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ROUND-UP Law and Policy
Round-Up Reproductive Health Matters, No 4, November 1994
sD PoMcY Ethical issues in p o s t - m e n o p a u s a l pregnancy
even s h o w n lying alone with a bottle h a n g i n g from its mouth, with no mention of the associated risks. In such cases, issues of commercial involvement in food aid p r o g r a m m e s arise. The UN High Commission for Refugees (UNHCR) has strict guidelines that discourage the use of breastmilk substitutes in e m e r g e n c y situations and clearly state that donations should not p r o m o t e any product. 1 Well-meaning but inexperienced relief agencies may be u n a w a r e of these guidelines and can b e c o m e an easy target for companies eag er to open up n ew markets. UNICEF, W H O and UNHCR will send breastfeeding experts into e m e r g e n c y situations to assist m o t h er s in p r o v i d i n g for their children. As a result, in Sarajevo, for example, the n u m b e r of mothers w h o are breastfeeding has risen from 20-30 per cent in 1987 to 60 p er cent in 1993. 2
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HIS p ap er is about the ethical issues surr o u n d i n g the successful extension of reproductive potential in w o m e n up to and b e y o n d the m e n o p a u s e t h r o u g h the use of d o n o r eggs, in vitro fertilisation and h o r m o n a l control of pregnancy. It concludes that chronological age alone is an insufficient criterion by w h i c h to evaluate the moral standing of pregnancy. A l t h o u g h some w o m e n will certainly w e lc o m e and want to use the technology that makes p o s t- m e n o p a u s a l p r e g n a n c y possible, Bettenhausen believes that the ability to start post-menopausal p r e g n a n c ie s calls for caution. She calls for f u r t h e r discussion a m o n g w o m e n of the c o n s e q u e n c e s of making sure w o m e n are never too old to have children and potentially of eliminating menopause, no matter h o w few w o m e n take a d v a n t a g e of this technology initially. 1
1. UNHCR Policy for acceptance, distribution and use of milk products in refugee feeding programmes. UNHCR/10M/88/89. 2. Bosnia baby food advert withdrawn. Baby Milk Action press release. Cambridge. 25 May 1994.
1. Bettenhausen E, 1994. Ethical issues in post-menopausal pregnancy and birth. Ethics IN~FIRE. 3(1):1-8.
Baby food for Bosnia and similar advertisements c o n d e m n e d In N o v e m b e r 1993 a small, n e w refugee relief agency made a national appeal for baby milk on a television p r o g r a m m e in Britain. Thousands of tins w e r e p u r c h a s e d by the public despite the fact that at the time, the agency had identified only 12 babies wh o might need tinned milk in one refugee camp in Croatia. In May 1994 a charity which delivers aid to Bosnia apologised for and decided to w i t h d r a w an advertisement following complaints about its d a m a g i n g and misleading portrayal of breastfeeding. The advertisement s h o w e d two m o t h er s breastfeeding healthy looking babies. The v o i c e - o v e r implied that the one child was h u n g r y and the other was unprotected against infection. People w e r e asked to donate £20 for a 'baby box' for Bosnia which was said to contain 30 essential items to keep a baby alive and healthy. The items included bottles, teats, baby milk and b r a n d e d baby foods, many of them highly sweetened. A baby was
British policy on donated ovarian tissue For some years n o w t h er e has been a shortage of d o n o r ova for infertility treatment in Britain. However, the British H u m a n Fertilisation and E m b r y o l o g y Authority ruled in July 1994, following a public consultation, that at this time ovarian tissue (ova) for infertility treatment could be used only from live donors, while the ova of w o m e n w h o had died and of aborted female fetuses could be used only for research purposes, for example, to create e m b r y o s for study. The publicity s u r r o u n d i n g the consultation helped to increase the n u m b e r of w o m e n coming f o r w a r d to offer to donate eggs for treatment, but has not succeeded in alleviating the shortage of eggs. Some w o m e n w h o volunteer change their minds w h e n they hear that they need to take fertility drugs to make m o r e than one eg g mature, and minor surgery to r e m o v e those eggs. Others are over age 35 and considered too old.
