The NHS Reverse

1406 CFU-GM IN PATIENTS TREATED WITH GM-CSF FOR

(GROUP 1)

OR

21

DAYS

(GROUP 2)

AFTER

14 AND 21

14 DAYS DAYS OF

THERAPY

*Group I vs group II, Wilcoxon rank sum test. PB peripheral blood. =

Twenty-eight patients with lymphoid malignancy were treated with GM-CSF (15-240 J.lgfm2 daily) by 2-h intravenous infusion for 14 (group I) or 21 days (group II) after autologous (twenty-seven patients) or syngeneic (1 patient) marrow infusion in phase I-II trials.4,5 Peripheral blood samples were obtained in nineteen patients (ten in group 1; nine in group II) for CFU-GM analysis. 2 x 105 peripheral blood cells/ml were plated in triplicate in Iscoves medium containing 1-25% methycellulose, 10% fetal calf serum, 1% deionised bovine serum albumin, and 10-6 mol/1 2T-cell mercaptoethanol. Phytohaemagglutinin-stimulated condition medium was used as a source of colony stimulating

Commentary from Westminster The NHS Reverse THE Bill that will introduce the biggest changes to the National Health Service since it was launched 40 years ago has begun its passage through Parliament. The aim is to turn the present integrated system of health provision into a competing market in which GPs, hospitals, and health authorities will be expected to both buy and provide services. Even when the Bill has completed its passage, the battles will not be over. Ministers are not like old-fashioned signalmen-able to pull down one lever and watch the signals change right down the railway line. Several big concessions have been made since the white-paper was published ten months ago. But, faced with a hostile and almost united medical opposition, ministers and managers will have to spend many months in negotiations with the doctors even after the Bill becomes an Act. Ministers have tried to marginalise the opposition of the doctors by pointing to the British Medical Association’s opposition to the original NHS proposals. But that is misleading. True, the majority of the profession disliked the 1944 white-paper, but that initial opposition stemmed from unpalatable but by no means crucial administrative proposals. On the main issues there was overwhelming support in 1944. Take just four key proposals-a free comprehensive service (60% to 37% in favour); group practices in health centres (68 to 24); a central board to keep doctors out of over-doctored areas (57 to 39); abolition of the sale of practices (56 to 33). True, there were two further polls in 1948, just before the start of the NHS, where more opposition was registered but the historians have suggested that once again this was not antagonism to fundamental principles but to the risk at that time of GPs being made full-time salaried employees, resentment of the strong-arm tactics of the health minister, Aneurin Bevan, and the fact

40 cells were counted after 14 days of incubation. The results are shown in the table. The mean white blood cell count (WBC) and bone marrow (BM) cellularity at day 14 did not differ between the groups (group I: WBC = 1 ’2 [SD 05] x 103/pl, BM cellularity = 12 [5]%; group II: WBC= 1 0 [1’0] x 103/al, BM cellularity = 11 [5]%). These data suggest that patients who receive GM-CSF from day 0 to 21 after BMT have fewer circulating CFU-GM 21 days after BMT compared with those who receive GM-CSF from days 0 to 14. This fmding may be related to temporary down modulation of GM-CSF receptors and/or temporary depletion of the progenitor cell pool targeted by GM-CSF.

