1030
In the appeal in Fl one judge said that to accept jurisdiction would have created conflict between the legal
interests of the mother and those of the unborn child. Another judge said that the only purpose of extending the law’s jurisdiction to include the fetus would be to control the mother’s actions. Taking matters to extremes, a court faced with saving a baby’s life or its mother’s would surely have to protect the baby. The cautious attitude adopted by the Court of Appeal in F should be contrasted with the interventionism of Sir Stephen Brown’s decision. In the United States the courts have gone even further down the route of interventionism, for a time anyway. The trend began with Jefferson vs Griffin Spalding County Hospital and the 1986 decision in Maydun where the judge ordered a hospital to protect the fetus, including a caesarean section if necessary, despite refusal by the mother. In Jefferson (a case of complete placenta praevia) a caesarean section would have an almost 100% chance of a successful outcome for both mother and child, in the doctor’s opinion, but the woman had refused a caesarean and blood transfusions on religious grounds. In Maydun, the judge said that the state’s interest in protecting "innocent third parties" (unborn children) may override the interest in
bodily integrity. Matters in the US came to a head with the June, 1987, decision to force an unwanted caesarean on a 27-year-old woman, 26 weeks pregnant, who was dying of cancer. She, her husband, and her parents were wholly opposed to the operation and her regular doctor refused to do it. The baby died within hours and the mother died 2 days later in the bitter knowledge that her dying wishes had been disregarded. The parents appealed, arguing that the operation had violated their daughter’s bodily integrity, and they were supported by womens’ and religious groups, the American Medical Association, and the American Civil Liberties Union. The Appeals Court in Washington, DC, agreed to hear the case (the family also sued the George Washington University Hospital) and on April 26, 1990, it decided by 7 to 1 that a pregnant woman may not be ordered to undergo a caesarean section to save her fetus. The leading judgment did not rule out all possibility of the courts’ overriding the wishes of a pregnant woman; a conflicting state interest may be so compelling that the patient’s interest must yield but "we anticipate that such cases will be extremely rare and truly exceptional". In April, 1987, a Family Court judge in Ontario, Canada, awarded 3 months temporary custody of a 38-week fetus to the Children’s Aid Society and had the mother-to-be compulsorily admitted to hospital. He argued that there was a substantial risk to the unborn child’s health and safety. The mother was refusing medical assistance despite severe abdominal pains, she was sleeping rough, and her attitude "was not conducive to the safe and healthy delivery of the child". It is easy to see how the intervention could be extended to include women who drink too much, take drugs, smoke, drive dangerously, eat unwisely, have violent partners, or live in unsafe areas. English law has always been clear that the fetus has no independent legal status and its interests are not equal to those of the carrying mother-and it should remain that way.
Diana Brahams 1. Brahams D. Fetus
as
ward of court? Lancet 1988; i: 369.
