-& Political Review Euthanasia around the world Euthanasia arouses strong feelings among both doctors and the public. Last year it reached political significance in the United States, where an attempt to legalise doctor assisted suicide was only narrowly defeated. The media coverage of the debate was enormous. This year there are likely to be more attempts worldwide to define legally doctors' obligations to their dying patients. We review the position im several countries.
Japan Last April a report of a 34 year old doctor who had given a lethal injection to a patient with cancer at Tokai University School of Medicine shocked Japan, where active euthanasia is rare.
The patient had been in hospital for four months when he developed renal failure. His family begged the medical staff to stop treating him. The doctor responsible for the "mercy killing" did not consult his colleagues. After withdrawing treatment he gave the patient a dose of intravenous potassium chloride in the presence of one of the patient's relatives. The patient-already in a coma-had a cardiac arrest a few minutes later. Kanagawa's prefectural police are investigating the case.
Even the Japanese Society for Dying with Dignity, which has 2800 members, thinks that Japan is not ready to consider active euthanasia. "It is too early, taking the spiritual climate of Japan into consideration," said the chairman, Taneo Oki. "We aim at passive euthanasia, which means that terminally ill patients should be allowed to die without being given treatment to keep them alive. We believe in the right to make a living will." According to a survey by the Japanese Medical Association in 1990, three quarters of doctors think that they should respect a patient's living will if he or she is terminally .-MASAYA YAMAUCHI, science reporter,
Chugoku Shimbun
Netherlands In the Netherlands it is still illegal to perform euthanasia and assisted suicide. But if doctors do so according to guidelines that are in the process of becoming law they will not be prosecuted. This is the compromise
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An easy death: US pathologistJack Kevorkian and his death machine (p9)
reached by the minister of justice and the parliamentary under secretary for public health after nearly 20 years of discussion. It has been approved by the cabinet and was sent to the second chamber at the end of last year. Basically nothing will change. What the government is doing is merely sanctioning what is already happening. A doctor who has carried out euthanasia must currently report it to the public prosecutor, who checks that the doctor has acted with "due carefulness." The public prosecutor checks this degree of carefulness against a list of 25 conditions, which includes consulting with a second doctor and writing a detailed report. The conditions were drawn up last year by the prosecution council in collaboration with the Royal Dutch Medical Association. The government has reached this position only two months after the report of the Remmelink commission into euthanasia (12 October, p 877). At the time the Lubbers government was accused of setting up the commission to postpone making any decisions on the issue. The Remmelink report stated that euthanasia accounts for no more than 2% of deaths a year. It reported that in 1000 cases a year the patient did not give permission-these were mostly cases involving comatose patients or severely handicapped babies. The government believes that these cases should be brought before a judge. The Royal Dutch Medical Association is unhappy with the government's proposal. It
argues that the threat of punishment still hangs over doctors' heads. The Netherlands Association for Voluntary Euthanasia calls the government's guidelines "extremely confusing." According to its chairwoman, Mrs Pit Bakker, as long as euthanasia remains an offence doctors will not report it. -HANK HELLEMA, medical journalist, the Netherlands
Canada It is a criminal offence to help anyone to commit suicide in Canada, but three recent widely publicised cases have raised questions about whether people should have the right to determine the time of their own deaths with medical help. A 24 year old woman in Quebec, known as Nancy B, has asked the Quebec Superior Court to order the hospital where she has been in intensive care for 30 months to disconnect the mechanical respirator that is keeping her alive. The court moved to her bedside to hear her testimony. Her doctor said that she would die within minutes once the respirator was disconnected. The woman, paralysed by Guillain-Barre syndrome since 1989, told the judge that she can no longer tolerate her existence. The court is expected to give its decision soon. In British Columbia Dr Tom Perry, a. pharmacologist and cabinet minister, 7
Headlines World's cancer deaths rising: WHO estimates that 15 million new cases of cancer will be diagnosed each year from 2015. About a third will- be tobacco related. Two thirds will be in developing countries.
America's teenage, mothers: The National Center for Health Statistics has reported the highest level in the number of teenage pregnancies in 15 years. Over this time the rate has increased by nearly one fifth. One in four births are now to unwed mothers. Cost of NHS reforms: About £380m has been made available to the NHS for implementing the NHS reforms last year. This is in addition to £300m and £80m provided in 1990-1 and 1989-90, respectively, and the money needed to maintain service levels.
American health costs up 10%: The average family will spend 12% of its income on health care this year according to a report from Families USA, a health care group from Washington, DC. This is a rise of nearly one tenth since 1980. More Americans lack health insurance: There are 34-7m Americans without health insurance, the highest number since the introduction of Medicare and Medicaid in 1965, according to the Center for National Health Program at Harvard Medical School. Relatively affluent families with incomes of $50 000 and over accounted for nearly one third of the increase. New DoH permanent secretary: Mr Graham Hart, secretary of the Scottish Home and Health Department, will succeed Sir Christopher France as permanent secretary at the Department of Health in the spring. Sir Christopher is moving to the Ministry of Defence.
Sir Donald Acheson chairs new prison committee: Sir Donald Acheson, former chief medical officer, has been appointed chairman of the health advisory committee for the prison service. The multidisciplinary committee will advise on ways of improving prisoners' health.
Award for BMJ assistant editor: Dr Fiona Godlee has won the Medical Journalists Association's 1991 medical journalism advancement award sponsored by Private Patients Plan.
