undergo chemical castration as a condition ... effect on 1 January 1997, castration would be optional for first time ... start with a voluntary programme, which can.
NEWS Caesareans without consent authorised A high court judge authorised doctors to perform caesarean sections against the woman's wishes in two separate cases, it emerged this week. In the two cases, heard coincidentally on the same day in June, Norfolk and Norwich NHS Trust and Rochdale Healthcare NHS Trust made emergency court applications while the patients were in labour. Mr Justice Johnson authorised the operations, in the Rochdale case after hearing only a two minute outline of the facts. The woman in the first case, W, had gone into the accident and emergency unit of a Norwich hospital at 9 am, already in labour but denying that she was pregnant. She had had three previous caesarean sections, and the judge was told that the consultant looking after her thought that the scars would reopen or the fetus would die unless it was delivered by 6 pm. W had a history of psychiatric treatment but did not have a mental disorder, though a psychiatrist who interviewed her thought that she could not make an informed choice. The second woman, C, had had a previous caesarean section and had told the consultant trying to deliver her baby that she would rather die than have another. There had not been time for a psychiatrist to see her, but the obstetrician thought that there was no question about her mental competence. Mr Leigh told the judge at 5 15 pm that the consultant believed that C and the fetus would die unless the operation was performed by 5 30. The judge made the order, which Mr Leigh relayed to the hospital by mobile phone. However, C had changed her mind while he was in court and agreed to the operation. In both cases the judge concluded that the pain and emotional stress of labour had prevented the women from weighing up all the considerations and making a choice-one of the three tests of competence laid down in an earlier case. The president of the court's family division, Sir Stephen Brown, was widely criticised by legal experts when he made the first compulsory order for a caesarean section three years ago. After that case the Royal College of Obstetricians and Gynaecologists issued a paper from its ethics committee stating that mentally competent women who refused a caesarean section should not have the operation imposed on them. Barbara Hewson, a barrister and one of the most vociferous critics of the 1993 ruling, is offering free legal advice to women in similar situations after learning of the latest cases. She said: "I'm dismayed that judges BMJ
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Legal principle stares that operations should not be imposed on patients who are mentally competent
are imposing interventions like caesareans, which have their own risks." The cases seem to contradict the well established legal principle that mentally competent patients may not be forced to undergo operations against their will, even if the result of refusing is certain death, however irrational their reasons may seem. Wendy Savage, consultant obstetrician at the Royal London Hospital, said: "I think it's a very sinister development. The idea that just because you're in labour, you're incapable of making a competent decision is ridiculous. If I had a woman in this situation, I would do my utmost to persuade her to have a caesarean section, but I wouldn't force her by going to the High Court." The BMA called for clear legal advice for doctors about whether they are expected to take future cases to court when the woman refusing a caesarean section is competent and informed. -ciAR DYER, legal corrspndent, Bm-
Contoversial surgical video is banned The High Court in London granted a permanent injunction this week banning the public sale of a controversial video showing operations on NHS patients. The health minister, Gerald Malone, pledged action to stop such products reaching the market in future. The Department of Health had earlier won a temporary injunction to prevent the sale of Everyday Operations,
made by the independent production company IMC Video, as it was about to go on sale for £12.99 ($20). Mr Malone said: "Such video nasties not only encroach on the confidentiality of NHS treatment and the doctor-patient relationship but might also deter patients from seeking treatment. There must also be serious worries about money being paid to senior doctors, as -aimed in the media, for the acquisition of such footage." He said he was looking at ways to tighten up the rules to prevent any recurrence of this situation. Press reports claimed that doctors had been paid around £1000 each to provide footage of operations. It emerged last weekend that some of the footage came from a training video, Dirty Surgery, commissioned by SmithKline Beecham more than five years ago for use abroad. A company spokesman said: "This material is being used without the knowledge or approval of SmithKline Beecham. The company is currently reviewing what legal action we can take." The General Medical Council confirmed that patients' consent was required for training videos and would need to be sought again if the material was used for any other purpose. But they refused to confirm or deny reports that it was investigating doctors for breach of confidentiality over their part in the video. A spokesman for IMC Video said they hoped still to be able to release the video. Mr Malone agreed that the makers could apply to have the ban lifted, but only "in the unlikely event of [their] obtaining the consent of the patients, doctors, health authorities, and trusts involved."-LARE DYER, legal correspondent, BmJ 705
Headlines freeze sector pay Public announced: A pay ceiling of under 3% for doctors has been implied by the Chancellor of the Exchequer, Kenneth Clarke. He told the review bodies that inflation is falling, there is no pressure on pay levels generally, and last year's settlements were relatively high. NHS trust faces bankruptcy: Anglian Harbours NHS Trust, based in Great Yarmouth, faces the loss of two thirds of its £26m ($39m) annual income after the East Norfolk and Suffolk health authorities said that they planned to withdraw contracts worth more than C17m. US healthcare system is praised: The left leaning Fabian Society has praised the United States' insurance based healthcare system, saying that it provides a higher quality of care for the majority of the population than Britain's national health service. The society's report No Pain-No Gain: Lessons from US Healthcare points out that hospitals in the United States do not tend to have waiting lists.
