increasing incidence of these states. Some take NDEs as evidence for an afterlife. If so, any medical efforts to postpone the joys of heaven would be misguided.
and public policy opine that the risks of asbestos exposure to society are "tiny." They project the interests of some over the health of all by promoting the social acceptability of unnecessary risks. Furthermore, their ephemeral "thresholds," right or wrong, are meaningless in view of the difficulty of any system to titrate controls. Thus, banning substitutable asbestos is ethically justified public policy in any country in which substitutes are available. The export of asbestos - a deliberate policy of the Canadian government - to countries in which the workers and the public are almost defenceless and there is no reasonable semblance of a regulatory infrastructure is especially repugnant in the universe of values Americans and Canadians purport to share. Sheldon W. Samuels Councillor Ramazzini Institute for Occupational and Environmental Health Research Solomons, Md.
Near-death experience denied B., the longtime total paraplegic, was granted her court-supported wish to have her life-support equipment disconnected. As a kindness this was done after administration of a large dose of morphine; however, this may have deprived the patient of one of the increasingly reported ecstatic near-death experiences, sometimes referred to as near-death out-of-body experiences (NDEs). Three recent booksl-3 attest to an increasing incidence of these iN ' ancy
states. Some take NDEs as evidence for an afterlife. If so, any medical efforts to postpone the joys of heaven would be misguided. How1700
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ever, Tom Harpur,4 the Canadian classical scholar and Anglican priest, states that although "there are those who claim too much for the NDE and . . . feel that they now have the elusive proof ... for immortality . . . they don't have any such proof ... [However,] it is foolish to pretend that all of this has no relevance. No natural explanation has been found ... [so] there is little alternative but to accept some kind of transcendental explanation in its stead." A reasonable "scientific" explanation would be that our sensing of the world around us depends on the continuing presence of external sensory experience and that sensing of our body likewise depends on continuing body sense awareness. Sensory deprivation experiments may result in unusual, sometimes mystical experiences. Anoxia experienced on high mountains is a case in point, when the pain of the climb is minimized by a sense of joy. Progressive cerebral anoxia may be assumed to affect first the more recently developed, higher centres of the brain and second the intermediate centres for appreciating body sense and pain, so that the mind is left free to experience the affective sense that presumably is part of basic human and animal life force. This seems to carry no sense of time but, when uninhibited by the basic brain functions needed for survival, gives rise to the ineffable joyous sense of enlightened out-of-body experience. When elicited by anoxia alone, undimmed by drugs or general anesthesia, this feeling may be strong enough to be recalled by the person who has been resuscitated. Thus, it is only in recent times, when there has been a dramatic increase in emergency resuscitation, that near-death experiences have become common and, more important, readily admitted by those who have them. We know that slowly developing anoxia is not painful. It is the
shortness of breath due to accumulating carbon dioxide that makes the initial stages of drowning so fearful. Indeed, many people who have been near death from drowning describe NDEs. True euthanasia would most easily be achieved if nitrogen or even nitrous oxide were substituted for the oxygen in the life-support system; this would likely have the added advantage of allowing an ecstatic out-of-body experience, the more so if the progressive anoxia were slowly induced. (I am reminded of some of our tentative and far from unpleasant experiences with nitrous oxide when we were learning about anesthesia.) Morley J. Tuttle, MD, FRCPC White Rock, BC
References 1. Harpur T: Life After Death, McLelland and Stewart, Toronto, 1991 2. Zaleski C: Otherworld Journeys: Accounts of Near-Death-Experiences in Medieval and Modern Times, Oxford U Pr, New York, 1987 3. Moody R: The Light Beyond, Bantam, New York, 1988 4. Harpur T: Life After Death, McLelland and Stewart, Toronto, 1991: 257
Primum non nocere In his letter (Can Med Assoc J 1992; 146: 104-105) Dr. Rick W. Swanson seems to indicate that the performance of a digital rectal examination (DRE), as part of a periodic health assessment, was inherently harmful for his patient. His conclusion is questionable. The prognosis for colorectal cancer is related to the Duke's classification at the time of initial diagnosis.' Despite the proximal migration of these tumours over the past 30 years, some of them remain palpable on DRE.2 It is for this reason that the US Preventive LE 15 MAI 1992
Services Task Force3 recommends annual DRE for both sexes beginning at age 40 years. The abnormal findings on DRE did not compel either the patient or Swanson to seek further management. Some people in this situation would want no stone unturned in seeking a cure, despite the associated iatrogenic risks. Others might adopt a waitand-see attitude. The diagnosis of a condition does not have to result in specific treatment for that condition. This reasoning is the basis for the concepts of patient autonomy and informed consent. Accordingly, I contend that the omission of DRE in this setting would be a failure to fulfil the obligation primum non nocere. Joseph A. Moran, MB, CCFP Assistant professor Department of Family Medicine University of Manitoba Winnipeg, Man.
References 1. Mastromarino AJ: Colorectal health check: a strategy for prevention. Tex Med 1987; 83 (4): 57-64 2. Rhodes JB: Changing distribution of primary cancers in the large bowel. JAMA 1977; 238: 1641-1643 3. US Preventive Services Task Force: Guide to Clinical Preventive Services: an Assessment of the Effectiveness of 169 Interventions, Williams & Wilkins, Baltimore, 1989: 63-65
[Dr. Swanson responds:] I was pleased to see Dr. Moran's comments on my letter. My purpose in writing was not to imply that DRE is inherently harmful to patients. Nor was it to imply, as
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some of my colleagues may have assumed, that physicians should not perform DRE. In the case I described, the alternative therapies were outlined, patient autonomy was respected and informed consent was obtained. The patient could have elected to adopt a "wait-and-see attitude." It could be argued that because DRE is an inexpensive screening tool we ought to continue to perform it on a regular basis, even though we have not proven that it reduces the risk of death from prostate or colorectal cancer. Physician and patient expectations and the "laying on of hands" are also important considerations. My inference from many of the recommendations of the Canadian Task Force on the Periodic Health Examination (Can Med Assoc J 1991; 145: 413-428) and the US Preventive Services Task Force' is that we do not have the evidence to "include or exclude" many of the manoeuvres that we typically do or do not perform in our periodic health assessments. Friedman and colleagues' conclusion2 that "screening by routine digital rectal examination appears to have little if any effect in preventing metastatic prostatic cancer" is based on only one casecontrol study. As a more general statement, we desperately need more evidence on effective preventive health strategies that truly reduce the risk of death from cancer. My purpose in raising the issue was to stimulate and enhance discussion that will lead to research into some of these criti-
cal questions. I am pleased that I have at least stimulated discussion. Critical research must follow. Also, I doubt that Moran and I are disagreeing on the importance of primum non nocere. Rick W. Swanson, MD Professor and head Department of Family Medicine University of Calgary Calgary, Alta.
References 1. US Preventive Services Task Force: Guide to Clinical Preventive Services: an Assessment of the Effectiveness of 169 Interventions, Williams & Wilkins, Baltimore, 1989: 63-65 2. Friedman GD, Hiatt RA, Quesenberry CP et al: Case-control study of screening for prostatic cancer by digital rectal examination. Lancet 1991; 337: 15261529
Reducing the cesarean section rate in a rural community hospital
[correction]
he first paragraph on page 1462 of this article (Can Med Assoc J 1991; 145: 1459-1464), by Drs. Stuart Iglesias, Robert Burn and L. Duncan Saunders, incorrectly states that the overall rate of cesarean section dropped from 23% to 12% and that the rate in the nulliparous group decreased from 23% to 11%. The lower figures should have been 13% and 12% respectively. - Ed.
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