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partners in government, the Liberals, supported the newlaw. It is uncertain whether the Constitutional Court will

reject the new law. In 1975, it had rejected something similarbut which did not carry the obligatory counselling and socialpackage.The most vehement protest against the new law has come

from the Catholic Church, which is threatening to stop thesocial counselling of pregnant women in their charity offices.The Protestant Church has been less antagonistic but isnevertheless concerned that the counselling may be acceptedby women only as a means to an end. Doctors’ organisationsare pleased: they have always said that doctors cannotobjectively judge social circumstances and that they are nowhappy to hand over the entire responsibility for the decisionto the woman.

Annette Tuffs

Medicine and the Law

Undue burden of abortion

On Monday the US Supreme Court announced itsdecision in Planned Parenthood vs Casey. The suit, broughtby abortion service providers, challenged five aspects of thePennsylvania Abortion Control Act requiring that a womanseeking abortion: be provided with information designed topersuade her to carry to term; wait 24 hours before

undergoing the abortion; if a minor, obtain parental consentor independent authorisation from a judge if parentalconsent is likely to be unreasonable (for example, where thepregnancy was due to incest); if married, notify her husbandbefore obtaining the abortion, unless there is evidence thatnotification places her at serious risk of physical harm fromhim; and permit her abortion and its circumstances to bereported on a statistical basis to public authorities. TheSupreme Court upheld all but the husband notificationprovisions as permissible expressions of State interests in theprotection of fetal life and a preference for childbirth overabortion.At issue was the continuing effect of the 1973 decision in

Roe vs Wade, which held that fetal life is not entitled to fulland equal protection of the law under the 14th Amendmentto the Constitution, and that therefore a woman’s liberty ofconscience and bodily integrity could not be sacrificed toState interests in protecting fetal life. According to the Caseydecision such liberty remains protected from State efforts toprohibit abortion, but State efforts to make abortion

financially, medically, or emotionally more difficult to

obtain are permissible unless they become a substantialobstacle to choosing abortion. This new standard-the"undue burden" test-represents a retreat from thatannounced in Roe vs Wade, which held that abortion, beinga fundamental right, was protected from all State

impediments except those based on a compelling need andimplemented in the least restrictive manner possible-the"strict scrutiny" test. In stating that "the interest in

protection of life falls short of justifying any plenary overrideof individual claim", the opinion makes specific reference tothe connection between State efforts to restrict abortion

(Roe vs Wade) and efforts to restrict the withholding andwithdrawal of extraordinary medical treatment (Cruzan vsDirector, Missouri Department of Health).The opinion, written by Justices O’Connor, Kennedy,

and Souter, and joined in part by Justices Stevens and

Blackmun, discards trimester analysis, but does reaffirm theRoe vs Wade holding that States are permitted to restrict allbut medically urgent abortions of fetuses defined as viable.Before viability, including the very earliest moments

following conception, restrictions are permitted if they donot demonstrably place a substantial obstacle in the way of awoman ultimately obtaining an abortion. The Court held,for example, that husband notification would be tantamountto making abortion ultimately unavailable. The 24 hourwaiting period, on the other hand, was not seen as such anobstacle, even though 83% of American counties have noabortion provider and women cannot easily get to a distantprovider two days in a row. The National Abortion

Federation, an organisation of physicians providingabortion services, stated that "these hurdles will be

responsible for an increase in delayed-and thereforeriskier-abortion procedures". The Court did, however,leave open the possibility that data collected in Pennsylvaniain the coming years might empirically demonstrate that thewaiting period does impose an undue burden, at which timethe Court would review its ruling on that point.

Chief Justice Rhenquist complained in his dissentingopinion that the undue burden standard was both

unprecedented in constitutional law and undefinable inpractice. He predicted that the need to review empirical datawould transform the Court into an arena for issuing abortionregulations rather than a forum for discussion of legalprinciple. Justice Scalia also dissented, stating that in theabsence of a specific constitutional guarantee or a

longstanding tradition of legality, the liberty to chooseabortion is not fundamental, is subject only to politicalprotection, and is properly the unfettered domain of theState legislatures. Justices White and Thomas joined theRhenquist and Scalia dissents.