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The Authority hope that research on freezing of ova and on grafting of immature ovarian t i s s u e f r o m live d o n o r s will s u c c e e d - in t h e n o t t o o d i s t a n t f u t u r e - in i n c r e a s i n g t h e availability o f t i s s u e f o r t r e a t m e n t . In t h e m e a n t i m e , t h e r e is still a w a i t i n g list f o r t r e a t m e n t o f w o m e n w h o require donated eggs. 1 1. Donated Ovarian Tissue in Embryo Research & Assisted Conception: Report. Human Fertilisation &
Embryology Authority. London, July 1994.
Three lesbian couples given equal parental rights S i n c e 1991, u n d e r t h e C h i l d r e n A c t in Britain, three lesbian couples have been granted joint r e s i d e n c e o r d e r s , in e a c h c a s e m a k i n g t h e m equal parents with joint responsibility for the c h i l d ( t e n ) w h o , in e a c h case, w e r e b o r n to o n e of t h e w o m e n in t h e couple. 1 1. Dyer C, 1994. More lesbian parents win. Guardian. 6 July.
Indian court accepts daughter's right to continue pregnancy A 1 6 - y e a r - o l d s c h o o l g i r l in M a d r a s e l o p e d a n d married against her father's wishes and then b e c a m e p r e g n a n t . H e r f a t h e r w e n t to t h e H i g h C o u r t to t r y f o r a n o r d e r to t e r m i n a t e t h e p r e g n a n c y a n d filed c h a r g e s a g a i n s t t h e girl's husband for kidnapping and rape of a minor. The j u d g e d e c i d e d t h a t t h e girl h a d a r i g h t to c o n t i n u e her pregnancy and ruled against her father, causing tremendous controversy. 1 1. Santhanam J, Khanna A and Mohan S, 1994. The right to give birth? Eve's. January:20-22.
Obstetrician/gynaecologist charged in England A c o n s u l t a n t o b s t e t r i c i a n / g y n a e c o l o g i s t at a h o s pital in N o t t i n g h a m in E n g l a n d w a s s t a r t i n g a h y s t e r e c t o m y o p e r a t i o n f o r a 35 y e a r old w o m a n , to alleviate p a i n c a u s e d b y e n d o m e t r i o s i s , w h e n he suspected she was pregnant. With the ana e s t h e t i s t , h e d e c i d e d to c o m p l e t e t h e i n t e n d e d surgery. Afterwards, when the pregnancy was
confirmed, he wrote to her doctor that he had b e e n u n a b l e t o c o n t a c t h e r h u s b a n d at t h e t i m e to a s k w h a t h e r w i s h e s m i g h t be. It t u r n e d o u t t h a t she had been trying for years to get pregnant and had been told that she could never have children. S h e r e p o r t e d t h e c a s e to t h e police. T h e c o n s u l t a n t w a s c h a r g e d i n S e p t e m b e r 1994 w i t h c a r r y i n g o u t a n illegal a b o r t i o n , 1 a c h a r g e w h i c h could sidestep many of the ethical issues involved in t h e case, w h a t e v e r t h e o u t c o m e . 1. Dyer C, 1994. Removal of womb leads to charge. Guardian. 24 September.
Woman in Pakistan poisons three daughters Persistent nagging and taunts by her husband of n i n e y e a r s a n d h i s m o t h e r a n d f a t h e r , f o r h e r inability t o b e a r m a l e c h i l d r e n , led a 28 y e a r old w o m a n f r o m F a i s a l a b a d in P a k i s t a n to p o i s o n h e r t h r e e y o u n g d a u g h t e r s e a r l i e r this year. S h e said h e r h u s b a n d h a d also b e a t e n h e r occasionally. S h e h a d t r i e d to t a k e r e f u g e w i t h h e r o w n p a r e n t s s e v e r a l t i m e s b u t w a s f o r c e d b y t h e m to r e t u r n to h e r h u s b a n d . A c c o r d i n g to t h e j o u r n a l N a t i o n a l Health, it is i n e v i t a b l e t h a t t h e w o m a n will b e charged with murder, imprisoned and get capital p u n i s h m e n t a n d t h e l a w will look n o f u r t h e r at w h o is guilty. T h e y call o n t h e m e d i a , d o c t o r s a n d o t h e r s o u r c e s o f p u b l i c e d u c a t i o n to i n f o r m everyone that the genetic responsibility for the sex of o f f s p r i n g r e s t s solely w i t h t h e f a t h e r . 1 1. Focus: Reproductive Health (Editorial). National Health. April-June 1994: 31.
