FROM OTHER JOURNALS

Responses to the cloning report

The US National Bioethics Advisory Commission was asked to examine the 'ethical and legal issues raised by the possibility of cloning human beings'. The report, published in June 1997, concluded that attempts to create a child using somatic cell nuclear transfer cloning are unethical at the present time. It recommended a continuation of the current moratorium on using federal funding for such research, calling for the private sector to comply voluntarily. It also called for legislation against any such efforts, for the next five years. Any future clinical use should be preceded by research trials regulated by ethics committees; efforts should be international; with extensive discussion among all groups for any future decisions, and efforts to inform the public on the matter.

The Hastings Center Report presents the commission’s executive summary followed by the reactions of five ethicists, including one of the NBAC members.

Cloning human beings: responding to the National Bioethics Advisory Commission’s report. Hastings Center Report. 1997; September- October: 6- 22.

Bioscience ethics
Irene Pollard and Steven Gilbert respond to the cloning controversy by emphasising the need for biologists and medical scientists to keep the lay public and bioethicists up to date on advances. Such information will help avoid frenzy such as that which followed the Scottish experiment for the creation of Dolly the sheep cloned from DNA taken from a live cell from the udder of a six-year-old ewe.

The authors ask how many are aware that genetically engineered domestic animals already exist, producing drugs such as interferon. They propose a practical framework for ethical decision making and an ecologically based model of medical care.

PollardIrene, Gilbert Steven:Bioscience ethics - a new conceptual approach to modern ethical challenges. Eubios Journal of Asian and International Bioethics 1997; 7: 131- 133.

The bioethicist of the future
In this reflection on the future of bioethics Frank Levitt refers to an aspect of medical ‘literature’ that has long needed correction. "...I have to admit that even after six years’ teaching in a medical school, hearing medical and biological lectures and reading the journals, I still find much of medical and biological literature incomprehensible."

The author strongly feels that the bioethicists of the future will emerge not from philosophy, but from the health and life sciences. Many of them will be nurses as their profession best combines human feeling with biological science, perhaps with training in cross-cultural spirituality.

Levitt Frank:The bioethicist of the future: commentary on Pollard and Gilbert, and Melanie Rock.Eubios Journal of Asian and International Bioethics 1997; 7: 133- 134.

Human gene therapy
Cloning is the topic of the day in bioethics. Nils Holtug assesses the cases for and against somatic gene therapy, germ- line therapy and gene therapy for enhancement. None of these therapies is inherently wrong, Holtug argues. Weighing their risks and benefits, he suggests that somatic therapy is a 'promising new treatment'; that germ- line therapy is soon to be superfluous except for enhancement engineering; and the possibility should not be ruled out that even enhancement engineering could save millions of lives.

Holtug Nils:Altering humans: the case for and against human gene therapy. Monash Bioethics Review 1997 16 (4): 14- 31.

‘Gay gene research’
Shuklenk and colleagues discuss another aspect of genetic studies that causes concern: research to determine sexual orientation on the basis of genetic tests.

The existing strong, widespread prejudice against men and women displaying homosexual behaviour is bound to be reflected in attitudes towards the foetus should there be a test that claims to determine sexual tendencyin utero. Adult homosexuals have been forced to undergo ‘treatment’ to ‘change’ their sexual orientation; foetuses showing features suggesting homosexual tendency will almost certainly be aborted. The essay discusses the fallacies inherent in using genetic tests to predict behaviour.

Shuklenk Udo, Stein Edward, Kerin Jacinta, Byne William:The ethics of genetic research on sexual orientation Hastings Center Report 1997; 27: 6- 13.

Cochlear implants
In an examination of the ethics of promoting cochlear implants, Robert A Crouch argues that the decision to forego a cochlear implant in the prelingually deaf child enables membership into world of the Deaf, with its rich history, language and values, far from condemning the child to a world of meaningless silence.

We need to recognise the limitations of cochlear implant. A recent study found that after five years of hard work, patients with such implants were able to correct pronounce just 70% of vowel sounds. Lest this sound satisfactory, the preceding sentence has just one word without a vowel.

We must also rethink the actual disadvantage in any form of handicap; the loss of one faculty is compensated by considerable sharpening of others.

Crouch Robert A:Letting the deaf be deaf reconsidering the use of cochlear implants in prelingually deaf children. Hastings Center Report 1997; 27: 14- 21

Managed care in the US
Howard Brody discusses the recourse to managed care as the principal, market- driven tool of cost containment which has generated a number of important changes in the practice of medicine in the US, which spends 15% of its GDP on health care.