Alta Charo

Noticeboard

Employing disabled peopleWhen, two years ago, Parkside Health Authority became the

NHS pilot district for employing people with disabilities it wasgiven a free rein to set its own goals and plans for action but noadditional money. It set a target of 1 % disabled staff by January,1992, and in December, 1990, it launched its plan of action to attractand appoint disabled people; retain staff who became disabled; raiseawareness and gain support from managers, staff, and trade unions;and improve access to buildings and information. The project hasbeen conducted during a period of economic recession. Therecession boosted numbers of applications so it was especiallyimportant for thought to be given to how candidates with disabilitiescould be given an opportunity to demonstrate their ability atinterview; two of the district’s units operated an interview guaranteescheme, whereby any candidate who met the basic requirements ofthe job was shortlisted. One unit ring-fenced two vacancies forpeople with disabilities, a move that raised debate aboutdiscrimination and equal opportunity.

Ring-fencing is only one of several approaches that are needed,says the report of the district’s experience; flexibility in jobdescriptions, for example, is another. And, the report adds, it isimportant to ensure that managers and staff had an adequateunderstanding of discrimination and realised why treating everyonethe same may not be good equal opportunities practice. As ithappened, the two vacancies that were ring-fenced were notaccepted.The report draws attention to several difficulties. Access, for

instance, was a point all were aware of, yet improvement was not asgreat as in other aspects of the project, partly because the disabilityissue was seen as an employment one and led by the personnel

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department, rather than an issue for the organisation as a whole.Drawing up a policy on how to retain staff who became disabled wasanother. The district opted to consider such individuals for

re-employment when a suitable vacancy arose, but it suggests thatsome of the existing retainer schemes (eg, that for retention ofnurses) could be extended to cover disabled staff.

1. Parkside Health Authority. A review of Parkside’s role as the NHS pilot on employingdisabled people. 1992. Pp 12.

RICHE projectThe second annual conference of the RICHE Special Interest

Group was held on June 15 and 16 in Brussels and representativesfrom western European countries were, for the first time, joined bycolleagues from Hungary, Czechoslovakia, and Bulgaria. The aimsof the meeting were to acquaint the participants with the scope ofthe RICHE project and what had been achieved in its first phase, toreview its applicability in the different European national healthsystems, and to highlight potential areas of future collaboration.RICHE (Roseau d’Information et de Communication

Hospitalier Europeen [Health Care Information andCommunication Network for Europe]) is a non-profit-makingfoundation that was developed partly by the CEC-ESPRIT(Commission of the European Communities and its StrategicProgramme for Research in Information Technology), and partlyby a consortium of European hospitals, health-care authorities, andinformation-systems companies.The project started in January, 1989, and the first phase ended

last month; 10 million ecu has been invested (40% in France), and300 hospitals in five countries have joined the scheme. The majorresult of the RICHE project has been the development of aframework architecture whereby units of a hospital’s system thathave developed separately can be integrated. Unfortunately, muchof the health-information systems on the European market are stillcharacterised by fragmentation, high unit costs, and dissatisfactionof users. Only 5% of European hospitals use integrated patient-based systems. The key characteristics of the RICHE architectureare openness, modularity, portability, integration, innovation, and aEuropean standard. In France the Plan Directeur project hasapplied the RICHE system to 62 hospitals so far and will beintroducing it to 45 more. In Italy, the pilot trials of the nursing carepart of RICHE are already operating in some hospitals.

Discussions at the conference were directed to the intelligent actmanagement system, customisation, platform strategies for opensystems, and the opportunity for suppliers and users of informationtechnology in health care to be included in the RICHE project. Asthe deputy project manager Prof Dr A. van der Werff said, "themission of RICHE is to construct a framework for overall openinformation and communication systems for health care in

Europe".