Medical negligence ruling considered unjust In a t w o m o n t h p e r i o d in 1986-87, a w o m a n w h o f e a r e d s h e w a s p r e g n a n t w e n t to a clinic five t i m e s f o r a p r e g n a n c y test. A t t h e first f o u r visits, doct o r s failed to d i a g n o s e p r e g n a n c y . A t t h e fifth visit, a b l o o d t e s t for p r e g n a n c y s h o w e d s h e w a s p r e g n a n t , b u t s h e w a s e r r o n e o u s l y told t h e t e s t w a s n e g a t i v e . It w a s o n l y at n e a r l y 20 w e e k s o f p r e g nancy that her GP confirmed her condition, and b y t h a t t i m e s h e c o u l d n o l o n g e r g e t a legal a b o r t i o n a n d w a s f o r c e d to h a v e t h e b a b y . S h e filed suit for medical negligence against the doctors. 116 I
Re pr oduc t i v e Health Matters, No 4, N o v e m b e r 1994
In April 1994, a N e w South W a l e s c o u r t in Australia r u l e d against her. It w o u l d a p p e a r that the j u d g e was m o r e c o n c e r n e d w i t h ruling on w h e t h e r h e r w i s h to h a v e an a b o r t i o n w a s legal or not, and as h e t h o u g h t it w a s not, t h e n she was not entitled to c o m p e n s a t i o n . 1. Medical negligence and the law on abortion in NSW. (Leaflet) Women's Abortion Action Campaign, Sydney, May 1994.
HIV testing, counselling and prophylaxis after sexual assault This article p r e s e n t s the p r o p o s a l s of the W o r k i n g G r o u p o n HIV Testing, C o u n s e l i n g , and Prophylaxis A f t e r Sexual Assault in the U S A for the d e v e l o p m e n t of policies a n d principles of clinical i n t e r v e n t i o n in the c a r e o f assault victims. It differs f r o m t h e existing l i t e r a t u r e in that it c o n c e n t r a t e s on q u e s t i o n s of m i t i g a t i n g h a r m to and benefiting t h e survivor, r a t h e r t h a n w h e t h e r it is justified to c o m p e l the p e r s o n a c c u s e d of assault to be tested. It finds ethical, public health, and legal justifications for a policy of limited c o m p u l s o r y HIV testing of p e r s o n s a c c u s e d of sexual assault b e c a u s e t h e r e could b e a beneficial effect on the m e n t a l health of s u r v i v o r s and their a d j u s t m e n t to the e x p e r i e n c e . 1 1. Gostin LO, Lazzarini Z, Alexander D et al, 1994. HIV testing, counseling, and prophylaxis after sexual assault. J A M A . 271(18):1436-44.
Use of drugs to suppress lactation not r e c o m m e n d e d The d r u g b r o m o c r i p t i n e (brand n a m e Parlodel) has c o m m o n l y b e e n u s e d to s u p p r e s s lactation after childbirth in m a n y countries. In the USA, since 1980 it w a s u s e d by o v e r 300,000 w o m e n p e r year. B e t w e e n 1980 and 1993 in t h e USA, 531 severe adverse reactions mostly hypertension, seizure and strokes, as well as 32 deaths, w e r e r e p o r t e d f o l l o w i n g its use. In 1988 the Public Citizen H e a l t h R e s e a r c h G r o u p p e t i t i o n e d the US F D A to b a n the use of d r u g s for lactation s u p p r e s s i o n . In mid-1989 the F D A ' s Fertility and M a t e r n a l H e a l t h D r u g s A d v i s o r y C o m m i t t e e r e c o m m e n d e d the withd r a w a l of t h e indication of p o s t p a r t u m lactation s u p p r e s s i o n for all drugs. Only Sandoz, the
m a n u f a c t u r e r of b r o m o c r i p t i n e , failed to comply. In 1993 and 1994, after f u r t h e r p r e s s u r e f r o m Public Citizen and t h e N a t i o n a l W o m e n ' s Health N e t w o r k , S a n d o z w i t h d r e w the i n d i c a t i o n in the U S A a n d C a n a d a . H o w e v e r , t h e y c o n t i n u e to m a r k e t the d r u g for lactation s u p p r e s s i o n in o t h e r countries. H e a l t h A c t i o n I n t e r n a t i o n a l h a v e called for w o r l d w i d e r e m o v a l of t h e indication. A c c o r d i n g to t h e FDA, lactation s u p p r e s s i o n can b e m a n a g e d effectively a n d m o r e safely using cold packs, c o m p r e s s i o n b a n d a g e s and pain m e d i c a t i o n , as n e e d e d . 1 1. Press Release, Health Action International Europe. 24 August 1994.