Conference Health and environment On Oct 10 and 11, an unusually warm and wet Cambridge, Massachusetts, was host to over 700 participants (150 or so had been expected) in a Harvard School of Public Health symposium on Human Health and the Environment: the Medical Consequences of Environmental Degradation. This was sponsored by Physicians for Social Responsibility and the Massachusetts Institute of Technology, along with the UN Environment Programme, and MEDACT, among others, and it was directed by Eric Chivian. To maintain the security of our material (notably mineral) wealth we make war, sometimes with drastic ecological consequences, but provide little defence for our biological wealth, explained Noel Brown, director of the North American office ofUNEP. 77% of carbon emissions come from the combustion of fossil fuels, the product of photosynthesis from atmospheric CO2 long ago, 23% is from the destruction of timber, explained Henry Kendall, 1990 Nobel laureate in physics. With a "business as usual" scenario, carbon emissions will rise from the current 5-6 billion metric tons (gigatons) (plus 1-2 from deforestation) to over 25 gigatons by the middle of the next century. Atmospheric CO2 has already increased by 25% since the middle of the 19th century, having been stable for thousands of years before that. Henry Kelly of the US Congressional Office of Technology Assessment (OTA) calculated that energy efficiency, with new technology and structural changes (eg, altered building designs and use of more daylight), could halve carbon emissions; the rest depends on harnessing renewable energy sources. 15 % of one south-west US State, if covered with photovoltaic panels could generate the combined electricity needs of all the other states. 81 million hectares of marketable crops also used as biomass could supply energy for all US vehicles and one-third of utility demands. Stored H2 or methanol/ethanol conversion to H2 are now within reach. Adjustment for the true price of energy, by an increase of 50%, based on costs of treating asthma and the loss of crops through acid rain, would make solar, wind, and biomass energy sources comparable and competitive with coal, oil, and gas combustion. Andrew Haines (London) explained how a warmer world could mean greater cardiovascular and cerebrovascular disease due to increased blood viscosity and platelet adhesion (though some adaptation might occur); and alterations in infectious diseases such as malaria and cholera. One molecule of chlorine, explained Alexander Leaf (Boston), remains in the stratosphere for 75-110 years and will break down 10* molecules of ozone. In 1990,100 million metric tons of chlorofluorohydrocarbons (CFCs) were released into the air. The Montreal Protocol of 1987 was revised in London in 1990 to encompass the complete phase-out of CFCs (and bromides) by the year 2000. The impact of ozone loss is now evident: for example, the incidence of melanoma rose by 83% between 1982 and 1989, and the increase in cataracts has been 18-fold in fishermen in Chesapeake Bay, Maryland. 65 000 synthetic chemicals have been produced by man; only 20% have been tested in animals. William G. Thilly (MIT) reviewed the biological techniques for assaying the mutagenicity of heavy metals and chemicals found in contaminated ground and surface water. In one area of
1031
eastern
Massachusetts, where
an
estimated 100
tonnes
of
cadmium and equivalent amounts of arsenic and mercury had been deposited, an excess of childhood leukaemia was reported first by local doctors, next by community members, and finally analysed epidemiologically by David Ozonoff and colleagues at Boston University Medical School. Working with cranberry farmers and nearby residents exposed to aerial spraying of pesticides, Ozonoff demonstrated a 2-3 fold increased risk of asocytoma. Many US coastal fishing grounds are grossly contaminated, explained Judy McDowell and John Stegeman, from the Woods Hole Oceanographic Institute. Polychlorinated biphenyls (PCBs) from insulation and electronics manufacturing are causing liver cancer and cholangiomas among fish. Avian ingestion of fish that contain PCBs damages their egg shells and prevents the reproduction of seabirds. Overgrowth of algae can block oxygen absorption in coastal shrimp and fish nurseries and threatens public health in three ways: (1) via "red tides" of temperate algae that cause paralytic, diarrhoeal, or the more permanent) amnesic form of shellfish poisoning; (2) via a reservoir for cholera in some tropical algae; and (3) via the diarrhoea associated directly with blue-green algae or cyanobacteria-like bodies. According to David Christiani (Boston) sulphates in coal and oil are producing rain with a pH of 4 1-4-3 in some parts of the US. Asthma prevalence doubled from the 1970s to the 1980s; and bronchospasm is directly correlated with increased concentration of hydrogen ions in inspired air. recent (and