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publicly revealed that he and members of his family who are medical professionals had taken turns to give morphine to their father, who was dying of cancer. He admitted that the drug may have hastened his father's death. He said that his reason for speaking out was to open up public discussions on euthanasia. The governing body of the medical profession has made its position clear after criticising the action of Dr Peter Graff, an internal medicine specialist, who prescribed doses of morphine that hastened the deaths of two gravely ill patients. This is the first time that a doctors' regulatory body in Canada has had to deal with euthanasia. Dr Graff argued in his own defence that he did not consider his actions -to be euthanasia but simply an attempt to relieve suffering. The coroner's inquiry concluded that both patients died after morphine overdoses. The Canadian House of Commons has a private member's bill before it that would enable doctors to comply with a dying. patient's wish to die sooner without the doctor facing legal charges. A recent public opinion poll found that 75% of Canadians favour mercy killings of incurably ill patients if the patient's request is in writing. Earlier this year the Ontario Medical Association concluded that the issue of euthanasia should be left for society to determine, not the medical profession. It said that doctors should not take the lead in publicly debating the question but should, if asked, provide scientific information that might help the public to make a decision. The Canadian Medical Association (CMA) has long stated that it is not unethical for a doctor to withhold heroic treatment that could prolong the life of a terminally ill patient. This in effect condones passive euthanasia but not active euthanasia to speed death. At its annual meeting last summer the CMA's committee on ethics reported that it had not finished revising the association's policy on euthanasia and was granted additional time to complete its report. -M DUNLOP, journalist, Toronto
France It is quite common in France, as in many other countries, to give patients who are terminally ill a "lytic cocktail," an overdose of a sedative or another lethal substance. But euthanasia is likely to remain in a legislative no man's land because legislation would, in the words of the neonatologist Alexandre Minkowski, "institutionalise provoked death." Last year the cancer specialist Leon
Schwartzenberg was temporarily suspended by the Conseil de l'Ordre des Medecins, France's medical association, for declaring that he had helped some of his terminally ill patients to die. A member of the European parliament and -briefly France's minister of health, Dr Schwartzenberg-later submitted a proposal on euthanasia to the European parliament, stating, "When a physician decides, in all conscience, to answer the insistent and permanent request of a patient to help him stop his existence, that has lost
all dignity in his eyes, he acts in respect of a human life." He said that he wanted euthanasia to be better understood. "There is no question of establishing a law-particularly in a country like France. . . where everything that is legal is seen as normal." The National Ethical Committee, presided over by the haematologist Dr Jean Bernard, also opposes the legalisation of euthanasia because it believes that a law would be abused and wrongly interpreted and would give doctors "an exorbitant power over the life of an individual." The committee recognised that the patient's request might be reasonable but it might be made ambivalently. What was worse, economic, family, or ideological considerations unrelated to the patient's distress, or even the shortage of hospital beds or a family's impatience to inherit, might play a part in the decision. Moreover, said Dr Bernard, "We now have the means to fight against pain." Father Michel Riquet, of the Society of Jesus, has commented that the word euthanasia is ambiguous. It literally means "good death" in Greek, and in the middle ages there were good death fraternities that aimed not at shortening patients' lives but at providing them with palliative care for their pain and moral and spiritual comfort to help them die in dignity and as Christians. Father Riquet points out that the "`interdiction to kill" pronounced by Pope Pius XII did not imply the obligation to use all possible and extraordinary means to prolong a life that was moving towards its end. ALEXANDER DOROZYNSKI, medical journalist, Paris
Australia In Australia attitudes among the medical profession and the public are changing in favour of euthanasia. Euthanasia is currently illegal in all of the six states and two territories that make up the federal system of
Australia. The state of Victoria has enacted legislation-unique among the Australian states and territories-on refusal of medical treatment. This act makes it a criminal offence to treat a patient against his or her wishes. Patients can name an agent to make decisions
4
Logos promoting euthanasia
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their treatment if they become unable to decide for themselves. South Australia and the Northern Territory have Natural Death Acts, which are similar to "living will" legislation in some states of the US. In 1988 the Centre for Human Bioethics at Monash University in Melbourne surveyed 2000 doctors in Victoria and found that 869 supported voluntary euthanasia. One third said that they had been involved in voluntary euthanasia at least once. Nearly half said that they would practise voluntary euthanasia if it was legal. Early results from a survey by the School of Community Medicine in the University of New South Wales indicate that withdrawal of treatment is a major ethical isstie among practitioners. So far intensive care specialists have been extremely cautious about discussing the issue in public. Their main line is that they will do nothing illegal. But many will withdraw life support when there is no hope of recovery and allow the dying process to occur with dignity by administering sedatives and analgesics. Active support of accelerated dying is not acknowledged. -PETER POCKLEY, science writer, Sydney on
Germany In German law the penal codes for first and second degree murder state fairly clearly that active euthanasia is a crime against human life and punishable by up to five years in prison. Even during the Third Reich, when active euthanasia was practised on a wide scale on mentally ill patients, it was never formally legalised. Passive euthanasia, the denial of life prolonging treatment to a terminally ill patient, has always been regarded in law as a matter between doctors and their patients. The doctor is left to decide when life prolonging measures have become futile; the patient or, if he or she is incapable of making such a decision, the relatives then decide whether or not such measures should be continued. There is no known case of a German court questioning a patient's right to reject clearly inadequate and inefficient treatment. Suicide and assisting a suicidal action are not forbidden by German law. Penal Code article 216 forbids only "killing on request," which carries the threat of between six months' and five years' imprisonment. This caused a great stir in 1984 when Dr Julius Hackethal of Erlangen, a professor of surgery and a popular author, publicly admitted that he had helped a patient with cancer to commit suicide by providing a toxic agent. But Dr Hackethal escaped prosecution, as did Dr Hans Henning Atrott of Augsburg, who in the 1970s became known for founding the German Society for Humane Dying (Deutsche
Gesellschaft fur
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United States The defeat of Washington state's referendum physician assisted suicide (BMJ, 16 November 1991, p 1223) did not resolve the core issue of the rights of terminally ill patients regarding their medical treatment. In California and Oregon voters are likely to be balloted on the euthanasia issue. Meanwhile, a new federal law enacted last month requires any health care facility receiving funds from either the Medicaid programme for the poor or the Medicare programme for the elderly to inform adult patients of their right to refuse life sustaining medical care. They also have the right to complete a "living will" or durable power of attorney directing the facility to withhold certain treatments. The Patient Self Determination Act, passed by Congress" last year, requires hospitals, hospices, home health agencies, nursing homes, and health maintenance organisations to discuss patients' wishes. It does not require the health care facility to comply with every wish. American Medical News, an official publication of the American Medical Association, says that only between 4% and 17% of Americans have completed a living will or durable power of attorney, although about 70% of people who die in-hospitals do so after the withdrawal of life sustaining treatment. The newspaper quotes Mary Mahowald, professor of ethics at Chicago University, as saying that care givers must still determine whether life sustaining care is futile and whether it is in the patient's best interest. Several physicians told American Medical News that they were concerned that the law's requirements would interfere with the relationship between doctor and patient. In fact, the law was designed so that a patient can write an advance directive without any help from a physician. -REX RHEIN, medical journalist, Washington, DC on
Dr Death faces grand jury A grand jury will decide whether Dr Jack Kevorkian, a retired pathologist in Michigan who has helped three patients to commit suicide in the past 18 months, should be charged with murder. His medical licence was suspended last October. Dr Kevorkian, dubbed "Dr Death," first came to international attention in June last year when he helped Janet Adkins, a patient suffering from Alzheimer's disease, to commit suicide. He inserted an intravenous line attached to a lethal solution of potassium chloride. Police charged him with murder ard impounded his suicide machine, but a judge dismissed the case, ruling that Michigan has no law against assisted suicide. Last October he helped two more women to die. The county examiner has stated that these deaths were not suicides because they were not self inflicted. -MICHAEL MORRIS, Royal College of Psychiatrists travelling fellow, Massachusetts
Britain Euthanasia is sure to be on the United Kingdom's legal and parliamentary agenda in the coming months. Attention will focus on a case in Winchester, where allegations of euthanasia have resulted in a senior consultant being charged with attempted murder. The prosecution, like another (which failed) in 1990, concerns the administration of potassium chloride, in this case to an elderly woman who was disabled by arthritis. The consultant is due to appear before magistrates on 8 January. The court proceedings will be closely watched by an all party parliamentary group of MPs and peers that was formed last year to review the case for legalising euthanasia. The new group, under the chairmanship of a
Humanes Ster-
ben, DGHS). The DGHS, which still exists, gives expert advice on ways to commit suicide and provides suitable drugs. Atrott hit the headlines again in 1981 when he proposed to have article 216 abolished and demanded that mercy killing should be allowed if a terminally ill patient, who was unable to kill himself or herself, requested it. The idea, however, had BMJ
chance in a country where euthanasia is still a dirty word.-HELMUT L KARCHER, science writer, Munich
no
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DrJulius Hackethal openly admits he practices euthanasia
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medical peer Lord Winstanley, is financed and serviced by the Voluntary Euthanasia Society. Later this month it will decide whether to sponsor an exploratory bill in the House of Lords to legitimise the "living will"-an advance declaration by patients that obliges doctors to withhold life sustaining treatment in the event of terminal illness. Any bill would be, more than anything, a device to raise the issue in debate. The chances of substantive legislation on any aspect of euthanasia are still considered to be remote. Although the euthanasia society claims that about 90 MPs are sympathetic to euthanasia, few would openly support it in the run up to a general election. There has never been a serious attempt in the Commons to legislate for euthanasia. The present drive reflects the extent to which a taboo has been lifted, but it is only the start of what promises to be a long drawn out campaign, possibly over two or more parliaments. Against it, the pro-life group of peers and MPs-best known as an antiabortion lobby-has regrouped to make the fight against euthanasia its top priority. JOHN WARDEN, parliamentary correspondent, BMJ
health visitor or general practitioner when a child attends an accident and emergency department after a road accident should be followed meticulously by all accident and emergency departments. The Department of Trade and Industry and the Department of Transport are starting a pilot scheme to determine how effective the hospital episodes system database will be for extracting information on road accidents. The report also refers to a model for an accident data system studied in Newcastle upon Tyne, which contained more socioeconomic information. This could help authorities to target preventive measures on more vulnerable groups. The report places health. professionals in the front line for preventive measures. Health visitors are urged to encourage the use of safe routes to school; community paediatricians are asked to monitor road traffic injuries, identify high risk areas, and advocate safe play areas and after school care. The report suggests that general practitioners should include road safety in health promotion clinics. The report also targets directors of public health, who are urged to identify research and training needs. -DAPHNE GLOAG, BMJ
NHS's key role in cutting children's road accidents In 1990, 48 000 children were injured in road traffic accidents. Nearly half of them were pedestrians and a fifth were on bicycles. Just over 400 children were killed. In a new report from the Health Education Authority Heather Ward argues that the NHS could do much more to prevent road accidents to children. She says that a wealth of information already exists within the NHS on road accidents to children. Her report asks for information to be distributed among highways, planning, and education authori-' ties and to be used for preventive work with children. In particular, the system of notifying the
How not to cross the road
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Preventing Road Accidents to Children, by Heather Ward, is published by the Health Education Authority, Hamilton House, Mabledon Place, London WClH 9TX, price £3.
