised vaccine to be used alongside surgery, chemotherapy and radiotherapy in the treatment of cancer (Independent 1999; 21 October).

First full human chromosome unencoded

The Sanger Centre in Cambridge has finally completed the decoding of chromosome 22, the smallest human chromosome. Once the details are published, scientists can use the information to develop new treatments for several previously incurable conditions such as schizophrenia or deafness. By May 2000, the codes of the remaining chromosomes should have been revealed and the complete sequence will be accessible on the Internet (Telegraph 1999; 28 November), (BMJ 2000;320:206, 2 January).

Menopause reversed

An Anglo-American team has performed the first successful ovary graft, a breakthrough that raises the prospect of ovary banks being set up to extend female fertility into old age. The discovery paves the way for treating sterility due to premature menopause and will allow doctors to protect fertility in patients undergoing cancer treatment. It could allow women in their 70s to have children and may help ameliorate the effects of ageing and prolong active life. The 'breakthrough' also opens the route to ovary transplants from accident victims or even fetuses (whose ovaries would have many eggs and would not encounter rejection problems). (Telegraph 1999; 23 September)

Male pill approaching

Scientists at Leicester University have developed a technique to boost or diminish fertility in mice; this could lead to the long sought-after male contraceptive pill. A receptor called P2X1 is found in the smooth muscle of the vas deferens; if a working copy of this receptor is absent, sperm is not added to the seminal fluid. Drugs already exist to block this receptor, or alternatively to stimulate it in cases of low sperm count, and it is hoped that drug companies will be interested in developing a human pill (Telegraph 2000; 6 January).

Free morning-after-pill trial

85,000 women between 16 and 29 years of age are to be offered five free packs of the morning-after-pill in 100 GP practices and family planning clinics in Lothian. This follows on from plans last summer by the British Pregnancy Advisory Service which allows women to buy the pill in advance. The BMA and the RCOG support over-the-counter sales of the morning-after-pill, which may act to prevent implantation of a fertilised egg. Drug companies are reluctant to produce it because of opposition from pro-life supporters (Telegraph 1999; 2 September), (BMJ 1999;319:661, 11 September).

Contraception and abortion in the third world

Increasing contraceptive availability means that 50% of couples in the developing world use contraception, compared to just 10% in the 1960's. In Africa, however, usage is only 18%. Total fertility has fallen from 6 children to just over 3. However, abortion rates are rising unprecedentedly. 35 million abortions are performed annually in developing countries, and 1 in 4 births are unwanted. More than 150 million women have an unmet need for contraception; annual global spending on family planning is £3.75 billion, but only 37% of the funding actually goes on family planning services (BMJ 1999;319:932-933, 9 October).

US passes anti-abortion law

The US state of Missouri has passed a law making partial-birth abortions (where the cervix is dilated and the fetus is partially extracted before its skull is collapsed) illegal. The law defines infanticide (which is a felony) as any act causing death of a fetus (of any age) outside or partially outside the uterus. Abortion is defined as when a baby is killed inside its mother. The measure does not provide an exception protecting the health of the woman, and the state has been charged with passing an unconstitutional law. Illinois and Wisconsin have a similar law that has been upheld as constitutional, whereas others were overturned in Nebraska, Iowa and Arkansas.

Although the law is not aimed at abortion itself (partial-birth abortion is very rare), the fetus is being considered as a person for the first time in criminal proceedings (BMJ 1999;319:874, 2 October), BMJ 1999;319;1220, 6 November), Telegraph 1999; 10 October).

Objection to abortion

The BMA has amended its guidance on abortion to take account of the resolution passed by the 1999 Annual Meeting, which abhorred harassment or discrimination against doctors 'who conscientiously object to participation in terminations of pregnancy'. Doctors with a conscientious objection must now make their views known to patients seeking terminations and should ensure that the treatment or advice they provide is not affected by their personal views (BMJ 1999;319:593,4 September).

Public to be given say in life of embryo

The HFEA has published a consultation document asking the public which diseases are serious enough to warrant an abortion. Pre-implantation genetic diagnosis (PGD) is already used for families who are at high risk of having a baby with a serious genetic disorder such as cystic fibrosis or muscular dystrophy. The HFEA has decided that PGD is only acceptable for life-threatening medical disorders and must not be used for sex-selection or physical, social or psychological characteristics. There is concern that embryo selection will become more and more acceptable and pregnancies will be prevented for increasingly trivial medical conditions. (Telegraph 1999; 28 November).

Genetically modified babies inevitable

Although germ-line therapy has been rejected by doctors and scientists on ethical grounds Lord Winston has said that genetically modified babies are inevitable and claims that more serious debate is needed on the subject. Many people believe that gene therapy will be increasingly used to alter behaviour and appearance in an effort to produce a perfect baby. However, any attempt to manipulate characteristics such as intelligence would be very difficult as they depend on many genes. Furthermore, the effects of such therapy would be very unpredictable for future generations (Telegraph 2000; 27 January).

Fewer embryos to be transferred to womb

Leading doctors have called for a decrease in the number of embryos to be transferred to women undergoing fertility treatment. The usual number is currently three, and the doctors want it to be lowered to two, saying that there is an unacceptably high rate of multiple births as a result of fertility treatments (Telegraph 2000; 21 January).

Controversy over US funding of stem cell research

The US National Institute of Health is preparing to allow federal funding of research into human pluripotent stem cells, for the first time ever. It is hoping to set up a research group to ensure its guidelines are strictly followed. Stem cells will be derived from human embryos or early fetal tissue. This has caused controversy because the government has previously stated that it does not want to be involved in termination of the life of embryos, and such funding contradicts this. However, stem cells are not embryos, and do not on their own, have the potential to become a person. (BMJ 1999;319:1517)

BMA opens door to human reproductive cloning

The BMA has released a discussion paper saying that public opposition to reproductive cloning may be based on nothing more than an 'illogical transient fear of new technology'. The paper was discussed at the World Medical Association meeting in Tel Aviv in October 1999.

The paper assumes that the potential hazards of cloning by cell nuclear replacement will eventually be overcome. It argues that most people object to human cloning on the grounds that a parent with a sick child might request a clone in order to use the cloned bone marrow to save the life of the existing child. But it asks whether this is any more unethical than the reasons for which many parents have children. 'Do people always have children for the sake of the child itself? In reality... it is more to do with their own wishes and desires... if the child were to be abandoned once the donation had taken place, he or she would have been treated merely as a means, and this would be rightly condemned, but the child would undoubtedly be loved and respected...perhaps even more so for having saved the life of their sibling' (BMJ 1999;319:1023, 16 October).

Patents for cloning

The first patents for the cloning technology used to make Dolly the sheep have been granted five years after they were filed by the Roslin Institute in Edinburgh. However, the first primate has already been cloned by embryo splitting; this technology reduces or even avoids the potential pitfalls of the Dolly technique (Telegraph 2000; 21 January), (Telegraph 2000; 14 January).