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Notes and News

ETHICAL DECISIONS ON LIFE AND DEATH

THE British Medical Association has been contemplating’ thethorny question of voluntary euthanasia and has pronounced thatactive intervention by a doctor to terminate a life should remainillegal. However, in clinical practice there are many cases where it isright that a doctor should accede to a request not to prolong the lifeof a patient.According to the report,* doctors should observe patients’ rights

to authorise or decline treatment. Nevertheless, patients do not havethe right to demand treatment which the doctor cannot provide witha clear conscience. Active intervention to terminate a patient’s life isjust such a treatment and patients should not ask doctors to

collaborate in their death. If a patient does make such a request thereshould be a presumption that the doctor will not agree. The BMAworking party on euthanasia, set up after the 1986 annual

representative meeting and chaired by Sir Henry Yellowlees(formerly chief medical officer, DHSS), draws the necessary andusual distinction between active and passive euthanasia andconcludes: "The law’s deep seated adherence to intent rather thanconsequence alone is an important reference point in the moralassessment of any action. A decision to withdraw treatment whichhas become a burden and is no longer of continuing benefit to apatient, has a different intent to one which involves ending the life ofa person. We except drug treatment which may involve a risk to thepatient’s life if the sole intention is to relieve illness, pain, distress, orsuffering. Any doctor, compelled by conscience to intervene to enda person’s life, will do so prepared to face the closest scrutiny of thisaction that the law might wish to make. The law should not bechanged and the deliberate taking of a human life should remain acrime. This rejection of a change in the law to permit doctors tointervene to end a person’s life is not just a subordination ofindividual wellbeing to social policy. It is, instead, an affirmation ofthe supreme value of the individual, no matter how worthless andhopeless that individual may feel.

BMA GU1DELINES ON THE USE OF FETAL TISSUE

THE British Medical Association has drawn up the followinginterim guidelines on the use of fetal tissue in transplantationtherapy for the treatment of certain conditions, includingParkinson’s disease (see p 1087). The BMA continues to supportthe recommendations of the Peel committee on the use of fetusesand fetal material for research (1972).1. Tissue may be obtained only from dead fetuses resulting from

therapeutic or spontaneous abortion. Death of the fetus is definedas an irreversible loss of function of the organism as a whole.

2. UK laws on transplantation must be followed. The women fromwhom the fetal material is obtained must consent to the use of thefetal material for research and/or therapeutic purposes.

3. Transplantation activity must not interfere with the method ofperforming abortions, nor the timing of abortions, nor influencethe routine abortion procedure of the hospital in any way.Abortions must be performed subject to the Abortion Act, andany subsequent amendments thereof, uninfluenced by the fate ofthe fetal tissue. The anonymity of the donor should bemaintained.

4. The generation or termination of a pregnancy solely to producesuitable material is unethical. There should be no link betweenthe donor and the recipient.

5. There must be no financial reward for the donation of fetalmaterial or a fetus.

6. Nervous tissue may be used only as isolated neurones or tissuefragments for transplantation. Other fetal organs may be used aseither complete or partial organs for transplantation.

1 The Euthanasia Report. Report of the Working Party to Review the BMA’s Evidenceon Euthanasia, April, 21, 1988 Available from the BMA, Tavistock Square,London WC1H 9JR.

7. All hospital staff directly involved in the procedures-includingthe abortion-must be informed about the procedures involved.

8. Every project involving transplantation of fetal tissue must beapproved by the local ethical research committee.

FUNDING FOR THE HOSPICES

THE Duchess of Norfolk, chairman of Help the Hospices, haswritten to Mr Tony Newton, Minister of Health, to seek help incontinuing the practice of paying hospice nurses the same as NHSnurses. The Duchess states: "Our calculations are that the nurses’

pay award will increase hospice running costs by at least 15 % in afull year. For a hospice providing care for 25 dying patients theincrease will be almost /J100 000. Such an extra burden couldcripple many of our hospices ... The Government has said that itwill bear the full impact of the pay award for NHS hospitals. It mustdo the same for our voluntary hospices which, after all, only care forNHS patients. Hospices never charge patients. Our help and care isfree. If we are to continue to provide this care for thousands eachyear, then the Government must face up to its responsibilities".Help the Hospices estimates that the nurses’ pay award will add15-20% to the running costs of each hospice. For those healthauthorities which give some financial aid to voluntrary hospices,there is no obligation to meet any part of this pay award. Unless theGovernment earmarks funds for the hospices, health authoritieswill have no money to fund the extra cost. There are 120 hospices inthe UK, of which 100 are in the voluntary sector. Most, but not all,receive some financial aid from local health authorities. However,those hospices which receive state help rarely receive more than25% of their running costs. Hospice care, which is nurse intensive,relies heavily on charitable support.