Education p r o g r a m m e against female genital mutilation in Egypt The E g y p t i a n M i n i s t e r o f Health c h a i r e d a highlevel m e e t i n g in O c t o b e r to launch a n a t i o n w i d e health e d u c a t i o n p r o g r a m m e to r e d u c e and e v e n t u a l l y eliminate f e m a l e genital mutilation. M o s q u e s and o t h e r p l a c e s of w o r s h i p , schools, public o r g a n i s a t i o n s a n d the m e d i a w e r e invited to j o i n an i n t e g r a t e d plan against the practice. A working group including ministry representatives and N G O s has b e e n set up to d e v i s e a l o n g - t e r m p r o g r a m m e plan. E g y p t ' s c u r r e n t legislation allows for a n y o n e w i t h o u t a m e d i c a l licence w h o c a r r i e s o u t the p!eocedure to be p r o s e c u t e d , until s u c h t i m e as a ban can be i n t r o d u c e d . It w a s t h o u g h t a p p r o p r i a t e to take steps to r e g u l a t e m a l e c i r c u m c i s i o n in a c c o r d a n c e w i t h s o u n d scientific m e t h o d s also. 1 1. Rich, V, 1994. Egypt against female circumcision. Lancet. 344(22 Oct): 1146.
W h e r e HIV prevention m o n e y is needed most N o r t h A m e r i c a n health c o n s u l t a n t s e s t i m a t e that only six p e r c e n t of g l o b a l f u n d i n g for the p r e v e n t i o n of HIV infection has b e e n s p e n t in the c o u n t r i e s w h e r e 80 p e r c e n t of p e o p l e with HIV live. 1 1. Prevention funding. A I D S N e w s l e t t e n 1994; 9(5~ 6):17. Original source: Hussain, FM et al, 1993. W e s t e r n Journal o f Medicine. 159(5):624-25. 117 I
sD PoMcY Ethical issues in p o s t - m e n o p a u s a l pregnancy
even s h o w n lying alone with a bottle h a n g i n g from its mouth, with no mention of the associated risks. In such cases, issues of commercial involvement in food aid p r o g r a m m e s arise. The UN High Commission for Refugees (UNHCR) has strict guidelines that discourage the use of breastmilk substitutes in e m e r g e n c y situations and clearly state that donations should not p r o m o t e any product. 1 Well-meaning but inexperienced relief agencies may be u n a w a r e of these guidelines and can b e c o m e an easy target for companies eag er to open up n ew markets. UNICEF, W H O and UNHCR will send breastfeeding experts into e m e r g e n c y situations to assist m o t h er s in p r o v i d i n g for their children. As a result, in Sarajevo, for example, the n u m b e r of mothers w h o are breastfeeding has risen from 20-30 per cent in 1987 to 60 p er cent in 1993. 2
~
HIS p ap er is about the ethical issues surr o u n d i n g the successful extension of reproductive potential in w o m e n up to and b e y o n d the m e n o p a u s e t h r o u g h the use of d o n o r eggs, in vitro fertilisation and h o r m o n a l control of pregnancy. It concludes that chronological age alone is an insufficient criterion by w h i c h to evaluate the moral standing of pregnancy. A l t h o u g h some w o m e n will certainly w e lc o m e and want to use the technology that makes p o s t- m e n o p a u s a l p r e g n a n c y possible, Bettenhausen believes that the ability to start post-menopausal p r e g n a n c ie s calls for caution. She calls for f u r t h e r discussion a m o n g w o m e n of the c o n s e q u e n c e s of making sure w o m e n are never too old to have children and potentially of eliminating menopause, no matter h o w few w o m e n take a d v a n t a g e of this technology initially. 1
1. UNHCR Policy for acceptance, distribution and use of milk products in refugee feeding programmes. UNHCR/10M/88/89. 2. Bosnia baby food advert withdrawn. Baby Milk Action press release. Cambridge. 25 May 1994.