Juniors may still reject pay deal A special conference of junior hospital doctors will decide later this month whether to accept the recommendations for new rates of pay for out of hours work. These will mean that many junior doctors will continue to be paid less than their basic rate of pay for working at night and at weekends. In June last year a ministerial working party agreed on arrangements to reduce junior doctors' hours over a realistic timetable, but few doctors have moved on to the proposed shift systems because of the uncertainty about pay. The review body reported on 16 December after a delay of nearly three months. It recommended that for out of hours work doctors should be paid 100% of basic pay if they were working on full shifts; 70% if -they were on partial shifts; and 50%1/ if they worked in the rota system. Thie BMA had asked for overtime rates of 120%, 80%, and 60%, respectively. Although in negotiations with the Departmentof Health thejunior DoctorsCommittee had estimated that most' doctors would continue to work Qo a rota system, it was hoped that doctors on shifts would be paid at premium rates to encourage them to work shifts. The new rates will ceriainly benefit those working in shifts but by not as much as the BMA had hoped. In future out of hours pay will be expressed in terms of additional duty hours (ADHs) in place of the four hourly unit of medical time (UMT). The following example shows how the new ADH rates compare with current
Demonstratson at Tory party conference
UMT rates on an hourly basis on the midpoint of the scale. UMT ADH rate rate
Preregistration house officer on full shift Senior house officer on partial shift Registrar on a rota Senior registrar on a rota
£2.25 £3.19 £3.14 £3.36
£5.93 £5.87 £4.62 £5.60
At present senior house officers at the top of the scale working an average 80 hour week earn £19515 for a basic 40 hour week and £7416 on average from units of medical time which are paid at 38% of the basic rate. In future if they work for a maximum of 60 hours on a full shift they will earn £9758 as overtime. If they work 72 hours on a partial shift they will earn £10 924 as overtime and if they work 83 hours on an on call rota they will earn £10 489. (Fuller details of the BMA's estimates of the new rates and a summary of its evidence to the review body are given on p 57.) The government has agreed to fund the recommended pay rates in full; the cost of the award is 5 8% of the junior doctors' pay bill or £44m in the United Kingdom. After the announcement of the award the chairman of the Junior Doctors Committee, Dr Edwin Borman, expressed his disappointment. "It means that junior doctors will continue to be cheap labour for managers to employ for prolonged hours, thus endangering the arrangement for the reduction of their excessive hours," he said. "Some doctors may get nothing as their hours have already been cut and those who work intensively for a concentrated period are likely to get less than those who are on duty for
lengthyperiodsbutworkinglessintensively." If doctors vote to accept the report at their conference on 18 January the new rates and the revised terms and conditions of service could take effect from 1 February. There are, however, likely to be renewed calls for industrial action. Last October's meeting of the Junior Doctors Committee heard that doctors were prepared to take industrial action if the review body report was not satisfactory. -LINDA BEECHAM, BMJ The Second Supplement to Twenty-First Report 1991, from the review body on doctors' and dentists' remuneration, is available from HMSO, price £2.35.
(Cmnd 1759.)
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organiser Dr Jon Beckwith, a member of the National Academy of Sciences and a molecular geneticist at Harvard Medical School. Dr Marvin Natowicz, head of the division of genetic medicine at Harvard's Shriver Center for Mental Retardation, echoed this: "There has- been a long, ugly history of scientific determinism based on genetics. Poorly used, it's nothing more than molecular phrenology."-JANICE HOPKINS TANNE, contributing editor, New York magazine
Upjohn fails to get Halcion ban liftedThe pharmaceutical company Upjohn has lost its appeal to the Committee on Safety of Medicines to lift its ban on the sleeping pill triazolam (Halcion). Upjohn is likely to request a further appeal hearing before the Medicines Commission. Upjohn is thought to have suggested that the ban, which has been in place in the United Kingdom since October, might be lifted if triazolam was distributed in smaller packets with information leaflets and a stronger warning that it should be taken for only short periods. The United States Food and Drug Administration has allowed triazolam to stay on the market under similar
Investigating alternative medicines
conditions.
The drug was recently discussed by the European Community's Committee on Proprietary Medicinal Products, which includes representatives of all drug regulatory authorities in Europe. The committee supported Upjohn's proposals for labelling and packaging the drug but emphasised the "absolute importance" of using triazolam only for short periods. Unfortunately for Upjohn, the European committee can only make recommendations-it has no powers to override the policies of individual countries. The Committee on Safety of Medicines may have been influenced by reports from a further trial published in a German pharmaceutical journal suggesting that triazolam produced more psychiatric symptoms than another benzodiazepine. More than 1300 patients aged under 60 took part in this trial, which was carried out in Britain. About 200 people in Britain are seeking compensation from Upjohn for side effects that they believe are due to triazolam.