Atmospheric ozone or photochemical smog directly damaged respiratory membranes, ciliated cells, and alveolar ducts. Ozone, acid rain, and particulates are not confined to the industrialised north; many urban areas of Africa, Asia and Latin America are dense with the products of coal burning. Reports of increased ozone and smog over the southern Atlantic are alarming. We are seeing "a trilogy of global change", according to US National Aeronautics and Space Administration officials: increased greenhouse gases in the troposphere, decreased ozone in the stratosphere, plus ozone drawn down into the 10 mile troposphere, adding to the greenhouse accumulation solar heat. Last year the US Congress allocated$3 billion to the clean-up of hazardous wastes surrounding weapons stores, plants, and bases; that is twice the budget of the Centers for Disease Control, explained Tara O’Toole (OTA), and $150-300 billion may ultimately be needed to remove this radioactive and toxic legacy of the cold war. Damage in the former Soviet Union may be worse; neither side considered the environment in its spiralling arms race. Companies on contract to the Department of Energy, reporting to the Department of Defense, have leaked millions of gallons of wastes into soils and ground water surrounding the plants for chemical processing, weapons assembly, and warhead
design. Addressing global changes that threaten the integrity of our health will require no less than a redirection of the international economy, removing disincentives to the achievement of a sustainable lifestyle, and providing incentives. No nation, stated Noel Brown, has a comprehensive climate-change policy. Physicians for Social Responsibility plans to arrange further such symposia and it will also look at the curricula of medical schools, to provide a research and policy input on the importance of global climate change. Paul R. Epstein
Noticeboard NHS guide to whistleblowing The Government has produced its draft guidance on "whistleblowing" for National Health Service staff. All NHS employees have a duty to draw to the attention of managers any matter that they judge to be damaging to patient interests. The working environment should encourage staff to freely express their views on all aspects of health-service operations, and under no circumstances should employees who raise bona fide concerns in accordance with locally agreed procedures be penalised for doing so. But any unauthorised disclosure of patient information, even when the employee believes he is acting in the patient’s best interests, will always warrant disciplinary action. Employees who have exhausted all the locally agreed procedures and are thinking of making public their grievance are reminded of their implied duty, under common law, of confidence and fidelity to their employer. Breach of this duty, even when the employment contract does not specifically address confidentiality, may also result in disciplinary action. For employees still contemplating disclosure of a matter of concern to the media, the recommendation is that they first seek advice from their professional or other representative bodies. The procedures that employing health authorities and trusts should set up in consultation with staff ought to provide for the issue to be considered, if necessary, up to general manager (of health authority) or chief executive (of trust) level; if the issue then remains unresolved, it may be referred to the chairman of the authority or trust. An alternative to using the management chain is to designate a senior officer to whom the employee can refer matters not resolved
by the immediate line manager. The Health Service Commissioner (Ombudsman) may look into complaints by staff on behalf of a patient, provided there is no-one more appropriate to act on the
patient’s behalf. An undue delay in resolving an issue might be seen as a violation of human rights (see Lancet Oct 3, p 846). The guidelines say that locally agreed procedures should allow for staff concerns to be resolved within agreed time limits. Comments on the draft guidance should be submitted by Nov 13 to Peter Hall, HAP2C Branch, NHS Management Executive, Room 2N34, Quarry House, Quarry Hill, Leeds LS2 7UE.