PREVENTION OF CORONARY HEART DISEASE

THE Coronary Prevention Group has issued a policy document’recommending that the establishment of healthy behaviour patternsto reduce the incidence of heart disease in adults should begin inchildhood. Practical recommendations highlight dietarymodification, particularly a progressive reduction of saturated fat inchildren’s diet and restricted intake of salt and sugar; a majoranti-smoking campaign directed towards schoolchildren; and theencouragement of exercise promoting cardiovascular fitness at andafter leaving school. Health education, including information onnutrition, should be a major part of the core curriculum at primaryand secondary schools and the school meal service should be centralto strategies for promoting healthy eating among children. Thedocument was drawn up by members of the CPG scientific andmedical advisory committee, chaired by Prof Barry Lewis. TheCPG proposes to press the Government and other relevant

organisations for implementation of these recommendations, whichare based on evidence from several western nations that suggeststhat the origins of cardiovascular disease may frequently beestablished in childhood. It is likely that children with elevated lipidlevels will become adults with raised lipid concentrations and so atrisk of CHD; that raised blood pressure is not uncommon inchildhood and might be modified by weight reduction (whereappropriate) and salt restriction; and that adult smoking habits,strongly associated with the risk of CHD, are usually establishedbefore the age of 20.The Royal College of General Practitioners has also published a

file of informationz for GPs and primary health care teams on theprevention of coronary heart disease. Dr Colin Waine, chairman ofthe College’s clinical and research division, urged GPs to take allknown risk factors into account. He commented: "Where practicesare screening for only one risk factor, this has been shown to reducethe effectiveness of preventing coronary heart disease. Screeningmust take into account the other risk factors, such as high blood

1. Children at Risk. Should the Prevention of Coronary Heart Disease Begin mChildhood? Policy Statement from the CPG Scientific and Medical AdvisoryCommittee. Available from CPG, 60 Great Ormond Street. London WC1N 3HR01-833 3687.

2 The Prevention of Coronary Heart Disease. By Colin Waine Roy al College of GeneralPractitioners. Available from the RCGP, 14 Princes Gate, London SW7 1PU01-581 3232

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cholesterol, smoking, and family history." A statement from theCollege emphasises its commitment to the prevention of disease. Itreads: "Coronary heart disease is the major cause of death in theUnited Kingdom. It causes a third of deaths in men and a quarter ofdeaths in women. Many of these deaths occur in people who areyoung and who may have major family responsibilities. There is aconsiderable body of evidence to show that coronary heart diseasecan be prevented or its effects minimised. No area is more worthy ofour efforts than the prevention of coronary heart disease".

THE ABNORMAL CERVICAL SMEAR

THERE is no need, these days, for any woman to die of cervicalcancer. With regular smear tests the disease can be detected andtreated in the precancerous stage, when the cure rate is virtually100 %. But the woman who is told that she has an abnormal smear is

unlikely to accept the news with equanimity. Her immediateresponse to what she probably perceives as a death warrant is morelikely to be sheer panic, and initially her doctor’s reassurance mayhave no meaning for her. For the small proportion of women whosesmears show abnormalities, and for the many who have felt toofrightened (by fear of cancer or fear of the test procedure itself) ortoo embarrassed even to ask for a smear, two doctors and a socialworker have written an admirable little book that will clear up manymisconceptions about cervical smears and cervical cancer.’ Theauthors, who run a colposcopy clinic, describe in simple languagehow a smear is taken, how the test results are interpreted, what anabnormal smear means, what colposcopy is, and what happens at acolposcopy clinic. A chapter that suggests ways of coping with theanxiety associated with having an abnormal smear and waiting fortreatment is particularly useful.

Government Funds for Voluntary OrganisationsThe Government has announced grants totalling over c6 million

to go to voluntary organisations, including groups providingsupport for deaf and blind people, people with motomeurondisease, and cancer patients. The grants are in addition to regularsupport, which last year exceeded 37 million, from the

Department of Health and Social Security.

MRC Clinician Scientist FellowshipsThe Medical Research Council has announced prestigious new

fellowships providing up to 7 years’ support to young clinicians toenable them to obtain research training in the basic medical sciencesand then to apply that training to clinical problems. Ms VivianParker, MRC, 20 Park Crescent, London WIN 4AL (01-6365422).

Pregnancy in Handicapped Women

The medical advisory committee of the Spastics Society hasconcluded that not enough is known about the subject of pregnancyin handicapped women. It would like to hear from people with apersonal experience of, or research interest in, the subject. Allinformation will be treated confidentially, and there will be nocorrespondence about specific cases: Ms Sheila Femando, SpasticsSociety, 12 Park Crescent, London WIN 4FQ.

A course entitled In Vitro Receptor Autoradiographic Techniques isto take place at the Royal Postgraduate Medical School, London Wl, on May16-20: Prof J. M. Polak, Histochemistry Unit, Royal Postgraduate MedicalSchool, Hammersmith Hospital, Du Cane Road, London W12 OHS

A lecture by Prof Peter Gay on The Bite of Wit: Humour andAggression in Wilhelm Busch will take place at the Wellcome Institute forthe History of Medicine, London NW1, on Tuesday, May 17: WellcomeInstitute for the History of Medicine, 183 Euston Road, London NW 2BP.