The Amish-cleared of depression
cases is a heroic job, but 181 drosocases wouldn't get you through the
enlargement of the study to include another family branch showed that the link between marker and disorder was statistically highly unlikely. The "alcoholism gene" on chromosome 5, supposedly present in one quarter of the American population, has been supported-and refuted-by two studies reported recently in the rournal of the American Medical Association. The link between schizophrenia and chromosome 5 remains controversial. Twin studies showing genetic linkage to behavioural disorders are flawed by adoptive agencies' habit of placing children in environments similar to those oftheir natural parents, said psychologist Dr Sandra Scarr, of the University of Virginia, Alcohol abuse, she pointed out, is more common in lower class families than upper class ones, and placing a child in a home of similar class might have more relevance than genetic inheritance. Nevertheless, people want to believe in a genetic basis for behaviour. "People assume we can explain how well a kid does in school with genes," Scarr said, and they want to abolish programmes to help disadvantaged children. "A large proportion of the American public wants to believe there is a gene for alcoholism. The worry about a genetic basis for behaviour is more common among scientists and reporters than the public," said Robert Bazell, science reporter for NBC-TV news. Journalists agreed it was difficult to air retractions and views opposed to published studies. "There's pressure to make the strongest possible statement [about genetic findings] because you're vying for space in the paper. There are also commercial interests in probes and diagnostic tests," said Richard Saltus, of the Boston Globe. "Political implications of IQ and sex differences [in mathematical ability, for example] are hyped. Reports about research in these areas often confuse individual differences with group differences," said Constance Holden, of
door." Indeed, the link between manic depression and chromosome 11, found through studies of a large Pennsylvanian Amish family, dissolved when two people in the original group became manic depressive although they did not have the marker, and
"The unfortunate thing is that when scientists find the gene for a disorder the prospects for a cure are way off, while the prospects for discrimination [against those who have the gene] are immediate," said conference
-
SHARON
KINGMAN,
freelance
medical
journalist
It's all in the genes The genetic basis for problems of human behaviour such as alcohol abuse and mental illness is weaker than many scientists and most newspaper readers think, but it raises the spectre of genetic discrimination. Speaking at a symposium of scientists and science journalists at Harvard Medical School organised by the Genetic Screening Study Group, Harvard geneticist Dr Richard Lewontin said, "A report of a highly significant correlation between a syndrome and genetic marker is often followed six months later by a report that the original researchers or somebody else find it not correct." Dr Lewontin pointed to the problem of sample
sizes
"A hundred and
eighty one
human
phila
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Science.
The National Poisons Unit at Guy's Hospital in London is starting to collect information on cases in which use of alternative medicines has made people ill. The unit hopes to establish how safe these preparations are. A search of its computerised surveillance system has shown that over 300 inquiries about poisoning with herbal medicines have been made since 1985. The Guy's project will receive joint funding from the Department of Health and the Ministry of Agriculture, Fisheries and Food. The Guy's unit plans to send-with the reporting doctor's consenta project team to investigate each case reported to it. Although many alternative medicines have been used for centuries with no ill effects, most have never been through any form of drug trial. The BMJ has published details of four women who suffered liver damage after taking Kalms and Neuralax to relieve stress. The harmful ingredients were probably valerian and skullcap (1989;299:1156). The National Poisons Unit has data on a 3 month old baby who died after taking an unknown amount of Indian medicine for constipation. At postmortem examination the fundus of her stomach showed considerable sloughing and she had peritonitis. Other children have contracted lead poisoning after using surma, an Indian eye remedy with a lead content of up to 86%-VIRGINIA S G MURRAY, consultant occupational toxicologist, National Poisons Unit, London
Playing the market In the NHS's new internal market the streetwise cardiologist opts for cost and volume contracts-and makes sure that the accountants get their costs right. That was the main message that emerged from a meeting held in London last month by the British Cardiac Society. As cardiology. and cardiac surgery are specialties dealing largely with tertiary referrals they potentially have a -lot to lose from the market. According to Dr Douglas Chamberlain, president of the society, this means that both specialties want to take a lead in making the market work. Just how complex the market could be was explained by some of the "providers." Mr John Parker's combined cardiology-cardiac surgery unit of 82 beds at St George's Hospital, London, has mostly block
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based on average specialty costs. Extracontractual referrals are charged at the average specialty cost, which means that districts are paying too much for low cost procedures. His unit is now trying to offer separate charges (still averaged) for cardiac and thoracic cases, but this might also distort districts' costs if they buy more or less than planned of each type. Mr Parker wanted to move to procedure costs to compete with private hospitals and to prevent the distortion of extracontractual referrals. He suggested a points system, whereby the contract was written in terms of "points" of cardiac care, each point being worth a certain sum and each procedure being worth a certain number of points. Dr John Perrins, a cardiologist at Leeds General Infirmary, already knows precisely the fixed and variable costs for all his procedures. He can thus offer cost per case contracts: purchasers pay the full price for a certain number of procedures; above that they pay only the variable cost of the extra procedures (and if the unit does not meet the contract it repays only the variable cost of the procedures not performed). In that way purchaser and provider share the risk, the contract allows for variations in workload, it encourages modest service expansion, and there is no delay in treating extra patients. But if the variable cost is too low the unit loses on all cases performed over the contract number; if it is too high it loses on repayments made on underachieved contracts. This happened at Leeds because the accountants had worked out the costs independently, fixed the contracts, and only then consulted the clinicians. This had led to the variable contracts
A strategy of purchasing for all GPs The Department of Health has recommended a series of collaborative projects between general practice fundholders and district health authorities, which will be more widely disseminated if they are successful. The aim of the projects-in east Hertfordshire, Leeds, Northampton, Northumberland, Plymouth, Salford, and Leeds-is to produce a range of practical examples of effective collaboration in purchasing. Fundholding will continue to be voluntary, although the list size criterion will go down from 9000 to 7000 in April 1993. In its latest proposals the department says that it is not the intention that "practices who cannot or do not wish to become fundholding practices should in any way have a 'second class' status as far as the purchase of secondary care is concerned." There are already several initiatives aimed at strengthening the district health authority's purchasing role and, in particular, at ensuring that all general practitioners are consulted before contracts are drawn up with provider units. A pilot project has now been proposed to enable a district health authority to purchase a
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cost for angioplasty being set at only £400, whereas the real cost was nearer £700. The unit had done 30 more procedures than contracted for, and this miscalculation had turned what looked like an extra £12 000 into a loss of £9000. The other main concern that emerged was the distortion in clinical priorities. Professor Peter Sleight claimed that his unit in Oxford had stopped treating local patients because the unit had already met its contract and Oxford Health Authority wouldn't pay any more. Instead the unit was treating people from Dorset at marginal costs. Despite these problems, providers are
wide range of acute care in accordance with the wishes of a volunteer group of nonfundholding practices. The proposals were welcomed by the General Medical Services Committee last month, which emphasised that it had not changed its policy on fundholding. (That would be for the local medical committee conference to decide.) The committee wants to see all general practitioners given an effective voice in deciding on secondary care
probably better informed than purchasers at the moment, yet a market needs two equally well informed partners to work properly. According to Dr Ron Akehurst, from the York Health Economics Consortium, the big questions about available interventions, their outcomes, and their resource consequences should be answered nationally. The information could then be applied locally. Yet the NHS has far to go in pursuing rational purchasing. British cardiologists are still answering questions on costs; no one last week doubted that they would soon start to be questioned on outcomes. -JANE SMITH, BMJ
The GMSC chairman believes that the committee's motions, which were passed overwhelmingly (see box), and the department's proposals will go a long way to ensuring that all general practitioners influence the quality of contracts and to achieving equity of care. He emphasised, however, that no projects or new arrangements could surmount the NHS's overriding problemshortage of funds. -LINDA BEECHAM, BMJ
for their patients.
The department's proposals go some way achieving this by recognising that there are different methods of purchasing care, including fundholding. GMSC chairman, Dr Bogle told his committee that purchasing and fundholding were different, but as more doctors collaborated with local purchasing authorities the feeling that becoming a fundholder was necessary to get the best for patients might not be so strong. Once all general practitioners became involved in purchasing fundholding could become superfluous. Because of concerns about the development of a two tier service last spring the committee called for a full evaluation of fundholding before the second wave was announced. Then in the summer new guidance agreed with the department and the Joint Consultants Committee was introduced aimed at ending fast tracking (BMJ 1991;302:1486). to
The GMSC... * Continues to believe that the government was wrong to introduce the NHS review changes without proper evaluation of pilot schemes and particularly without having addressed the long term problems caused by inadequate funding of the NHS * Notes the proposed continuing development ofthe role ofdistrict health authorities and general practice fundholders as purchasers of care * Insists that any such development uses fully the opportunities for all purchasers to collaborate and cooperate for the benefit of all patients * Insists that all general practitioners, both at practice level and through their local medical committees, should be in a position to influence purchasing decisions in respect of secondary care.