Combating emerging infections in the USA In 1970 infectious diseases seemed to be largely on the wane in the United States. The previous decade had seen vaccines virtually eliminate poliomyelitis due to wild-type virus and diminish the incidence of measles by 90%; the recently licensed rubella vaccine was coming into widespread use; and potent new antibiotics were available. From the perspective of 1970, it seemed as if infectious diseases such as tuberculosis and cholera might remain problems in less-developed countries but would be of only historic interest to the medical profession in the USA, where little more than occasional influenza epidemics would be expected. The sobering, disconcerting, epidemiological experience over the next two decades demonstrated how naive such projections were. Reports appeared of legionnaires’ disease, Lyme disease, an endemic focus of cholera along the Gulf of Mexico coast, AIDS, periodic resurgences of measles, haemorrhagic colitis and haemolyticuraemic syndrome due to 0157:H7 and other enterohaemorrhagic Escherichia coli, and multiple-drug-resistant tuberculosis. A multidisciplinary committee co-chaired by Nobel Laureate Joshua Lederberg of Rockefeller University and Robert Shope of Yale University has analysed environmental, human sociological, and microbiological factors that interact to facilitate the emergence or re-emergence of infectious diseases and has made some specific recommendations for strengthening the capability of the US to deal with current and future problems of this kind.’ The factors that foster emergence of infectious disease threats include: human demography and behaviour; technology and industry; economic development and land use; international travel and commerce; microbial adaptation and change; and breakdown of public health
In the appeal in Fl one judge said that to accept jurisdiction would have created conflict between the legal
interests of the mother and those of the unborn child. Another judge said that the only purpose of extending the law’s jurisdiction to include the fetus would be to control the mother’s actions. Taking matters to extremes, a court faced with saving a baby’s life or its mother’s would surely have to protect the baby. The cautious attitude adopted by the Court of Appeal in F should be contrasted with the interventionism of Sir Stephen Brown’s decision. In the United States the courts have gone even further down the route of interventionism, for a time anyway. The trend began with Jefferson vs Griffin Spalding County Hospital and the 1986 decision in Maydun where the judge ordered a hospital to protect the fetus, including a caesarean section if necessary, despite refusal by the mother. In Jefferson (a case of complete placenta praevia) a caesarean section would have an almost 100% chance of a successful outcome for both mother and child, in the doctor’s opinion, but the woman had refused a caesarean and blood transfusions on religious grounds. In Maydun, the judge said that the state’s interest in protecting "innocent third parties" (unborn children) may override the interest in
bodily integrity. Matters in the US came to a head with the June, 1987, decision to force an unwanted caesarean on a 27-year-old woman, 26 weeks pregnant, who was dying of cancer. She, her husband, and her parents were wholly opposed to the operation and her regular doctor refused to do it. The baby died within hours and the mother died 2 days later in the bitter knowledge that her dying wishes had been disregarded. The parents appealed, arguing that the operation had violated their daughter’s bodily integrity, and they were supported by womens’ and religious groups, the American Medical Association, and the American Civil Liberties Union. The Appeals Court in Washington, DC, agreed to hear the case (the family also sued the George Washington University Hospital) and on April 26, 1990, it decided by 7 to 1 that a pregnant woman may not be ordered to undergo a caesarean section to save her fetus. The leading judgment did not rule out all possibility of the courts’ overriding the wishes of a pregnant woman; a conflicting state interest may be so compelling that the patient’s interest must yield but "we anticipate that such cases will be extremely rare and truly exceptional". In April, 1987, a Family Court judge in Ontario, Canada, awarded 3 months temporary custody of a 38-week fetus to the Children’s Aid Society and had the mother-to-be compulsorily admitted to hospital. He argued that there was a substantial risk to the unborn child’s health and safety. The mother was refusing medical assistance despite severe abdominal pains, she was sleeping rough, and her attitude "was not conducive to the safe and healthy delivery of the child". It is easy to see how the intervention could be extended to include women who drink too much, take drugs, smoke, drive dangerously, eat unwisely, have violent partners, or live in unsafe areas. English law has always been clear that the fetus has no independent legal status and its interests are not equal to those of the carrying mother-and it should remain that way.
Diana Brahams 1. Brahams D. Fetus
as
ward of court? Lancet 1988; i: 369.