activity. Colonies of over

Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98104, USA

JOHN NEMUNAITIS FREDERICK APPELBAUM

JACK SINGER

Thompson J, Lee DJ, Kidd P, et al. Subcutaneous granulocyte-macrophage colony-stimulating factor in patients with myelodysplastic syndrome: toxicity, pharmacokinetics, and hematological effects. J Clin Oncol 1989; 7: 629-37. 2. Walker F, Nicola NA, Metcalf D, Burgess AW, Hierarchical down-modulation of hemopoietic growth factor receptors. Cell 1985; 43: 269-76. 3. Metcalf D, Begley CG, Williamson DJ, et al. Hematopoietic responses in mice injected with purified recombinant murine GM-CSF. Exp Hematol 1987; 15: 1-9. 4. Nemunaitis J, Singer JW, Buckner CD, et al. The use of recombinant human granulocyte macrophage colony stimulating factor (rhGM-CSF) m autologous marrow transplantation for lymphoid malignancies. Blood 1988; 72: 834-36. 5. Nemunaitis J, Singer JW, Buckner CD, et al. Use of recombinant granulocyte macrophage colony stimulating factor (rhGM-CSF) in autologous marrow transplantation for lymphoid malignancies. In. Dickey KA, ed. Proceedings of the third international symposium. Houston: University of Texas, 1988: 631-36 1.

that a Labour Government was perceived as more partisan than the Coalition Government that produced the first

white-paper. Compare then, this underlying medical support of 40 years ago with the almost united opposition of the medical world against the key issues in this year’s package-GP drug budgets, opted-out hospitals, and tax concessions to the elderly for private health insurance. Some 800 motions were submitted to the BMA’s special representative meeting in May. Almost every one was hostile to the Government. Lapsed members have been rejoining the BMA in their hundreds. Compare too, the differences in public opinion. Forty years ago the NHS proposals were widely supported. The only doubts in 1944 were about the vested interests, such as the insurance companies, who many thought would whittle away the free service. Compare this with the 71 % who were opposed to the Government’s plan in June, or the even larger 73% recorded in August. The public are deeply suspicious about the Government’s motives: 75% believe the proposals will result in service cuts; 67% believe they will mean cheaper rather than better service; 70% believe the GP drug budgets will be too small; 69% believe elderly people will have more difficulty obtaining treatment. Belatedly, the Bill does make a few concessions: the Health Secretary will have powers to intervene in any opted-out hospital that tries to reduce medical education or research; cash limits will not be imposed on regional health authority drug budgets as the white-paper originally proposed (logically, therefore there should not be cash limits imposed on GP drug budgets but some believe the Government is trying to bring this through the back door with the Bill’s regulations controlling family practitioner committees); and health authorities that want to buy the services of an opted-out hospital in another district will not place the contract with the authority in which the hospital is situated. The biggest concession, of course, has been the slowdown in the introduction of the changes-the Government

1407

other choice because the original deadlines just But what remains is a Bill that will still do far than harm more good: there will be no proper consultation about opting out; there are no clear guidelines on the core services that opted-out hospitals will have to offer their local community, a formerly integrated health service will be fragmented and turned into a two-tier system. Administrative costs, which at 4-5% of total expenditure were the cheapest in the world, will have to soar. The biggest absurdity of all is that the Government will be introducing a market system without a proper pricing mechanism. But ministers have belatedly conceded that individual hospitals will be unable to work out their individual costs. Instead,

has

no

cannot be met.

Jehovah’s Witness Transfused without Consent: Canadian

MALCOLM DEAN

time were better placed to decide whether blood was required. The experts called by the patient were specialists in surgery without blood transfusion but that was not an appropriate standard against which to judge the casualty officer.

Medicine and the Law

a

there will be a national tariff. Ministers dislike the term but that is what they are going to have to settle for. What the Bill will do is to restore several of the more serious defects that the NHS was designed to eliminateuncoordinated planning (because the opted-out hospitals will be self-governing); fragmented and unintegrated provision (because of the independent status granted to hospitals); and inequitable distribution of services (because money rather than need will be the main yardstick by which services are bought). Opponents must now aim for damagelimitation. There have already been some concessions. A spirited fight in Parliament could produce some more.

case

LAST year the Ontario High Court held a doctor liable in for giving an unconscious patient a life-saving blood transfusion. The patient carried a card stating that she was a Jehovah’s Witness and the doctor saw the card before deciding to give her blood. The court held that though the doctor had acted promptly and professionally he was guilty of battery. The patient was awarded$Can 20 000 for "mental distress".1 No allowance seems to have been made by the Canadian Court for the priceless gift to the patient of her life.