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Japan Last April a report of a 34 year old doctor who had given a lethal injection to a patient with cancer at Tokai University School of Medicine shocked Japan, where active euthanasia is rare.
The patient had been in hospital for four months when he developed renal failure. His family begged the medical staff to stop treating him. The doctor responsible for the "mercy killing" did not consult his colleagues. After withdrawing treatment he gave the patient a dose of intravenous potassium chloride in the presence of one of the patient's relatives. The patient-already in a coma-had a cardiac arrest a few minutes later. Kanagawa's prefectural police are investigating the case.
Even the Japanese Society for Dying with Dignity, which has 2800 members, thinks that Japan is not ready to consider active euthanasia. "It is too early, taking the spiritual climate of Japan into consideration," said the chairman, Taneo Oki. "We aim at passive euthanasia, which means that terminally ill patients should be allowed to die without being given treatment to keep them alive. We believe in the right to make a living will." According to a survey by the Japanese Medical Association in 1990, three quarters of doctors think that they should respect a patient's living will if he or she is terminally .-MASAYA YAMAUCHI, science reporter,
Chugoku Shimbun
Netherlands In the Netherlands it is still illegal to perform euthanasia and assisted suicide. But if doctors do so according to guidelines that are in the process of becoming law they will not be prosecuted. This is the compromise
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An easy death: US pathologistJack Kevorkian and his death machine (p9)
reached by the minister of justice and the parliamentary under secretary for public health after nearly 20 years of discussion. It has been approved by the cabinet and was sent to the second chamber at the end of last year. Basically nothing will change. What the government is doing is merely sanctioning what is already happening. A doctor who has carried out euthanasia must currently report it to the public prosecutor, who checks that the doctor has acted with "due carefulness." The public prosecutor checks this degree of carefulness against a list of 25 conditions, which includes consulting with a second doctor and writing a detailed report. The conditions were drawn up last year by the prosecution council in collaboration with the Royal Dutch Medical Association. The government has reached this position only two months after the report of the Remmelink commission into euthanasia (12 October, p 877). At the time the Lubbers government was accused of setting up the commission to postpone making any decisions on the issue. The Remmelink report stated that euthanasia accounts for no more than 2% of deaths a year. It reported that in 1000 cases a year the patient did not give permission-these were mostly cases involving comatose patients or severely handicapped babies. The government believes that these cases should be brought before a judge. The Royal Dutch Medical Association is unhappy with the government's proposal. It
argues that the threat of punishment still hangs over doctors' heads. The Netherlands Association for Voluntary Euthanasia calls the government's guidelines "extremely confusing." According to its chairwoman, Mrs Pit Bakker, as long as euthanasia remains an offence doctors will not report it. -HANK HELLEMA, medical journalist, the Netherlands
Canada It is a criminal offence to help anyone to commit suicide in Canada, but three recent widely publicised cases have raised questions about whether people should have the right to determine the time of their own deaths with medical help. A 24 year old woman in Quebec, known as Nancy B, has asked the Quebec Superior Court to order the hospital where she has been in intensive care for 30 months to disconnect the mechanical respirator that is keeping her alive. The court moved to her bedside to hear her testimony. Her doctor said that she would die within minutes once the respirator was disconnected. The woman, paralysed by Guillain-Barre syndrome since 1989, told the judge that she can no longer tolerate her existence. The court is expected to give its decision soon. In British Columbia Dr Tom Perry, a. pharmacologist and cabinet minister, 7
Headlines World's cancer deaths rising: WHO estimates that 15 million new cases of cancer will be diagnosed each year from 2015. About a third will- be tobacco related. Two thirds will be in developing countries.
America's teenage, mothers: The National Center for Health Statistics has reported the highest level in the number of teenage pregnancies in 15 years. Over this time the rate has increased by nearly one fifth. One in four births are now to unwed mothers. Cost of NHS reforms: About £380m has been made available to the NHS for implementing the NHS reforms last year. This is in addition to £300m and £80m provided in 1990-1 and 1989-90, respectively, and the money needed to maintain service levels.
American health costs up 10%: The average family will spend 12% of its income on health care this year according to a report from Families USA, a health care group from Washington, DC. This is a rise of nearly one tenth since 1980. More Americans lack health insurance: There are 34-7m Americans without health insurance, the highest number since the introduction of Medicare and Medicaid in 1965, according to the Center for National Health Program at Harvard Medical School. Relatively affluent families with incomes of $50 000 and over accounted for nearly one third of the increase. New DoH permanent secretary: Mr Graham Hart, secretary of the Scottish Home and Health Department, will succeed Sir Christopher France as permanent secretary at the Department of Health in the spring. Sir Christopher is moving to the Ministry of Defence.
Sir Donald Acheson chairs new prison committee: Sir Donald Acheson, former chief medical officer, has been appointed chairman of the health advisory committee for the prison service. The multidisciplinary committee will advise on ways of improving prisoners' health.
Award for BMJ assistant editor: Dr Fiona Godlee has won the Medical Journalists Association's 1991 medical journalism advancement award sponsored by Private Patients Plan.
8
publicly revealed that he and members of his family who are medical professionals had taken turns to give morphine to their father, who was dying of cancer. He admitted that the drug may have hastened his father's death. He said that his reason for speaking out was to open up public discussions on euthanasia. The governing body of the medical profession has made its position clear after criticising the action of Dr Peter Graff, an internal medicine specialist, who prescribed doses of morphine that hastened the deaths of two gravely ill patients. This is the first time that a doctors' regulatory body in Canada has had to deal with euthanasia. Dr Graff argued in his own defence that he did not consider his actions -to be euthanasia but simply an attempt to relieve suffering. The coroner's inquiry concluded that both patients died after morphine overdoses. The Canadian House of Commons has a private member's bill before it that would enable doctors to comply with a dying. patient's wish to die sooner without the doctor facing legal charges. A recent public opinion poll found that 75% of Canadians favour mercy killings of incurably ill patients if the patient's request is in writing. Earlier this year the Ontario Medical Association concluded that the issue of euthanasia should be left for society to determine, not the medical profession. It said that doctors should not take the lead in publicly debating the question but should, if asked, provide scientific information that might help the public to make a decision. The Canadian Medical Association (CMA) has long stated that it is not unethical for a doctor to withhold heroic treatment that could prolong the life of a terminally ill patient. This in effect condones passive euthanasia but not active euthanasia to speed death. At its annual meeting last summer the CMA's committee on ethics reported that it had not finished revising the association's policy on euthanasia and was granted additional time to complete its report. -M DUNLOP, journalist, Toronto
France It is quite common in France, as in many other countries, to give patients who are terminally ill a "lytic cocktail," an overdose of a sedative or another lethal substance. But euthanasia is likely to remain in a legislative no man's land because legislation would, in the words of the neonatologist Alexandre Minkowski, "institutionalise provoked death." Last year the cancer specialist Leon
Schwartzenberg was temporarily suspended by the Conseil de l'Ordre des Medecins, France's medical association, for declaring that he had helped some of his terminally ill patients to die. A member of the European parliament and -briefly France's minister of health, Dr Schwartzenberg-later submitted a proposal on euthanasia to the European parliament, stating, "When a physician decides, in all conscience, to answer the insistent and permanent request of a patient to help him stop his existence, that has lost
all dignity in his eyes, he acts in respect of a human life." He said that he wanted euthanasia to be better understood. "There is no question of establishing a law-particularly in a country like France. . . where everything that is legal is seen as normal." The National Ethical Committee, presided over by the haematologist Dr Jean Bernard, also opposes the legalisation of euthanasia because it believes that a law would be abused and wrongly interpreted and would give doctors "an exorbitant power over the life of an individual." The committee recognised that the patient's request might be reasonable but it might be made ambivalently. What was worse, economic, family, or ideological considerations unrelated to the patient's distress, or even the shortage of hospital beds or a family's impatience to inherit, might play a part in the decision. Moreover, said Dr Bernard, "We now have the means to fight against pain." Father Michel Riquet, of the Society of Jesus, has commented that the word euthanasia is ambiguous. It literally means "good death" in Greek, and in the middle ages there were good death fraternities that aimed not at shortening patients' lives but at providing them with palliative care for their pain and moral and spiritual comfort to help them die in dignity and as Christians. Father Riquet points out that the "`interdiction to kill" pronounced by Pope Pius XII did not imply the obligation to use all possible and extraordinary means to prolong a life that was moving towards its end. ALEXANDER DOROZYNSKI, medical journalist, Paris