Warning over exodus of university doctors: There are now 57 professorial clinical chairs vacant across the United Kingdom, the British Medical Association has said. The Committee of Vice Chancellors and Principals says that the situation is so serious that it has set up an independent inquiry into the disincentives to a career in academic medicine.
Catalogue of errors found at Grimsby Hospital: An investigation by the Northern and Yorkshire region found several problems with the obstetrics and gynaecology service at the hospital, including surgery carried out by unsupervised, inexperienced staff. The consultant in charge, Michael Muldoon, escaped overall condemnation but was accused of poor communication, lack of leadership in specific cases, and failing to supervise
Researchers try crystal ball gazing to predict future A team of researchers have tried to predict when artificial hearts, lungs, livers, and kidneys will come into clinical use. Such devices are all at various stages of development around the world and could help to solve the severe shortages of donor organs. A team of futurologists and researchers put together by British Telecommunications (BT) has tried to look into the future by combing the literature and talking with leading practitioners, and it has produced a timetable for major medical and scientific developments. The timetable, which starts in 1998 with the arrival of home health diagnostic systems and virtual reality exercises in the home, goes through to the year 2035, when artificial eyes and genetic programs to enhance human wellbeing are predicted to have just come on line. By 2025 the genetic, chemical, and physiological basis of human behaviour will be understood, and in 2010 genetic screening will be widely used. The full futures timetable, which will be published and accessible on the Internet later this year, also gives dates for major developments in a range of other disciplines, including the development of human hibernation for space travel in 2030. Ian Pearson, the BT futures researcher behind the project, said: "The dates are based on the latest information that we have collected from a number of sources in each speciality." Dr Terence Kealey, biochemist, author, and consultant chemical pathologist at Addenbrooke's Hospital in Cambridge, said: "We are actually living in the most extraordinary phase of human development. The idea that technology will increase by leaps and bounds is absolutely correct, but the details are of course more difficult. Many of these kinds of predictions are not unrealistic.
"It is unquestionably
true
that science
progresses and the number of science papers doubles every 15 years and has done so since 1830. As we know, the total amount of knowledge has doubled every 15 years
since 1790." The timetable also carries some events without dates as some events are unpredictable. As John Petersen of the US Arlington Institute and a contributor to the timetable points out, wildcard events such as a worldwide epidemic, a virus that becomes immune to treatment, and an AIDS virus that mutates to become transmittable by air could happen any time.-ROGER DOBSON, medical journalist, Gwent, Wales
Timetable of events 1998 2000 2005 2010 2012 2015
2017 2020
2025 2030
Artificial pancreas Artificial blood Full medical records stored on smart cards Personal wearable health monitors Determination of whole human DNA base sequence Artificial heart Artificial senses Robots extensively employed for routine hospital tasks Customised food for specific medical conditions Genetic links to all diseases identified Individual's genome is part of medical record Artificial lungs and kidneys Robots for guiding blind people Artificial brain cells Artificial liver Extension of average human life span to 100 years Artificial brain implants Artificial eyes Human intelligence enhanced by external means
juniors.
IVF pioneer hits back at accusations of making designer babies: Lord Robert Winston, professor of fertility studies at the Hammersmith Hospital, London, said that it was now possible to screen embryos for a predisposition to cancer. Writing in the Times, Lord Winston said that preimplantation diagnosis could be useful for families who carry a strong predisposition to certain cancers and that spurious arguments about practising eugenics were a poor reason to prevent such work.
Medical technology will continue to increase by leaps and bounds
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Personality changes due to "roid rage" Anabolic steroids lead to substantial personality changes within a short period of use, according to a new study. Previous studies into what has become known as "roid rage" have suggested that changes in personality are minor. But researchers from the Sports Science Institute of South Africa found that most ofthe steroid users studied showed abnormal personality traits, including being paranoid, schizophrenic, antisocial, and histrionic (British Journal of Sports Medicine 1996;30:246-50). The study compared 12 body builders who had used anabolic androgenic steroids for not more than 18 months with 12 body builders who claimed never to have used these drugs. Personality changes were assessed by a mental health questionnaire with additional information from friends and family. Steroid users were all heavier than the control group; most (83%) showed at least one personality disorder and more than half showed two types of disorder. A recent paper in the BMJ (1996;313:100-1) reported that the possible effects of long term steroid use included infertility, liver disease, jaundice, reduced libido, mood changes, and prostatic carcinoma. Another study, in the Medical Journal ofAustralia (1996;165:222-6), linked high doses of steroid use for several weeks to uncontrollable bursts of aggression. In the United States 20 cases of murder have been attributed to anabolic steroids. In Britain, public awareness of the issue recently increased when the soap opera Brookside featured a character who became aggressive after taking steroids before a body building competition. Dr Mike Turner, chief medical adviser of the Jockey Club, said: "In the United Kingdom, in an average gym, there is evidence that 35% of people attending the gym take anabolic steroids. We are not talking about professional body builders but anybody, for whatever reason. And of course the best person to notice this is the family and not the general practitioner."-MARTN MULUBE, Clegg scholar, BMJ
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