Conference Health and environment On Oct 10 and 11, an unusually warm and wet Cambridge, Massachusetts, was host to over 700 participants (150 or so had been expected) in a Harvard School of Public Health symposium on Human Health and the Environment: the Medical Consequences of Environmental Degradation. This was sponsored by Physicians for Social Responsibility and the Massachusetts Institute of Technology, along with the UN Environment Programme, and MEDACT, among others, and it was directed by Eric Chivian. To maintain the security of our material (notably mineral) wealth we make war, sometimes with drastic ecological consequences, but provide little defence for our biological wealth, explained Noel Brown, director of the North American office ofUNEP. 77% of carbon emissions come from the combustion of fossil fuels, the product of photosynthesis from atmospheric CO2 long ago, 23% is from the destruction of timber, explained Henry Kendall, 1990 Nobel laureate in physics. With a "business as usual" scenario, carbon emissions will rise from the current 5-6 billion metric tons (gigatons) (plus 1-2 from deforestation) to over 25 gigatons by the middle of the next century. Atmospheric CO2 has already increased by 25% since the middle of the 19th century, having been stable for thousands of years before that. Henry Kelly of the US Congressional Office of Technology Assessment (OTA) calculated that energy efficiency, with new technology and structural changes (eg, altered building designs and use of more daylight), could halve carbon emissions; the rest depends on harnessing renewable energy sources. 15 % of one south-west US State, if covered with photovoltaic panels could generate the combined electricity needs of all the other states. 81 million hectares of marketable crops also used as biomass could supply energy for all US vehicles and one-third of utility demands. Stored H2 or methanol/ethanol conversion to H2 are now within reach. Adjustment for the true price of energy, by an increase of 50%, based on costs of treating asthma and the loss of crops through acid rain, would make solar, wind, and biomass energy sources comparable and competitive with coal, oil, and gas combustion. Andrew Haines (London) explained how a warmer world could mean greater cardiovascular and cerebrovascular disease due to increased blood viscosity and platelet adhesion (though some adaptation might occur); and alterations in infectious diseases such as malaria and cholera. One molecule of chlorine, explained Alexander Leaf (Boston), remains in the stratosphere for 75-110 years and will break down 10* molecules of ozone. In 1990,100 million metric tons of chlorofluorohydrocarbons (CFCs) were released into the air. The Montreal Protocol of 1987 was revised in London in 1990 to encompass the complete phase-out of CFCs (and bromides) by the year 2000. The impact of ozone loss is now evident: for example, the incidence of melanoma rose by 83% between 1982 and 1989, and the increase in cataracts has been 18-fold in fishermen in Chesapeake Bay, Maryland. 65 000 synthetic chemicals have been produced by man; only 20% have been tested in animals. William G. Thilly (MIT) reviewed the biological techniques for assaying the mutagenicity of heavy metals and chemicals found in contaminated ground and surface water. In one area of
1031
eastern
Massachusetts, where
an
estimated 100
tonnes
of
cadmium and equivalent amounts of arsenic and mercury had been deposited, an excess of childhood leukaemia was reported first by local doctors, next by community members, and finally analysed epidemiologically by David Ozonoff and colleagues at Boston University Medical School. Working with cranberry farmers and nearby residents exposed to aerial spraying of pesticides, Ozonoff demonstrated a 2-3 fold increased risk of asocytoma. Many US coastal fishing grounds are grossly contaminated, explained Judy McDowell and John Stegeman, from the Woods Hole Oceanographic Institute. Polychlorinated biphenyls (PCBs) from insulation and electronics manufacturing are causing liver cancer and cholangiomas among fish. Avian ingestion of fish that contain PCBs damages their egg shells and prevents the reproduction of seabirds. Overgrowth of algae can block oxygen absorption in coastal shrimp and fish nurseries and threatens public health in three ways: (1) via "red tides" of temperate algae that cause paralytic, diarrhoeal, or the more permanent) amnesic form of shellfish poisoning; (2) via a reservoir for cholera in some tropical algae; and (3) via the diarrhoea associated directly with blue-green algae or cyanobacteria-like bodies. According to David Christiani (Boston) sulphates in coal and oil are producing rain with a pH of 4 1-4-3 in some parts of the US. Asthma prevalence doubled from the 1970s to the 1980s; and bronchospasm is directly correlated with increased concentration of hydrogen ions in inspired air. recent (and