Australia In Australia attitudes among the medical profession and the public are changing in favour of euthanasia. Euthanasia is currently illegal in all of the six states and two territories that make up the federal system of
Australia. The state of Victoria has enacted legislation-unique among the Australian states and territories-on refusal of medical treatment. This act makes it a criminal offence to treat a patient against his or her wishes. Patients can name an agent to make decisions
4
Logos promoting euthanasia
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their treatment if they become unable to decide for themselves. South Australia and the Northern Territory have Natural Death Acts, which are similar to "living will" legislation in some states of the US. In 1988 the Centre for Human Bioethics at Monash University in Melbourne surveyed 2000 doctors in Victoria and found that 869 supported voluntary euthanasia. One third said that they had been involved in voluntary euthanasia at least once. Nearly half said that they would practise voluntary euthanasia if it was legal. Early results from a survey by the School of Community Medicine in the University of New South Wales indicate that withdrawal of treatment is a major ethical isstie among practitioners. So far intensive care specialists have been extremely cautious about discussing the issue in public. Their main line is that they will do nothing illegal. But many will withdraw life support when there is no hope of recovery and allow the dying process to occur with dignity by administering sedatives and analgesics. Active support of accelerated dying is not acknowledged. -PETER POCKLEY, science writer, Sydney on
Germany In German law the penal codes for first and second degree murder state fairly clearly that active euthanasia is a crime against human life and punishable by up to five years in prison. Even during the Third Reich, when active euthanasia was practised on a wide scale on mentally ill patients, it was never formally legalised. Passive euthanasia, the denial of life prolonging treatment to a terminally ill patient, has always been regarded in law as a matter between doctors and their patients. The doctor is left to decide when life prolonging measures have become futile; the patient or, if he or she is incapable of making such a decision, the relatives then decide whether or not such measures should be continued. There is no known case of a German court questioning a patient's right to reject clearly inadequate and inefficient treatment. Suicide and assisting a suicidal action are not forbidden by German law. Penal Code article 216 forbids only "killing on request," which carries the threat of between six months' and five years' imprisonment. This caused a great stir in 1984 when Dr Julius Hackethal of Erlangen, a professor of surgery and a popular author, publicly admitted that he had helped a patient with cancer to commit suicide by providing a toxic agent. But Dr Hackethal escaped prosecution, as did Dr Hans Henning Atrott of Augsburg, who in the 1970s became known for founding the German Society for Humane Dying (Deutsche
Gesellschaft fur
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United States The defeat of Washington state's referendum physician assisted suicide (BMJ, 16 November 1991, p 1223) did not resolve the core issue of the rights of terminally ill patients regarding their medical treatment. In California and Oregon voters are likely to be balloted on the euthanasia issue. Meanwhile, a new federal law enacted last month requires any health care facility receiving funds from either the Medicaid programme for the poor or the Medicare programme for the elderly to inform adult patients of their right to refuse life sustaining medical care. They also have the right to complete a "living will" or durable power of attorney directing the facility to withhold certain treatments. The Patient Self Determination Act, passed by Congress" last year, requires hospitals, hospices, home health agencies, nursing homes, and health maintenance organisations to discuss patients' wishes. It does not require the health care facility to comply with every wish. American Medical News, an official publication of the American Medical Association, says that only between 4% and 17% of Americans have completed a living will or durable power of attorney, although about 70% of people who die in-hospitals do so after the withdrawal of life sustaining treatment. The newspaper quotes Mary Mahowald, professor of ethics at Chicago University, as saying that care givers must still determine whether life sustaining care is futile and whether it is in the patient's best interest. Several physicians told American Medical News that they were concerned that the law's requirements would interfere with the relationship between doctor and patient. In fact, the law was designed so that a patient can write an advance directive without any help from a physician. -REX RHEIN, medical journalist, Washington, DC on
Dr Death faces grand jury A grand jury will decide whether Dr Jack Kevorkian, a retired pathologist in Michigan who has helped three patients to commit suicide in the past 18 months, should be charged with murder. His medical licence was suspended last October. Dr Kevorkian, dubbed "Dr Death," first came to international attention in June last year when he helped Janet Adkins, a patient suffering from Alzheimer's disease, to commit suicide. He inserted an intravenous line attached to a lethal solution of potassium chloride. Police charged him with murder ard impounded his suicide machine, but a judge dismissed the case, ruling that Michigan has no law against assisted suicide. Last October he helped two more women to die. The county examiner has stated that these deaths were not suicides because they were not self inflicted. -MICHAEL MORRIS, Royal College of Psychiatrists travelling fellow, Massachusetts
Britain Euthanasia is sure to be on the United Kingdom's legal and parliamentary agenda in the coming months. Attention will focus on a case in Winchester, where allegations of euthanasia have resulted in a senior consultant being charged with attempted murder. The prosecution, like another (which failed) in 1990, concerns the administration of potassium chloride, in this case to an elderly woman who was disabled by arthritis. The consultant is due to appear before magistrates on 8 January. The court proceedings will be closely watched by an all party parliamentary group of MPs and peers that was formed last year to review the case for legalising euthanasia. The new group, under the chairmanship of a
Humanes Ster-
ben, DGHS). The DGHS, which still exists, gives expert advice on ways to commit suicide and provides suitable drugs. Atrott hit the headlines again in 1981 when he proposed to have article 216 abolished and demanded that mercy killing should be allowed if a terminally ill patient, who was unable to kill himself or herself, requested it. The idea, however, had BMJ
chance in a country where euthanasia is still a dirty word.-HELMUT L KARCHER, science writer, Munich
no
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DrJulius Hackethal openly admits he practices euthanasia
9
medical peer Lord Winstanley, is financed and serviced by the Voluntary Euthanasia Society. Later this month it will decide whether to sponsor an exploratory bill in the House of Lords to legitimise the "living will"-an advance declaration by patients that obliges doctors to withhold life sustaining treatment in the event of terminal illness. Any bill would be, more than anything, a device to raise the issue in debate. The chances of substantive legislation on any aspect of euthanasia are still considered to be remote. Although the euthanasia society claims that about 90 MPs are sympathetic to euthanasia, few would openly support it in the run up to a general election. There has never been a serious attempt in the Commons to legislate for euthanasia. The present drive reflects the extent to which a taboo has been lifted, but it is only the start of what promises to be a long drawn out campaign, possibly over two or more parliaments. Against it, the pro-life group of peers and MPs-best known as an antiabortion lobby-has regrouped to make the fight against euthanasia its top priority. JOHN WARDEN, parliamentary correspondent, BMJ
health visitor or general practitioner when a child attends an accident and emergency department after a road accident should be followed meticulously by all accident and emergency departments. The Department of Trade and Industry and the Department of Transport are starting a pilot scheme to determine how effective the hospital episodes system database will be for extracting information on road accidents. The report also refers to a model for an accident data system studied in Newcastle upon Tyne, which contained more socioeconomic information. This could help authorities to target preventive measures on more vulnerable groups. The report places health. professionals in the front line for preventive measures. Health visitors are urged to encourage the use of safe routes to school; community paediatricians are asked to monitor road traffic injuries, identify high risk areas, and advocate safe play areas and after school care. The report suggests that general practitioners should include road safety in health promotion clinics. The report also targets directors of public health, who are urged to identify research and training needs. -DAPHNE GLOAG, BMJ
NHS's key role in cutting children's road accidents In 1990, 48 000 children were injured in road traffic accidents. Nearly half of them were pedestrians and a fifth were on bicycles. Just over 400 children were killed. In a new report from the Health Education Authority Heather Ward argues that the NHS could do much more to prevent road accidents to children. She says that a wealth of information already exists within the NHS on road accidents to children. Her report asks for information to be distributed among highways, planning, and education authori-' ties and to be used for preventive work with children. In particular, the system of notifying the
How not to cross the road
10
Preventing Road Accidents to Children, by Heather Ward, is published by the Health Education Authority, Hamilton House, Mabledon Place, London WClH 9TX, price £3.
