148
Letters
to
the Editor
ETHICAL PROBLEMS OF SCREENING FOR NEURAL-TUBE DEFECTS on Jan. 31, published a letter which I had chairman of an ethical working-group in the Northern Region regarding the proposal to start routine prenatal screening for neural-tube defects. The working-group had been concerned about the pressures on the Department of Health and Social Security to undertake nation-wide screening, while scant attention had been paid to its ethical implications. The study by the working-group of the ethical problems of routine screening has continued, and we wish to report our main conclusion-namely, that each stage of the screening process should be clearly understood to be voluntary. Personal ethical problems associated with routine prenatal screening centre on the fact that the only "treatment" offered, in the event of a positive result, is abortion. For those who believe that abortion is in almost any and every circumstance wrong, the main issue is already foreclosed. For those who find no difficulty in contemplating abortion at 18-20 weeks or even later, the personal implications of screening are relatively minor. For others, who accept abortion as a regrettable necessity only when there seem to be strong reasons for it, the problems are harder, not least because of the narrow dividing line between late abortion and infanticide. Related to this central moral issue are a number of secondary problems. The most serious of these is the unnecessary anxiety and distress which would be caused to expectant mothers to whom abortion, for whatever reason, was unacceptable, and who discovered that they were among the small minority recommended for further investigation after the initial blood-test. This group would have their normal maternal fears of deformity greatly heightened, without having any corresponding relief in knowing that "treatment" was available. There are also questions concerning a pregnant woman’s growing relationship with her child, and the possible damage to this relationship if false hopes have been aroused, or unnecessary guilt or fear engendered. Furthermore, there is the possibility that, in a society where defect was being systematically eliminated by abortion, those who had slipped through the net might find themselves burdened’ by a sense that they were unwanted and ought not to have been born. None of these problems may seem of much significance in comparison with the difficulties of coping emotionally with and caring for the seriously deformed. Cumulatively, however, they articulate the hesitations of those who see the long-term dangers in moves towards a society in which the elimination of a widening variety of those with genetic defects has grown to seem as normal and inevitable as abortion seems today. Some degree of encroachment on the rights of every individual to be born and to receive maximum care, would seem to be justified in view of the already very large medical encroachment on the natural processes of selection and mortality. The question is, how much? and what safeguards is it possible to build into the procedures so that individual wishes are respected and the drift towards centralised decision-making about acceptable types of human being is not allowed to develop too far? The most obvious safeguard would be to ensure that each step, and especially the first one, in the testing process was voluntary, otherwise the patient might face the ethical dilemma for the first time when amniocentesis was offered (on the basis of the screening blood-test). A system of contract-
SIR,-The Times,
written
as
would ensure this, but would have the disadvantage that the social classes most at risk (i.e., iv and v) are those least likely to enter a voluntary scheme, and have the greatest tendency to book late. A system of contracting-out would ensure that a much higher proportion of the population was screened,
but it could put undesirable pressure on individuals to conform unless adequate opportunities were provided for explanation and expert counselling. We believe that, before introducing a screening test, the appropriate health authority should give careful thought to the way in which potential antenatal patients can be informed of all the implications of what, at the outset, appears to be a simple blood-test. Auckland Castle,
Bishop Auckland,
JOHN DUNELM*
Co. Durham DL14 7NR
REPEAT HLA-DR MISMATCHES IN SECOND
TRANSPLANTS
SIR,-We have evidence suggesting that matching for
antigens improves the success-rate of cadaveric renal transplantation,2 indicating that these antigens, like the HLA A and B antigens, may act as histocompatibility antigens. Our findings have been supported by others. 2,3 Many transplant units would not transplant a second kidney which shared at least one mismatched HLA A and B antigen with the first donor, and few surgeons would do a transplant if all the mismatched antigens of the first donor-recipient combination were repeated in the second. Such second transplants have a signifiHLA-DR
RESULTS OF SECOND TRANSPLANTS WHEN A MISMATCHED DR
ANTIGEN OF THE FIRST DONOR WAS REPEATED IN THE SECOND TRANSPLANT
(CASES 1-5) AND WHEN IT WAS (CASES 6-12)
NOT REPEATED
Mismatched DR antigens repeated in the 2nd donor are underlined. * Positive B-cell cross-match with second donor. tNF never functioned; F failure (and day of failure); S Success (and post-transplant day when last seen). =
cantly
=
worse success-rate
than
=
grafts
not
repeating previous
to see whether the fate of second transplants is influenced by a repeat DR antigen mismatch from the first donor. We have done twelve second transplants (all from cadaveric donors) where the recipient and the two donors were DR typed for the seven "official" antigens, DRwl-7. In no case did the second donor share mismatched HLA A and B antigens with the first donor. In five cases, however, the second donor did share the mismatched DR antigen present in the first donor, and four of these grafts have failed (see table). In contrast no failures were seen in the seven patients who received second transplants which did not repeat DR mismatches from their
mismatches.4 We have re-examined
our
data
ing-in
1. 2.
Ting, A., Morris, P. J. Lancet, 1978, i, 575. Albrechtsen, D., Flatmark, A., Jervell, J., Solheim, B., Thorsby, 825.
3. 4.
Martins-da-Silva, B., Vassalli, P., Jeannet, M. ibid. p. 1047. Opelz, G., Terasaki, P. I. Transplantation, 1976, 21, 483.