1. Bettenhausen E, 1994. Ethical issues in post-menopausal pregnancy and birth. Ethics IN~FIRE. 3(1):1-8.
Baby food for Bosnia and similar advertisements c o n d e m n e d In N o v e m b e r 1993 a small, n e w refugee relief agency made a national appeal for baby milk on a television p r o g r a m m e in Britain. Thousands of tins w e r e p u r c h a s e d by the public despite the fact that at the time, the agency had identified only 12 babies wh o might need tinned milk in one refugee camp in Croatia. In May 1994 a charity which delivers aid to Bosnia apologised for and decided to w i t h d r a w an advertisement following complaints about its d a m a g i n g and misleading portrayal of breastfeeding. The advertisement s h o w e d two m o t h er s breastfeeding healthy looking babies. The v o i c e - o v e r implied that the one child was h u n g r y and the other was unprotected against infection. People w e r e asked to donate £20 for a 'baby box' for Bosnia which was said to contain 30 essential items to keep a baby alive and healthy. The items included bottles, teats, baby milk and b r a n d e d baby foods, many of them highly sweetened. A baby was
British policy on donated ovarian tissue For some years n o w t h er e has been a shortage of d o n o r ova for infertility treatment in Britain. However, the British H u m a n Fertilisation and E m b r y o l o g y Authority ruled in July 1994, following a public consultation, that at this time ovarian tissue (ova) for infertility treatment could be used only from live donors, while the ova of w o m e n w h o had died and of aborted female fetuses could be used only for research purposes, for example, to create e m b r y o s for study. The publicity s u r r o u n d i n g the consultation helped to increase the n u m b e r of w o m e n coming f o r w a r d to offer to donate eggs for treatment, but has not succeeded in alleviating the shortage of eggs. Some w o m e n w h o volunteer change their minds w h e n they hear that they need to take fertility drugs to make m o r e than one eg g mature, and minor surgery to r e m o v e those eggs. Others are over age 35 and considered too old.
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The Authority hope that research on freezing of ova and on grafting of immature ovarian t i s s u e f r o m live d o n o r s will s u c c e e d - in t h e n o t t o o d i s t a n t f u t u r e - in i n c r e a s i n g t h e availability o f t i s s u e f o r t r e a t m e n t . In t h e m e a n t i m e , t h e r e is still a w a i t i n g list f o r t r e a t m e n t o f w o m e n w h o require donated eggs. 1 1. Donated Ovarian Tissue in Embryo Research & Assisted Conception: Report. Human Fertilisation &
Embryology Authority. London, July 1994.
Three lesbian couples given equal parental rights S i n c e 1991, u n d e r t h e C h i l d r e n A c t in Britain, three lesbian couples have been granted joint r e s i d e n c e o r d e r s , in e a c h c a s e m a k i n g t h e m equal parents with joint responsibility for the c h i l d ( t e n ) w h o , in e a c h case, w e r e b o r n to o n e of t h e w o m e n in t h e couple. 1 1. Dyer C, 1994. More lesbian parents win. Guardian. 6 July.
Indian court accepts daughter's right to continue pregnancy A 1 6 - y e a r - o l d s c h o o l g i r l in M a d r a s e l o p e d a n d married against her father's wishes and then b e c a m e p r e g n a n t . H e r f a t h e r w e n t to t h e H i g h C o u r t to t r y f o r a n o r d e r to t e r m i n a t e t h e p r e g n a n c y a n d filed c h a r g e s a g a i n s t t h e girl's husband for kidnapping and rape of a minor. The j u d g e d e c i d e d t h a t t h e girl h a d a r i g h t to c o n t i n u e her pregnancy and ruled against her father, causing tremendous controversy. 1 1. Santhanam J, Khanna A and Mohan S, 1994. The right to give birth? Eve's. January:20-22.