Juniors may still reject pay deal A special conference of junior hospital doctors will decide later this month whether to accept the recommendations for new rates of pay for out of hours work. These will mean that many junior doctors will continue to be paid less than their basic rate of pay for working at night and at weekends. In June last year a ministerial working party agreed on arrangements to reduce junior doctors' hours over a realistic timetable, but few doctors have moved on to the proposed shift systems because of the uncertainty about pay. The review body reported on 16 December after a delay of nearly three months. It recommended that for out of hours work doctors should be paid 100% of basic pay if they were working on full shifts; 70% if -they were on partial shifts; and 50%1/ if they worked in the rota system. Thie BMA had asked for overtime rates of 120%, 80%, and 60%, respectively. Although in negotiations with the Departmentof Health thejunior DoctorsCommittee had estimated that most' doctors would continue to work Qo a rota system, it was hoped that doctors on shifts would be paid at premium rates to encourage them to work shifts. The new rates will ceriainly benefit those working in shifts but by not as much as the BMA had hoped. In future out of hours pay will be expressed in terms of additional duty hours (ADHs) in place of the four hourly unit of medical time (UMT). The following example shows how the new ADH rates compare with current
Demonstratson at Tory party conference
UMT rates on an hourly basis on the midpoint of the scale. UMT ADH rate rate
Preregistration house officer on full shift Senior house officer on partial shift Registrar on a rota Senior registrar on a rota
£2.25 £3.19 £3.14 £3.36
£5.93 £5.87 £4.62 £5.60
At present senior house officers at the top of the scale working an average 80 hour week earn £19515 for a basic 40 hour week and £7416 on average from units of medical time which are paid at 38% of the basic rate. In future if they work for a maximum of 60 hours on a full shift they will earn £9758 as overtime. If they work 72 hours on a partial shift they will earn £10 924 as overtime and if they work 83 hours on an on call rota they will earn £10 489. (Fuller details of the BMA's estimates of the new rates and a summary of its evidence to the review body are given on p 57.) The government has agreed to fund the recommended pay rates in full; the cost of the award is 5 8% of the junior doctors' pay bill or £44m in the United Kingdom. After the announcement of the award the chairman of the Junior Doctors Committee, Dr Edwin Borman, expressed his disappointment. "It means that junior doctors will continue to be cheap labour for managers to employ for prolonged hours, thus endangering the arrangement for the reduction of their excessive hours," he said. "Some doctors may get nothing as their hours have already been cut and those who work intensively for a concentrated period are likely to get less than those who are on duty for
lengthyperiodsbutworkinglessintensively." If doctors vote to accept the report at their conference on 18 January the new rates and the revised terms and conditions of service could take effect from 1 February. There are, however, likely to be renewed calls for industrial action. Last October's meeting of the Junior Doctors Committee heard that doctors were prepared to take industrial action if the review body report was not satisfactory. -LINDA BEECHAM, BMJ The Second Supplement to Twenty-First Report 1991, from the review body on doctors' and dentists' remuneration, is available from HMSO, price £2.35.
(Cmnd 1759.)
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organiser Dr Jon Beckwith, a member of the National Academy of Sciences and a molecular geneticist at Harvard Medical School. Dr Marvin Natowicz, head of the division of genetic medicine at Harvard's Shriver Center for Mental Retardation, echoed this: "There has- been a long, ugly history of scientific determinism based on genetics. Poorly used, it's nothing more than molecular phrenology."-JANICE HOPKINS TANNE, contributing editor, New York magazine
Upjohn fails to get Halcion ban liftedThe pharmaceutical company Upjohn has lost its appeal to the Committee on Safety of Medicines to lift its ban on the sleeping pill triazolam (Halcion). Upjohn is likely to request a further appeal hearing before the Medicines Commission. Upjohn is thought to have suggested that the ban, which has been in place in the United Kingdom since October, might be lifted if triazolam was distributed in smaller packets with information leaflets and a stronger warning that it should be taken for only short periods. The United States Food and Drug Administration has allowed triazolam to stay on the market under similar
Investigating alternative medicines
conditions.
The drug was recently discussed by the European Community's Committee on Proprietary Medicinal Products, which includes representatives of all drug regulatory authorities in Europe. The committee supported Upjohn's proposals for labelling and packaging the drug but emphasised the "absolute importance" of using triazolam only for short periods. Unfortunately for Upjohn, the European committee can only make recommendations-it has no powers to override the policies of individual countries. The Committee on Safety of Medicines may have been influenced by reports from a further trial published in a German pharmaceutical journal suggesting that triazolam produced more psychiatric symptoms than another benzodiazepine. More than 1300 patients aged under 60 took part in this trial, which was carried out in Britain. About 200 people in Britain are seeking compensation from Upjohn for side effects that they believe are due to triazolam.
The Amish-cleared of depression
cases is a heroic job, but 181 drosocases wouldn't get you through the
enlargement of the study to include another family branch showed that the link between marker and disorder was statistically highly unlikely. The "alcoholism gene" on chromosome 5, supposedly present in one quarter of the American population, has been supported-and refuted-by two studies reported recently in the rournal of the American Medical Association. The link between schizophrenia and chromosome 5 remains controversial. Twin studies showing genetic linkage to behavioural disorders are flawed by adoptive agencies' habit of placing children in environments similar to those oftheir natural parents, said psychologist Dr Sandra Scarr, of the University of Virginia, Alcohol abuse, she pointed out, is more common in lower class families than upper class ones, and placing a child in a home of similar class might have more relevance than genetic inheritance. Nevertheless, people want to believe in a genetic basis for behaviour. "People assume we can explain how well a kid does in school with genes," Scarr said, and they want to abolish programmes to help disadvantaged children. "A large proportion of the American public wants to believe there is a gene for alcoholism. The worry about a genetic basis for behaviour is more common among scientists and reporters than the public," said Robert Bazell, science reporter for NBC-TV news. Journalists agreed it was difficult to air retractions and views opposed to published studies. "There's pressure to make the strongest possible statement [about genetic findings] because you're vying for space in the paper. There are also commercial interests in probes and diagnostic tests," said Richard Saltus, of the Boston Globe. "Political implications of IQ and sex differences [in mathematical ability, for example] are hyped. Reports about research in these areas often confuse individual differences with group differences," said Constance Holden, of
door." Indeed, the link between manic depression and chromosome 11, found through studies of a large Pennsylvanian Amish family, dissolved when two people in the original group became manic depressive although they did not have the marker, and
"The unfortunate thing is that when scientists find the gene for a disorder the prospects for a cure are way off, while the prospects for discrimination [against those who have the gene] are immediate," said conference
-
SHARON
KINGMAN,
freelance
medical
journalist
It's all in the genes The genetic basis for problems of human behaviour such as alcohol abuse and mental illness is weaker than many scientists and most newspaper readers think, but it raises the spectre of genetic discrimination. Speaking at a symposium of scientists and science journalists at Harvard Medical School organised by the Genetic Screening Study Group, Harvard geneticist Dr Richard Lewontin said, "A report of a highly significant correlation between a syndrome and genetic marker is often followed six months later by a report that the original researchers or somebody else find it not correct." Dr Lewontin pointed to the problem of sample
sizes
"A hundred and
eighty one
human
phila
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Science.
