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State to private employment. A district nursing officer in StAlbans objected: "We have had several private hospitals inthe district, and after their initial recruitment drives we didhave a shortage of staff". A district administrator in Mid-Essex said: "The prospect of competing with a privatehospital for staff, particularly nursing staff, is very real". Aspokesman for Oxford RHA declared: "We are concernedthat a private hospital next to an NHS hospital could be acontinual drain on staff, especially nurses. The NHS couldfind itself training staff who then move to greener fields nextdoor".

There are some signs, however, that the boom in privatemedicine is slowing down. Nuffield’s chief executive, MrOliver Rowell, told the survey that too many beds nowappeared to be chasing too few patients, even in the south-eastof England. As long as a year ago Mr Eric Hemming, BUPA’shospital development director, was suggesting that thedemand for private surgical and acute medical beds mighthave reached saturation point, though his prediction then ofthe existence of 11 000 private beds in 1984 appears to havebeen exaggerated. According to BUPA’s executive director ofhospitals, Mr Mike Smith, "our research indicates that whenthe hospitals currently under construction are complete,there will scarcely be a centre in the country which wouldsupport a (private) hospital of more than 30 beds".The adaptability of the entrepreneurs is already evident.

Some of the larger hospital chains are starting to take over thesmaller fry, to consolidate their grip on a market which maysoon grow more slowly. Nuffield and BUPA at least, as wellas some American concerns, are taking a growing interest inthe commercial provision of nursing homes for the elderly,which has become a more attractive proposition as theGovernment’s thinking moves more towards privatising suchcare. "Hi-tech" medical screening and so-called day-caresurgery for minor operations, are also now being seen aspossibly profitable ventures.Future growth of the private hospitals, NHS Unlimited

points out, will depend largely on future demand, and that islargely dependent on future Government policy. Somerelatively minor fiscal concessions to private medicine in thebudget next Spring could help the private hospitals a little.Further tax concessions for those who take out private,medical insurance, for instance, are not to be ruled out. Butsuch small-scale adjustments are not likely to make a majordifference to the size of the market for private care. Thatcould be achieved only by a larger scale and more determinedswitch by the Government to health cover based on privateinsurance for the majority of the population. This idea hasbeen chewed over within the Conservative Party and theCabinet many times. But the present Social Services

Secretary, Mr Norman Fowler, insists that such an upheavalwill not happen as long as he remains in his post, because theidea presents more problems than it solves.But not all his Cabinet colleagues accept that view.

Extensive private health cover appeals strongly, as a theory,to the Prime Minister, the Chancellor, and other right-wingers in the Government. It would, in theory at least, slashthe amount of public expenditure needed by the NHS andliberate those resources for distribution in the form of taxcuts. If Mr Fowler is the only barrier to the further

exploration of this option, then the idea could come to the foreagain if Mr Fowler is switched to another job in some futureCabinet reshuffle. That change is not expected in the minorreshuffle predicted for this autumn. But there is always nextyear.

Meanwhile, like a spectre at the private medical firms’banquet, the Labour Party lurks. If Labour wins the nextelection the health entrepreneurs will get short shrift. Theirtax advantages are likely to disappear in Labour’s first

budget, all applications for more private beds will be rejected,and such private medical facilities as might be useful to theNHS will-it is threatened-be nationalised immediately.

RODNEY DEITCH

Medicine and the Law

Warnock Report on Human Fertilisationand Embryology

The legal implications of the recommendations in the Warnockreport seem to fall under four main heads.The Licensing Authority ,

The committee states: "of all the recommendations we havemade, by far the most urgent is ... that a statutory body should beestablished, within whose power would fall the licensing andmonitoring of provision for infertility treatment and of research onthe human embryo". Legislation will presumably lay down thelimits within which the authority will operate, what it may license,and what it may not. The question here is, what powers will it haveto monitor the operations it may license? How detailed will be thesupervision? How much money will there be to pay for the

inspectorate? How is it to know what it is licensing and that thelimits it sets are observed? These are partly matters of finance andpartly of definition. The latter will be the responsibility of thelawyers in Parliament and the Civil Service, but since the former,with one or two exceptions, are seldom able to practise theirprofession and the latter, again with a few exceptions, have seldomdone so, it is not a task for which they are particularly well equipped.In the area of embryo research especially the inspectorate will haveto contain some highly qualified individuals, for the tendency ofspecialisation is to produce a situation in which nobody canunderstand what anybody else is doing.