damages

BACKGROUND

The plaintiff, a 57-year-old woman, had been a passenger in a car involved in a traffic accident. She was taken to Kirkland and District Hospital, where the casualty officer found her semiconscious with severe facial lacerations and profuse haemorrhage of bright red blood from nose and mouth; she was cold and perspiring and internal injuries were indicated by the blood pressure and pulse rate. Intravenous glucose was administered followed by Ringer’s lactate. In the patient’s handbag a nurse found an undated card in French which (translated) said: "NO BLOOD TRANSFUSION! As one of Jehovah’s witnesses with firm religious convictions, I request that no blood or other blood products be administered to me under any circumstances. I fully realise the implications of this position, but I have resolutely decided to obey the Bible command: ’Keep abstaining ... from blood’ (Acts15:28, 29). However, I have no religious objection to use of the nonblood alternatives, such as Dextran, Haemaccel, PVP, Ringer’s lactate or saline solution." The issue was considered by the hospital executive director and other doctors, including the casualty officer, whose decision it was. When the patient’s systolic blood pressure fell to 50 mm Hg or less,

accompanied by depressed respiration and worsening consciousness, the doctor decided to administer blood, and he gave the transfusion himself. When the patient’s daughter arrived she objected. She signed a consent-to-treatment form along with a release of liability, which specifically prohibited blood transfusions, but the doctor took the view that, ethically, he was bound to continue the transfusions. The patient was discharged from hospital 6 weeks later and sued the casualty officer for negligence, in that by the time she reached hospital the bleeding had largely stopped and a transfusion was unnecessary, and for battery. The judge accepted the plea of battery but rejected the allegation of negligence. He said that the doctors attending the patient at the

OBJECTING TO TREATMENT Under English law, the effect of a close relative objecting to treatment is only effective as evidence of what would have been likely to have been the patient’s wish. The patient’s daughter confirmed what the hospital already knew-that the patient would have objected to a blood transfusion. In such circumstances an English court would probably be driven to find the treatment a battery, though it is likely that only nominal damages would be awarded. Though some analogy may be drawn from the medicolegal attitude towards resuscitation in attempted suicide, there are differences. With the Suicide Act 1961 it ceased to be a criminal offence to commit suicide, but to aid and abet remains an offence. Furthermore, it is well recognised that many suicide attempts are attention-seeking actions by people whose balance of mind is disturbed. However, when the patient is old and has a serious, incurable, or terminal condition the doctor may be less likely to intervene. Though the Canadian patient’s reaction seems ungrateful and the court’s award too high, this case demonstrates how doctors must respect their patients’ wishes, provided they are in a fit state to make those wishes plain or have indicated them in advance. Doctors must not substitute their decision for that of the patient’s validly made, even if they disapprove. However, where the patient is under 18 and incapable of making such a decision and the parents refuse life-saving emergency treatment it is to be hoped that the doctor would feel empowered and indeed under a duty to act, to try to save the child’s life. The general principles regarding consent to medical treatment under English law were analysed, albeit under very different circumstances, in the case of F, a mentally handicapped adult.2 A doctor cannot lawfully operate on adult patients of sound mind or give any other treatment involving physical force (however minor) without consent. If he does he commits trespass on that person. There are exceptions-for example, where a patient is unconscious and an operation cannot be safely delayed until consciouness returns or where an adult lacks the mental capacity to understand the nature or purpose of the treatment. As Lord Brandon pointed out in F it is necessary in such circumstances for some other person, with appropriate 2. In re F (mental patient:

1. Malette v Shulman and others

[1988] 47 DLR 18;

see

Health Law Letter 1989;

no

1.

sterilisation) [1989] 2 WLR 1025; see Brahams D. of mentally handicapped woman. Lancet 1989, i: 1275-76.

Sterilisation