Managed care involves rationing at two levels - access to managed care insurance plans and the distribution of resources within the plan itself.

Brody quotes Normal Levinsky:"... Physicians are required to do everything they believe may benefit each individual patient without regard to costs or to other societal considerations..." and "It is society, not the individual practitioner, that must make the decision to limit the availability of effective but expensive types of medical care."

On the other hand, he quotes David Eddy: "When physicians hoard resources for their own patients, they are not taking from administrators or insurers; they are taking from other patients."

Brody Howard:Managed care, the marketplace and the future of the physicianpatient relationship. Social Responsibility,Business, Journalism, Law, Medicine 1997; 23: 53- 65.

Hepatitis C and stigma
Hepatitis C is a recently discovered but common cause of chronic liver disease in industrialised countries. Because it is basically blood- borne, and because blood donors in the West are systematically screened, the only major group now at risk of infection are injecting drug users. There are increasing reports of stigmatisation of people with hepatitis C. The authors collected 37 reports of such incidents in Australia in 1994, the most common being health care settings.

In general, action did not follow from such incidents, despite the fact that Australia has a very strong framework of anti- discrimination legislation and process.

Crofts Nick et al:The next plague: stigmatisation and discrimination related to hepatitis C virus infection in Australia. Health and Human Rights 1997; 2 (2): 87-97.

Physicians and juveniles
The United Nation Convention on the Rights of the Child (CRC) is used as a framework to examine issues of psychiatric institutionalisation of juveniles in the US. The current system allows children diagnosed with abuse relatively mild, non- psychotic disorders or exhibiting delinquent behaviours to be placed in institutions. Failure to regulate treatment in these facilities also results in abuse by treatment providers. Parents can institutionalise a child under the guise of mental health 'treatment'. The social, mental and physical health consequences of economic deprivation of liberty are discussed. Recommendations include that the US ratify the CRC, guarantee due process for juveniles faced with institutionalisation, conduct systematic treatment reviews, and correct institutional abuses.

Molnar Beth E:Juveniles and psychiatric institutionalization: Towards better due process and treatment review in the United States. Health and Human Rights 1997; 2 (2): 98-116.

A double bind
How do health care professionals function ethically within a patently repressive regime? Members of the International Civilian Mission’s Medical unit asked themselves this question when working in Haiti from 1991 to 1994. The medical unit was set up by an international human rights observers mission after a 1991 military coup overthrew the 30-year-old Duvalier dictatorship in Haiti. They had to facilitate victims’ access to medical care, ensure their safety in the context of continued violations, intervene in prison settings, and perform medical documentation of human rights violations. The report provides an account of the team’s experiences.

Marotte Ceclie and Razafimbahiny Herve Rakoto:Haiti 1991-1994: the International Civilian Mission’s Medical Unit. Health and Human Rights 1997; 2 (2): 117- 126.

Health professions and abuse
This article, based on a 1995 workshop organised by the Research, Action and Information Network for Bodily Integrity of Women, discusses the role of health professionals in promoting or suppressing human rights. The first case study is of the history of the movement against female genital mutilation in Egypt, actively supported by some physicians, while others have supported its medicalisation. The second case study is of abortion in the US, where medical professionals played a leading role in criminalising the procedure, and where doctors are not required to be trained in the procedure.

Moore Kirsten et al:The synergistic relationship between health and human rights: a case study using female genital mutilation. Heath and Human Rights 1997; 2 (2): 137-146.

The law and assisted suicide
On June 26,1997, the US Supreme Court refused to recognise the constitutional right to die using a doctor- prescribed drug. This decision is discussed by two legal scholars, an anthropologist and an ethicist.

Aid- in- Dying:The Supreme Court and the Public Response. Hastings Center Report. 1997 September- October: 25-38.

Ethics in research
Research ethics is taking yet another public bashing with news of the HIV trials in Africa and the ICMR study on cervical cancer. So this special supplement on ethics committees is particularly relevant. Julian Savulescu et al make some suggestions for improving performance and accountability in ethics committees,. and in a two- part paper, Benjamin Freedman et al attack placebo orthodoxy in clinical research.

Savulescu Julian et al, Freedman Benjamin et al:Monash Bioethics Review 1997: 16 (4).