SurrogacyRecommendation 56 would render criminal the creation or

operation in the UK of agencies for the recruitment of women forsurrogate pregnancies or making arrangements for individuals orservices who wish to utilise the services of a carrying mother,whether profit-making or not.

’

Recommendation 57 would render criminally liable the actions ofprofessionals and others who knowingly assist in the establishmentof a surrogate pregnancy. The first essential here is to make the

penalties sufficiently severe to be an effective deterrent, for in such apotentially profitable field there would be a number of operatorswho would regard a fine of modest proportions as an acceptableoccupational hazard. The second is to make the clearest ofdistinctions between the establishment of a surrogate pregnancyand the giving of medical and nursing help when needed to carryingmothers. Doctors and nurses must not be or appear to be in anydanger from performing services in the latter category.Recommendation 58 is that it be provided by statute that all

surrogacy arrangements are illegal contracts and thereforeunenforceable in the courts. This seems not entirely to deal with therealities. The commissioning couple could not then successfully suethe carrying mother for breach of contract if after the birth she didnot hand over the child to the parents who had, whether for moneyor not, commissioned her to carry the child. But if the

commissioning mother had supplied the egg, which woman,irrespective of the law of contract, will the courts accept as themother? Is the legislation to provide that the woman who gives birthis to be regarded for all purposes as the mother so leaving the womanwho commissioned her to be treated simply as an egg donor (see.

1 Report of the Committee of Inquiry into Human Fertilisation and Embryology.London. HM Stationery Office, 1984 See Lancet 1984; ii: 202, 217, 238.

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recommedation 54)? Further, where the commissioning parents arerash enough to part with money and the carrying mother then insistson keeping the child, will the former be able to reclaim the cash bymeans of an action for money had and received, which is an actionfor breach of trust rather than of contract? Or are the courts to beinvited to ride that dangerous horse, public policy? These seem to bematters which require further definition.

Research on EmbryosThis is a subject of ethics and policy rather than of law, the

principal legal questions being the problems of definition discussedabove in relation to the licensing authority. All the proposalsregarding research appear to assume that in this area research issynonymous with experimentation. Is this so? Might not mereobservation, as distinct from a mechancial process applied to anembryo, rank as research? The answer to this may have somebearing on the 14 days’ limit from the date of fertilisation

(recommendation 44). It may be added that the argument that thisperiod should be extended to coincide with that during which, givencertain conditions, a pregnancy may be terminated is fallacious.Experiments with an embryo may lead to an otherwise normal childbeing born with handicap or malformation.

Rights of Parenthood and of ChildhoodParenthood.-The main changes here are in relation to AID,

where the donor of the semen is to have neither the rights nor theduties of the father of a child born out of wedlock and the consentinghusband is to have the right to register the birth of the child as thefather. These are doubtless in line with the gradual elimination ofthe distinction between births in and out of wedlock, thoughwhether sufficient consideration has been given to the effects thismay have on the concept of the family as the basic social unit is notaltogether clear.Childhood.-The effect of the recommendation that on achieving

majority the child is to be informed of the nature of his origin willnot be known for eighteen years or so. In this sense all children bornthrough artificial insemination or IVF are the subjects of

experiment.W. T. WELLS, QC

International Diary1984

2nd international symposium on Fetal Liver Transplantation: Pesaro,Italy, Sept 29-Oct 1 (Dr L. Moretti, c/o Divisione di Ematologia-USL 3,Trebbiantico, 61100 Pesaro).

International workshop on Down’s Syndrome-an InterdisciplinaryApproach: Rimini, Italy, Oct 21-23 (Up Service srl, Via Matteotti 51, 60121Ancona, Italy).

1985

8th annual Infectious Diseases in Clinical Practice: Steamboat Springs,Colorado, Jan 19-26 (Universal Travel-UC Desk, 140 Geary Street, Suite404, San Francisco, CA 94108, USA).

2nd international symposium on Current Topics in Infectious Diseases:Grindelwald, Switzerland, Feb 9-16 (Travel Planners Inc, PO Box 32366, SanAntonio, Texas 78216, USA).