Obstetrician/gynaecologist charged in England A c o n s u l t a n t o b s t e t r i c i a n / g y n a e c o l o g i s t at a h o s pital in N o t t i n g h a m in E n g l a n d w a s s t a r t i n g a h y s t e r e c t o m y o p e r a t i o n f o r a 35 y e a r old w o m a n , to alleviate p a i n c a u s e d b y e n d o m e t r i o s i s , w h e n he suspected she was pregnant. With the ana e s t h e t i s t , h e d e c i d e d to c o m p l e t e t h e i n t e n d e d surgery. Afterwards, when the pregnancy was
confirmed, he wrote to her doctor that he had b e e n u n a b l e t o c o n t a c t h e r h u s b a n d at t h e t i m e to a s k w h a t h e r w i s h e s m i g h t be. It t u r n e d o u t t h a t she had been trying for years to get pregnant and had been told that she could never have children. S h e r e p o r t e d t h e c a s e to t h e police. T h e c o n s u l t a n t w a s c h a r g e d i n S e p t e m b e r 1994 w i t h c a r r y i n g o u t a n illegal a b o r t i o n , 1 a c h a r g e w h i c h could sidestep many of the ethical issues involved in t h e case, w h a t e v e r t h e o u t c o m e . 1. Dyer C, 1994. Removal of womb leads to charge. Guardian. 24 September.
Woman in Pakistan poisons three daughters Persistent nagging and taunts by her husband of n i n e y e a r s a n d h i s m o t h e r a n d f a t h e r , f o r h e r inability t o b e a r m a l e c h i l d r e n , led a 28 y e a r old w o m a n f r o m F a i s a l a b a d in P a k i s t a n to p o i s o n h e r t h r e e y o u n g d a u g h t e r s e a r l i e r this year. S h e said h e r h u s b a n d h a d also b e a t e n h e r occasionally. S h e h a d t r i e d to t a k e r e f u g e w i t h h e r o w n p a r e n t s s e v e r a l t i m e s b u t w a s f o r c e d b y t h e m to r e t u r n to h e r h u s b a n d . A c c o r d i n g to t h e j o u r n a l N a t i o n a l Health, it is i n e v i t a b l e t h a t t h e w o m a n will b e charged with murder, imprisoned and get capital p u n i s h m e n t a n d t h e l a w will look n o f u r t h e r at w h o is guilty. T h e y call o n t h e m e d i a , d o c t o r s a n d o t h e r s o u r c e s o f p u b l i c e d u c a t i o n to i n f o r m everyone that the genetic responsibility for the sex of o f f s p r i n g r e s t s solely w i t h t h e f a t h e r . 1 1. Focus: Reproductive Health (Editorial). National Health. April-June 1994: 31.
Medical negligence ruling considered unjust In a t w o m o n t h p e r i o d in 1986-87, a w o m a n w h o f e a r e d s h e w a s p r e g n a n t w e n t to a clinic five t i m e s f o r a p r e g n a n c y test. A t t h e first f o u r visits, doct o r s failed to d i a g n o s e p r e g n a n c y . A t t h e fifth visit, a b l o o d t e s t for p r e g n a n c y s h o w e d s h e w a s p r e g n a n t , b u t s h e w a s e r r o n e o u s l y told t h e t e s t w a s n e g a t i v e . It w a s o n l y at n e a r l y 20 w e e k s o f p r e g nancy that her GP confirmed her condition, and b y t h a t t i m e s h e c o u l d n o l o n g e r g e t a legal a b o r t i o n a n d w a s f o r c e d to h a v e t h e b a b y . S h e filed suit for medical negligence against the doctors. 116 I
Re pr oduc t i v e Health Matters, No 4, N o v e m b e r 1994
In April 1994, a N e w South W a l e s c o u r t in Australia r u l e d against her. It w o u l d a p p e a r that the j u d g e was m o r e c o n c e r n e d w i t h ruling on w h e t h e r h e r w i s h to h a v e an a b o r t i o n w a s legal or not, and as h e t h o u g h t it w a s not, t h e n she was not entitled to c o m p e n s a t i o n . 1. Medical negligence and the law on abortion in NSW. (Leaflet) Women's Abortion Action Campaign, Sydney, May 1994.
HIV testing, counselling and prophylaxis after sexual assault This article p r e s e n t s the p r o p o s a l s of the W o r k i n g G r o u p o n HIV Testing, C o u n s e l i n g , and Prophylaxis A f t e r Sexual Assault in the U S A for the d e v e l o p m e n t of policies a n d principles of clinical i n t e r v e n t i o n in the c a r e o f assault victims. It differs f r o m t h e existing l i t e r a t u r e in that it c o n c e n t r a t e s on q u e s t i o n s of m i t i g a t i n g h a r m to and benefiting t h e survivor, r a t h e r t h a n w h e t h e r it is justified to c o m p e l the p e r s o n a c c u s e d of assault to be tested. It finds ethical, public health, and legal justifications for a policy of limited c o m p u l s o r y HIV testing of p e r s o n s a c c u s e d of sexual assault b e c a u s e t h e r e could b e a beneficial effect on the m e n t a l health of s u r v i v o r s and their a d j u s t m e n t to the e x p e r i e n c e . 1 1. Gostin LO, Lazzarini Z, Alexander D et al, 1994. HIV testing, counseling, and prophylaxis after sexual assault. J A M A . 271(18):1436-44.