The 15th Sandoz foundation lecture in endocrmology entitled Dopingand Sport is to be held at the Middlesex Hospital, London WC1, onWednesday, May 18: Mrs H. C. Roberts, Executive Officer, British

Postgraduate Medical Federation, 33 Millman Street, London WC1N 3EJ(01-831 6222).

1 Cervical Cancer and How to Stop Worrying about It. By Judith Harvey, Sue Mack,and Julian Woolfson London Faber and Faber. 1988 Pp 88 £3 95 (paperback).

The 32nd Crookshank lecture on Is Research Really Necessary? will begiven by Sir John Kingman in the Jarvis Hall, 66 Portland Place, LondonWl, on Friday, May 20: Royal College of Radiologists, 38 Portland Place,London WIN 3DG (01-636 4432).

A conference on The NHS-Future in Doubt? will be held in CentralLondon on Saturday, May 21: Socialist Health Association, 195 WalworthRoad, London SE17 1RP (01-703 6838).

A conference entitled Psychotherapy and Black People in the UnitedKingdom is to take place at St Stephen’s Centre, Birmingham, on May21-22: Dr Mahendra Dayal, All Saints Hospital, Lodge Road, WinsonGreen, Birmingham B18 5SD (021-523 5151 extension 12).

A meeting on Radiology ’88 is to take place at the Scottish Exhibition andConference Centre, Glasgow, on May 23-25: British Institute of Radiology,36 Portland Place, London WIN 4AT (01-580 4085).

A meeting on Medical Student Learning-Progress and Problemswill take place at the Royal College of Physicians, London Wl, on Monday,May 23: Maureen Gyle, Association for the Study of Medical Education, 2Roseangle, Dundee DD1 4LR (0382-26801).

Corrections

Tell-year Results of Renal Transplantation unth AzathlOprme andPredlllsolone as Only lmmunosuppression.-In this article by Prof M. G.McGeown and colleagues (April 30, p 983), the third and fourth sentences ofparagraph 3 of the Discussion should read: "4 patients died later of malignantneoplasms-2 at 11, 1 at 12, and 1 at 121 years- when they were in theirfifties. Overall mortality up to 18 years post-graft due to cancer was thus6-4%".

Fzsh Ozl Supplementatlon.- The first sentence of the second paragraph ofthis letter by Dr Anne Tobin (May 7, p 1047) should read: "’MaxEPA’...contains not only 0-178 g EPA per capsule but also 0 114 g docosahexaenoicacid (DHA), 92 ug vitamin A, and 530 pg vitamin E."

Diary of the Week

MAY 15 TO 21

Monday, 16thLONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE, Keppel

Street, London WC t9 am Dr A. Bryceson, Dr G. Wyatt, and Dr G Brown: Miscellaneous Fevers (1).

ST GEORGE’S HOSPITAL MEDICAL SCHOOL, Cranmer Terrace, LondonSW17 ORE

12.30 pm Mr M. Pearce. Early Doppler in Hypertensive Disease in PregnancyROYAL SOCIETY OF MEDICINE, 1 Wimpole Street, London W1M 8AE

6 pm Symposium-New Patterns of Nursing and Medical Education.

Tuesday, 17thLONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE

2 pm Dr D. G. Fleck, Prof M. G. R Varma, and Dr D Weir: Miscellaneous Fevers (2)ICRF CANCER EPIDEMIOLOGY AND CLINICAL TRIALS UNIT, Ida Green

Seminar Room, Observer’s House, Green College, Oxford5 pm Charles Stiller The Effect of Referral Patterns on Survival from Childhood

CancersDURHAM POSTGRADUATE MEDICAL SCHOOL, Drybum Hospital, Durham

1.15 pm Prof M J. Davies: How Does Coronary Atheroma Produce Clinical

Symptoms)

Wednesday, 18thROYAL FREE HOSPITAL, Pond Street, London NW3 2QG

5 pm Dr M. Hughes: Survival Data and Cox Modelling in Clinical Medicine.CHACE POSTGRADUATE MEDICAL CENTRE, Chase Farm Hospital, The

Ridgeway, Enfield, Middlesex1 pm Dr P Gishen Carcinoma on the Lung and CT.

Thursday, 19thSOUTHMEAD CENTRE FOR MEDICAL EDUCATION, Southmead Hospital,

BX’estbur-,,-on-Trvm, Bristol BS10 5NB1.10 pm Mr A Stephenson. The Unit General Manager’s View of Southmead

Hospital

Friday, 20thROYAL POSTGRADUATE MEDICAL SCHOOL, Hammersmith Hospital, Du

Cane Road, London W12 OHS12 30 pm Mrs Azmma Govmdji New Thoughts on the Diabetic Diet

LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE9 am Mr J Rennie, Mr J. Church, and Mr P. Bewes: Surgery in the Tropics.

CARDIOTHORACIC INSTITUTE, Fulham Road, London SW3 6HP8 am Dr James Milledge Acute Mountain Sickness, Susceptibility, and Resistance.