Atmospheric ozone or photochemical smog directly damaged respiratory membranes, ciliated cells, and alveolar ducts. Ozone, acid rain, and particulates are not confined to the industrialised north; many urban areas of Africa, Asia and Latin America are dense with the products of coal burning. Reports of increased ozone and smog over the southern Atlantic are alarming. We are seeing "a trilogy of global change", according to US National Aeronautics and Space Administration officials: increased greenhouse gases in the troposphere, decreased ozone in the stratosphere, plus ozone drawn down into the 10 mile troposphere, adding to the greenhouse accumulation solar heat. Last year the US Congress allocated$3 billion to the clean-up of hazardous wastes surrounding weapons stores, plants, and bases; that is twice the budget of the Centers for Disease Control, explained Tara O’Toole (OTA), and $150-300 billion may ultimately be needed to remove this radioactive and toxic legacy of the cold war. Damage in the former Soviet Union may be worse; neither side considered the environment in its spiralling arms race. Companies on contract to the Department of Energy, reporting to the Department of Defense, have leaked millions of gallons of wastes into soils and ground water surrounding the plants for chemical processing, weapons assembly, and warhead
design. Addressing global changes that threaten the integrity of our health will require no less than a redirection of the international economy, removing disincentives to the achievement of a sustainable lifestyle, and providing incentives. No nation, stated Noel Brown, has a comprehensive climate-change policy. Physicians for Social Responsibility plans to arrange further such symposia and it will also look at the curricula of medical schools, to provide a research and policy input on the importance of global climate change. Paul R. Epstein
Noticeboard NHS guide to whistleblowing The Government has produced its draft guidance on "whistleblowing" for National Health Service staff. All NHS employees have a duty to draw to the attention of managers any matter that they judge to be damaging to patient interests. The working environment should encourage staff to freely express their views on all aspects of health-service operations, and under no circumstances should employees who raise bona fide concerns in accordance with locally agreed procedures be penalised for doing so. But any unauthorised disclosure of patient information, even when the employee believes he is acting in the patient’s best interests, will always warrant disciplinary action. Employees who have exhausted all the locally agreed procedures and are thinking of making public their grievance are reminded of their implied duty, under common law, of confidence and fidelity to their employer. Breach of this duty, even when the employment contract does not specifically address confidentiality, may also result in disciplinary action. For employees still contemplating disclosure of a matter of concern to the media, the recommendation is that they first seek advice from their professional or other representative bodies. The procedures that employing health authorities and trusts should set up in consultation with staff ought to provide for the issue to be considered, if necessary, up to general manager (of health authority) or chief executive (of trust) level; if the issue then remains unresolved, it may be referred to the chairman of the authority or trust. An alternative to using the management chain is to designate a senior officer to whom the employee can refer matters not resolved
by the immediate line manager. The Health Service Commissioner (Ombudsman) may look into complaints by staff on behalf of a patient, provided there is no-one more appropriate to act on the
patient’s behalf. An undue delay in resolving an issue might be seen as a violation of human rights (see Lancet Oct 3, p 846). The guidelines say that locally agreed procedures should allow for staff concerns to be resolved within agreed time limits. Comments on the draft guidance should be submitted by Nov 13 to Peter Hall, HAP2C Branch, NHS Management Executive, Room 2N34, Quarry House, Quarry Hill, Leeds LS2 7UE.
Combating emerging infections in the USA In 1970 infectious diseases seemed to be largely on the wane in the United States. The previous decade had seen vaccines virtually eliminate poliomyelitis due to wild-type virus and diminish the incidence of measles by 90%; the recently licensed rubella vaccine was coming into widespread use; and potent new antibiotics were available. From the perspective of 1970, it seemed as if infectious diseases such as tuberculosis and cholera might remain problems in less-developed countries but would be of only historic interest to the medical profession in the USA, where little more than occasional influenza epidemics would be expected. The sobering, disconcerting, epidemiological experience over the next two decades demonstrated how naive such projections were. Reports appeared of legionnaires’ disease, Lyme disease, an endemic focus of cholera along the Gulf of Mexico coast, AIDS, periodic resurgences of measles, haemorrhagic colitis and haemolyticuraemic syndrome due to 0157:H7 and other enterohaemorrhagic Escherichia coli, and multiple-drug-resistant tuberculosis. A multidisciplinary committee co-chaired by Nobel Laureate Joshua Lederberg of Rockefeller University and Robert Shope of Yale University has analysed environmental, human sociological, and microbiological factors that interact to facilitate the emergence or re-emergence of infectious diseases and has made some specific recommendations for strengthening the capability of the US to deal with current and future problems of this kind.’ The factors that foster emergence of infectious disease threats include: human demography and behaviour; technology and industry; economic development and land use; international travel and commerce; microbial adaptation and change; and breakdown of public health