Use of drugs to suppress lactation not r e c o m m e n d e d The d r u g b r o m o c r i p t i n e (brand n a m e Parlodel) has c o m m o n l y b e e n u s e d to s u p p r e s s lactation after childbirth in m a n y countries. In the USA, since 1980 it w a s u s e d by o v e r 300,000 w o m e n p e r year. B e t w e e n 1980 and 1993 in t h e USA, 531 severe adverse reactions mostly hypertension, seizure and strokes, as well as 32 deaths, w e r e r e p o r t e d f o l l o w i n g its use. In 1988 the Public Citizen H e a l t h R e s e a r c h G r o u p p e t i t i o n e d the US F D A to b a n the use of d r u g s for lactation s u p p r e s s i o n . In mid-1989 the F D A ' s Fertility and M a t e r n a l H e a l t h D r u g s A d v i s o r y C o m m i t t e e r e c o m m e n d e d the withd r a w a l of t h e indication of p o s t p a r t u m lactation s u p p r e s s i o n for all drugs. Only Sandoz, the
m a n u f a c t u r e r of b r o m o c r i p t i n e , failed to comply. In 1993 and 1994, after f u r t h e r p r e s s u r e f r o m Public Citizen and t h e N a t i o n a l W o m e n ' s Health N e t w o r k , S a n d o z w i t h d r e w the i n d i c a t i o n in the U S A a n d C a n a d a . H o w e v e r , t h e y c o n t i n u e to m a r k e t the d r u g for lactation s u p p r e s s i o n in o t h e r countries. H e a l t h A c t i o n I n t e r n a t i o n a l h a v e called for w o r l d w i d e r e m o v a l of t h e indication. A c c o r d i n g to t h e FDA, lactation s u p p r e s s i o n can b e m a n a g e d effectively a n d m o r e safely using cold packs, c o m p r e s s i o n b a n d a g e s and pain m e d i c a t i o n , as n e e d e d . 1 1. Press Release, Health Action International Europe. 24 August 1994.
Education p r o g r a m m e against female genital mutilation in Egypt The E g y p t i a n M i n i s t e r o f Health c h a i r e d a highlevel m e e t i n g in O c t o b e r to launch a n a t i o n w i d e health e d u c a t i o n p r o g r a m m e to r e d u c e and e v e n t u a l l y eliminate f e m a l e genital mutilation. M o s q u e s and o t h e r p l a c e s of w o r s h i p , schools, public o r g a n i s a t i o n s a n d the m e d i a w e r e invited to j o i n an i n t e g r a t e d plan against the practice. A working group including ministry representatives and N G O s has b e e n set up to d e v i s e a l o n g - t e r m p r o g r a m m e plan. E g y p t ' s c u r r e n t legislation allows for a n y o n e w i t h o u t a m e d i c a l licence w h o c a r r i e s o u t the p!eocedure to be p r o s e c u t e d , until s u c h t i m e as a ban can be i n t r o d u c e d . It w a s t h o u g h t a p p r o p r i a t e to take steps to r e g u l a t e m a l e c i r c u m c i s i o n in a c c o r d a n c e w i t h s o u n d scientific m e t h o d s also. 1 1. Rich, V, 1994. Egypt against female circumcision. Lancet. 344(22 Oct): 1146.
W h e r e HIV prevention m o n e y is needed most N o r t h A m e r i c a n health c o n s u l t a n t s e s t i m a t e that only six p e r c e n t of g l o b a l f u n d i n g for the p r e v e n t i o n of HIV infection has b e e n s p e n t in the c o u n t r i e s w h e r e 80 p e r c e n t of p e o p l e with HIV live. 1 1. Prevention funding. A I D S N e w s l e t t e n 1994; 9(5~ 6):17. Original source: Hussain, FM et al, 1993. W e s t e r n Journal o f Medicine. 159(5):624-25. 117 I