International symposium on The Impact of Biotechnology on

Diagnostics: Rome, Italy, April 16-18 (Fondazione Giovanni Lorenzini, ViaMonte Napoleone 23, 20121 Milano, Italy).

1st European symposium on Thyroid Cancer: Montpellier, France, June6-7 (Societe Internationale de Congres et Services, 337 rue de la CombeCaude, 34100 Montpellier, Cedex).

3rd European conference on Clinical Oncology and Cancer Nursing:Stockholm, Sweden, June 16-20 (Mrs I. Thilen, Stockholm ConventionBureau, Jakobs Torg 3, S-111 52, Stockholm).

International symposium on Hexachlorobenzene: Lyons, France, June24-28 (Dr J. R. P. Cabral, IARG, 150 Cours Albert Thomas, 69372 Lyon,Cedex 08).

6th Asian colloquium in Nephrology: Kuala Lumpur, Malaysia, Nov14-17 (The Sixth Asian Colloquium in Nephrology, 4th Floor MMA House,124 Jalan Pahang, Kuala Lumpur).

Obituary

JULIUS HIRAM COMROEMD Pennsylvania

Dr Comroe, an international authority on cardio-

pulmonary physiology and disease who was director emeritusof the Cardiovascular Research Institute at the University ofCalifornia San Francisco, died on July 31. He was 73.He was born in York, Pennsylvania, the son of a physician, and he

graduated from the University of Pennsylvania, where he becamefirst an intern and then a faculty member on the hospital’spharmacology staff. At 35, he was appointed professor andchairman of the department of physiology and pharmacology in theGraduate School of Medicine. He held this post, interrupted onlybyemployment in the Chemical Warfare Service during the 1939-45war, until 1957, when he was recruited to UCSF to lead thefledgling Cardiovascular Research Institute. He is well known forhis early work on lung physiology, especially the function ofchemoreceptors. In the ’40s his studies broadened to include reflexregulation of the abnormal increase in ventilation accompanyingexercise, the cardiovascular effect of drugs such as morphine, andthe action of different oxygen mixtures on the cardiovascular

system. His paper with Robert D. Dripps on the inefficiency ofmanual artificial respiration inspired the development of mouth-to-mouth resuscitation. Later he and his colleagues devised newmethods and instruments for the study of pulmonary function inman. He was among the first to recognise the importance of the non-respiratory functions of the lungs.As CVRI director for 16 years, he recruited leading research

workers in heart, lung, and kidney physiology. Advances whichemerged from his Institute included the first progress in thetreatment of respiratory distress syndrome and developments inneonatal intensive care. Under his guidance, the CVRI became amajor centre for training in research and he has had a lasting effecton medical education.He was a popular and lucid lecturer; and he wrote TheLung(1955)

and Physiology of Respiration (1965) and developed Physiology forPhysicians, a series which he edited for three years (1963-66). From1975 to 1983 he was also director of the National PulmonaryFaculty Training Center at UCSF. During these years, he had agreat influence on biomedical research through his work on theNational Advisory Heart Council. He was a member of the board ofmedicine of the National Academy of Sciences and of the executivecommittee of the Academy’s Institute of Medicine. He sat on theadvisory committee to the director of the National Institutes ofHealth and on the National Academy of Science’s recombinantDNA advisory committee. After his retirement as director of theCVRI in 1973 he was appointed Morris Herzstein professor ofbiology at UCSF.

After more than 40 years as medical educator and researcher, hethen embarked on another career as medical historian. Stimulated

by observations in the ’60s which appeared to show that goal-directed inquiry was the most productive type of research (a findingthat shifted the Government’s funding emphasis towards contract-supported "payoff" research), he and his friend and colleagueDripps began to collect data on the development of life-savingadvances in medicine. Confining themselves to progress since the’40s, they examined advances in cardiovascular disease. Their

findings, published in 1976 (Dripps died in 1973), showed that over40% of all advances essential to later clinical benefits were the resultof basic research-a percentage too large for the Government toignore.His investigations continued in essays written for the American

Review of Respiratory Disease, later collected into an impressivebook, Retrospectroscope: Insight into Medical Discovery (1977) III

which he points out the false starts, missed opportunities, chancediscoveries, and success for the very few in medical research.His achievements were recognised by honorary degrees,

including an MD from the Karolinska Institute, Stockholm, andother distinctions, such as election to the National Academy of