The National Poisons Unit at Guy's Hospital in London is starting to collect information on cases in which use of alternative medicines has made people ill. The unit hopes to establish how safe these preparations are. A search of its computerised surveillance system has shown that over 300 inquiries about poisoning with herbal medicines have been made since 1985. The Guy's project will receive joint funding from the Department of Health and the Ministry of Agriculture, Fisheries and Food. The Guy's unit plans to send-with the reporting doctor's consenta project team to investigate each case reported to it. Although many alternative medicines have been used for centuries with no ill effects, most have never been through any form of drug trial. The BMJ has published details of four women who suffered liver damage after taking Kalms and Neuralax to relieve stress. The harmful ingredients were probably valerian and skullcap (1989;299:1156). The National Poisons Unit has data on a 3 month old baby who died after taking an unknown amount of Indian medicine for constipation. At postmortem examination the fundus of her stomach showed considerable sloughing and she had peritonitis. Other children have contracted lead poisoning after using surma, an Indian eye remedy with a lead content of up to 86%-VIRGINIA S G MURRAY, consultant occupational toxicologist, National Poisons Unit, London
Playing the market In the NHS's new internal market the streetwise cardiologist opts for cost and volume contracts-and makes sure that the accountants get their costs right. That was the main message that emerged from a meeting held in London last month by the British Cardiac Society. As cardiology. and cardiac surgery are specialties dealing largely with tertiary referrals they potentially have a -lot to lose from the market. According to Dr Douglas Chamberlain, president of the society, this means that both specialties want to take a lead in making the market work. Just how complex the market could be was explained by some of the "providers." Mr John Parker's combined cardiology-cardiac surgery unit of 82 beds at St George's Hospital, London, has mostly block
11
based on average specialty costs. Extracontractual referrals are charged at the average specialty cost, which means that districts are paying too much for low cost procedures. His unit is now trying to offer separate charges (still averaged) for cardiac and thoracic cases, but this might also distort districts' costs if they buy more or less than planned of each type. Mr Parker wanted to move to procedure costs to compete with private hospitals and to prevent the distortion of extracontractual referrals. He suggested a points system, whereby the contract was written in terms of "points" of cardiac care, each point being worth a certain sum and each procedure being worth a certain number of points. Dr John Perrins, a cardiologist at Leeds General Infirmary, already knows precisely the fixed and variable costs for all his procedures. He can thus offer cost per case contracts: purchasers pay the full price for a certain number of procedures; above that they pay only the variable cost of the extra procedures (and if the unit does not meet the contract it repays only the variable cost of the procedures not performed). In that way purchaser and provider share the risk, the contract allows for variations in workload, it encourages modest service expansion, and there is no delay in treating extra patients. But if the variable cost is too low the unit loses on all cases performed over the contract number; if it is too high it loses on repayments made on underachieved contracts. This happened at Leeds because the accountants had worked out the costs independently, fixed the contracts, and only then consulted the clinicians. This had led to the variable contracts
A strategy of purchasing for all GPs The Department of Health has recommended a series of collaborative projects between general practice fundholders and district health authorities, which will be more widely disseminated if they are successful. The aim of the projects-in east Hertfordshire, Leeds, Northampton, Northumberland, Plymouth, Salford, and Leeds-is to produce a range of practical examples of effective collaboration in purchasing. Fundholding will continue to be voluntary, although the list size criterion will go down from 9000 to 7000 in April 1993. In its latest proposals the department says that it is not the intention that "practices who cannot or do not wish to become fundholding practices should in any way have a 'second class' status as far as the purchase of secondary care is concerned." There are already several initiatives aimed at strengthening the district health authority's purchasing role and, in particular, at ensuring that all general practitioners are consulted before contracts are drawn up with provider units. A pilot project has now been proposed to enable a district health authority to purchase a
12
cost for angioplasty being set at only £400, whereas the real cost was nearer £700. The unit had done 30 more procedures than contracted for, and this miscalculation had turned what looked like an extra £12 000 into a loss of £9000. The other main concern that emerged was the distortion in clinical priorities. Professor Peter Sleight claimed that his unit in Oxford had stopped treating local patients because the unit had already met its contract and Oxford Health Authority wouldn't pay any more. Instead the unit was treating people from Dorset at marginal costs. Despite these problems, providers are
wide range of acute care in accordance with the wishes of a volunteer group of nonfundholding practices. The proposals were welcomed by the General Medical Services Committee last month, which emphasised that it had not changed its policy on fundholding. (That would be for the local medical committee conference to decide.) The committee wants to see all general practitioners given an effective voice in deciding on secondary care
probably better informed than purchasers at the moment, yet a market needs two equally well informed partners to work properly. According to Dr Ron Akehurst, from the York Health Economics Consortium, the big questions about available interventions, their outcomes, and their resource consequences should be answered nationally. The information could then be applied locally. Yet the NHS has far to go in pursuing rational purchasing. British cardiologists are still answering questions on costs; no one last week doubted that they would soon start to be questioned on outcomes. -JANE SMITH, BMJ
The GMSC chairman believes that the committee's motions, which were passed overwhelmingly (see box), and the department's proposals will go a long way to ensuring that all general practitioners influence the quality of contracts and to achieving equity of care. He emphasised, however, that no projects or new arrangements could surmount the NHS's overriding problemshortage of funds. -LINDA BEECHAM, BMJ
for their patients.
The department's proposals go some way achieving this by recognising that there are different methods of purchasing care, including fundholding. GMSC chairman, Dr Bogle told his committee that purchasing and fundholding were different, but as more doctors collaborated with local purchasing authorities the feeling that becoming a fundholder was necessary to get the best for patients might not be so strong. Once all general practitioners became involved in purchasing fundholding could become superfluous. Because of concerns about the development of a two tier service last spring the committee called for a full evaluation of fundholding before the second wave was announced. Then in the summer new guidance agreed with the department and the Joint Consultants Committee was introduced aimed at ending fast tracking (BMJ 1991;302:1486). to
The GMSC... * Continues to believe that the government was wrong to introduce the NHS review changes without proper evaluation of pilot schemes and particularly without having addressed the long term problems caused by inadequate funding of the NHS * Notes the proposed continuing development ofthe role ofdistrict health authorities and general practice fundholders as purchasers of care * Insists that any such development uses fully the opportunities for all purchasers to collaborate and cooperate for the benefit of all patients * Insists that all general practitioners, both at practice level and through their local medical committees, should be in a position to influence purchasing decisions in respect of secondary care.
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