E. ibid. p.
Letters
to
the Editor
ETHICAL PROBLEMS OF SCREENING FOR NEURAL-TUBE DEFECTS on Jan. 31, published a letter which I had chairman of an ethical working-group in the Northern Region regarding the proposal to start routine prenatal screening for neural-tube defects. The working-group had been concerned about the pressures on the Department of Health and Social Security to undertake nation-wide screening, while scant attention had been paid to its ethical implications. The study by the working-group of the ethical problems of routine screening has continued, and we wish to report our main conclusion-namely, that each stage of the screening process should be clearly understood to be voluntary. Personal ethical problems associated with routine prenatal screening centre on the fact that the only "treatment" offered, in the event of a positive result, is abortion. For those who believe that abortion is in almost any and every circumstance wrong, the main issue is already foreclosed. For those who find no difficulty in contemplating abortion at 18-20 weeks or even later, the personal implications of screening are relatively minor. For others, who accept abortion as a regrettable necessity only when there seem to be strong reasons for it, the problems are harder, not least because of the narrow dividing line between late abortion and infanticide. Related to this central moral issue are a number of secondary problems. The most serious of these is the unnecessary anxiety and distress which would be caused to expectant mothers to whom abortion, for whatever reason, was unacceptable, and who discovered that they were among the small minority recommended for further investigation after the initial blood-test. This group would have their normal maternal fears of deformity greatly heightened, without having any corresponding relief in knowing that "treatment" was available. There are also questions concerning a pregnant woman’s growing relationship with her child, and the possible damage to this relationship if false hopes have been aroused, or unnecessary guilt or fear engendered. Furthermore, there is the possibility that, in a society where defect was being systematically eliminated by abortion, those who had slipped through the net might find themselves burdened’ by a sense that they were unwanted and ought not to have been born. None of these problems may seem of much significance in comparison with the difficulties of coping emotionally with and caring for the seriously deformed. Cumulatively, however, they articulate the hesitations of those who see the long-term dangers in moves towards a society in which the elimination of a widening variety of those with genetic defects has grown to seem as normal and inevitable as abortion seems today. Some degree of encroachment on the rights of every individual to be born and to receive maximum care, would seem to be justified in view of the already very large medical encroachment on the natural processes of selection and mortality. The question is, how much? and what safeguards is it possible to build into the procedures so that individual wishes are respected and the drift towards centralised decision-making about acceptable types of human being is not allowed to develop too far? The most obvious safeguard would be to ensure that each step, and especially the first one, in the testing process was voluntary, otherwise the patient might face the ethical dilemma for the first time when amniocentesis was offered (on the basis of the screening blood-test). A system of contract-
SIR,-The Times,
written
as
would ensure this, but would have the disadvantage that the social classes most at risk (i.e., iv and v) are those least likely to enter a voluntary scheme, and have the greatest tendency to book late. A system of contracting-out would ensure that a much higher proportion of the population was screened,
but it could put undesirable pressure on individuals to conform unless adequate opportunities were provided for explanation and expert counselling. We believe that, before introducing a screening test, the appropriate health authority should give careful thought to the way in which potential antenatal patients can be informed of all the implications of what, at the outset, appears to be a simple blood-test. Auckland Castle,
Bishop Auckland,
JOHN DUNELM*
Co. Durham DL14 7NR
REPEAT HLA-DR MISMATCHES IN SECOND
TRANSPLANTS
SIR,-We have evidence suggesting that matching for
antigens improves the success-rate of cadaveric renal transplantation,2 indicating that these antigens, like the HLA A and B antigens, may act as histocompatibility antigens. Our findings have been supported by others. 2,3 Many transplant units would not transplant a second kidney which shared at least one mismatched HLA A and B antigen with the first donor, and few surgeons would do a transplant if all the mismatched antigens of the first donor-recipient combination were repeated in the second. Such second transplants have a signifiHLA-DR
RESULTS OF SECOND TRANSPLANTS WHEN A MISMATCHED DR
ANTIGEN OF THE FIRST DONOR WAS REPEATED IN THE SECOND TRANSPLANT
(CASES 1-5) AND WHEN IT WAS (CASES 6-12)
NOT REPEATED
Mismatched DR antigens repeated in the 2nd donor are underlined. * Positive B-cell cross-match with second donor. tNF never functioned; F failure (and day of failure); S Success (and post-transplant day when last seen). =
cantly
=
worse success-rate
than
=
grafts
not
repeating previous
to see whether the fate of second transplants is influenced by a repeat DR antigen mismatch from the first donor. We have done twelve second transplants (all from cadaveric donors) where the recipient and the two donors were DR typed for the seven "official" antigens, DRwl-7. In no case did the second donor share mismatched HLA A and B antigens with the first donor. In five cases, however, the second donor did share the mismatched DR antigen present in the first donor, and four of these grafts have failed (see table). In contrast no failures were seen in the seven patients who received second transplants which did not repeat DR mismatches from their
mismatches.4 We have re-examined
our
data
ing-in
1. 2.
Ting, A., Morris, P. J. Lancet, 1978, i, 575. Albrechtsen, D., Flatmark, A., Jervell, J., Solheim, B., Thorsby, 825.
3. 4.
Martins-da-Silva, B., Vassalli, P., Jeannet, M. ibid. p. 1047. Opelz, G., Terasaki, P. I. Transplantation, 1976, 21, 483.
E. ibid. p.