Chemical weapons draft treaty completed

Negotiators from the 39 countries of the Geneva disarmamentconference have returned to their capitals taking with them thecompleted 188-page draft treaty prohibiting chemical weapons (seeLancet June 20, p 1530). They will reassemble on July 20, some nodoubt bringing their Governments’ proposed amendments. Theseamendments are likely to be minor. The intention is that countriesthat have major reservations, such as China and Pakistan, anddecline to sign the treaty will simply be left to reflect on theadvisability of not associating themselves with an instrument ofinternational legislation. The Hague was chosen as the site of themonitoring body of the treaty, which will come into force onratification by 65 countries-a process expected to take perhaps 2years, even with 50 or so initial signatories.The verification procedures, including challenge inspection, that

are set out in the completed text are far more exigent than thoseadministered by the International Atomic Energy Agency at

nuclear energy installations. Negotiators describe the result of theirlabours as a unique endeavour and the first treaty ever achieved onabolishing an entire category of weapons.

DMPA, zalcitabine, and the FDA

The US Food and Drug Administration’s (FDA) Fertility andMaternal Health Drugs Advisory Committee voted unanimouslyon June 19 to recommend approval of the use of depotmedroxyprogesterone acetate (DMPA, Depo Provera, Upjohn) as acontraceptive. The drug is approved in the US for use inendometrial and renal carcinoma.! The committee evaluated datafrom New Zealand showing a possible increased risk of osteoporosisassociated with long-term use of DMPA .2 New data from Thailandalso indicate that there may be a higher risk of low-birth-weightbabies born to women exposed to DMPA during pregnancy. Thecommittee suggested that the informed consent document discussthe possibility of osteoporosis and that post-marketing studies beconducted to address this problem. They further recommend thatthe label should warn against prescribing the drug to pregnantwomen. FDA had denied Upjohn’s application for approval ofDMPA for contraception in 1978 because of safety questions(development of mammary tumours in dogs given the product), andthe decision was upheld in 1984 by a board of inquiry set up inresponse to Upjohn’s appeal.

Cindy Pearson of the US National Women’s Health Network(NWHN) drew attention to the three case-control studies

suggesting increasing risk of breast cancer with use of DMPA.3--5 DrDavid Thomas, coordinator of the multinational study funded bythe World Health Organisation,5 explained that the additionalbreast cancer risk applied to women aged under 35 years rather thanto all users. He also pointed out that DMPA protects women againstendometrial cancer.On June 22, the FDA approved zalcitabine (dideoxycytidine) for

use in combination with zidovudine as a treatment option for adultswith advanced HIV infection (see Lancet April 25, p 1047). It is thefirst drug to be approved under the agency’s accelerated drugapproval process (see Lancet April 18, p 982).

1. Physicians’ Desk Reference. 46th ed. Montvale, NJ: Medical Economics Data; 1992:2336-37.

2. Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depotmedroxyprogesterone acetate for contraception. BMJ 1991; 303: 13-16.

3. Lee NC, Rosero-Bixby L, Oberle W, et al. A case-control study of breast cancer andhormonal contraception in Costa Rica. J Natl Cancer Institute 1987; 79: 1247-54.

4. Paul C, Skegg DCG, Spears GFS. Depot medroxyprogesterone (Depo Provera) andrisk of breast cancer. BMJ 1989; 299: 759-62.

5. WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Breast cancerand depot-medroxyprogesterone acetate: a multinational study. Lancet 1991; 338:833-38.

Public funding and private genesThe patenting of human genome DNA sequences is ethically

unacceptable and all those working in this area of research ought toresist commercial pressures to patent, says a BMA working party setup to consider the implications of genetic technology on thecommunity and to bring these matters to the attention of the public.They add that more public funds should be found for pure researchto reduce the influence of private companies wishing, for financialreasons, to promote developments in a particular area. The resultsof human genome work should be as freely available as the results ofother research projects and the work should concentrate onmaximising therapeutic benefits. The report is equally firm in itsrecommendations on the use of genetic information. Genetic

screening in the workplace, for example, should be used only as ameans of promoting or maintaining an individual’s health, not toselect "suitable" people for employment. The potentialcontribution of susceptibility to genetic disease to the overall risk ofmorbidity through accident or industrial disease should be takeninto account in workplace screening. The working party believesthat insurance companies are not justified in screening clients andthat it is better for everyone to pay higher premiums than to forcesome to undergo tests against their wishes. DNA profiles should bekept on police records only if the person is found guilty, and profilesobtained for medical or civil purposes should not be transferable toother databases.The report outlines the history and science of genetics before

discussing the scope and ethics of the various ways that genetictechnology can be applied. Clinicians form part of the readership at