- Email: [email protected]
United States
940
developments of existing aspects of Cuban life. The new purpose-built housing will be the ground level of "microbrigade" others are
blocks-self built homes which workers can choose to erect instead of doing their regular work as long as their colleagues agree to cover for them at work and output does not fall. The ground floors of these blocks will be constructed for use by the elderly, with shared laundry and dining facilities but private rooms for around 40 people who will generally be cared for under the supervision of the committees for the Defence of the Revolution. Some existing blocks will be converted. The network of day centres-Casas de los Abuelos or houses of the grandparents-is the extension of a pilot project which has already established 10 such centres in Cuba. They are large houses which have been taken over for the social and minor medical needs of the neighbourhood’s elderly. Around 60 people can attend on weekdays with a half day on Saturdays to meet friends, play dominoes, read, and benefit from visiting entertainers. Other plans for the elderly in Cuba include giving a 30 peso a month bonus to nurses who work with psychogeriatric patients, setting up at least one geriatric hospital, and designating the third Sunday of every month as the Day of the Homes of the Elderly when special community support should be forthcoming. Mednel, 18 St Ann’s Road, London W 11 4SR
1. Ubell RN.
JAD ADAMS
High-tech
medicine
in
the Caribbean: 25 years of Cuban health
care.
N Engl J Med 1983; 309: 1468-72. 2 Werner D. Health care in Cuba: A model service or a means of social control or both? In:
Morley D, Rohde J, Williams G, eds. Practising health for all. Oxford: Oxford University Press, 1983. 3. Oliva M. Old age can be enjoyable Gramma (weekly review). Dec 9, 1984: 12. Havana. 4. Perez EA, Macfadyen DM. Report of WHO/PAHO mission to Cuba on technical cooperation in health of the elderly March 25-30 1984. Copenhagen. WHO, 1984. 5. Adams J, Shenton J. The time bomb of old age. Who cares series, Channel 4. May, 31 1985. 6. Asamblea Nacional Sobre
del Poder Popular—Estudio la
al Anciano 3. Government
West
Atencion Institucional:
of Cuba, 1984.
Germany ETHICAL ISSUES IN GYNAECOLOGY AND OBSTETRICS
THE German
formed
Society for Gynaecology and Obstetrics, which was
a century ago, acted as host in West Berlin last month to the 1 lath World Congress on Gynaecology and Obstetrics. In his opening address, Prof Klaus Thomsen questioned whether, in attempts to prolong life and to develop new techniques, we had strayed too far from the principles of humanity which should govern the practice of medicine. In particular the use of aggressive treatment in advanced malignant disease must be reassessed. Was it justified to continue the treatment of hopelessly ill patients with new and increasingly aggressive combinations of cytotoxic agents until death came? If highly sophisticated and expensive treatments could merely postpone death for a few days or weeks during which the patient lived nothing but a miserable life, such treatment had to be called an act of inhumanity. One of the themes which attracted much attention was that of "the fetus, our patient". Prof John Hobbins (Yale) discussed the issues which arose when a fetus was obviously abnormal. Using hydramnios as an example, he pointed out that, despite the clear physical abnormality, normal or even superior intelligence was a possible outcome. The consequences of hydramnios could depend more on the aetiology of the condition than on the extent of the damage. For example, in obstructive nephropathy, intrauterine surgery or delivery and immediate operation was possible. But in such conditions as anencephaly or trisomy 18, Professor Hobbins thought that termination was often advisable, though only when diagnostic procedures showed that the defects were incompatible with survival. In order to identify such defects, advanced scanning techniques were required, although present anxiety about the safety of ultrasound was not conducive to the development of this work. Prof Charles Martin (Wisconsin) reported that his studies had shown that it was now possible to identify a fetus in which hypoxia, growth
exactly
retardation, and other defects were affecting general development. He had used in combination a tocograph and two scanners, one to detect facial movement and one body movement. Pregnant women in his centre were observed for a period of two hours at intervals of two weeks during late pregnancy. Also supporting the case for scanning, Prof Stuart Campbell (King’s College Hospital, London) described how he used a combination of ultrasound, Doppler-shift analysis of blood flow in the fetal arteries and in the arcuate arteries of the placenta, and imaging and computer analysis to determine with considerable accuracy the condition of the fetus. He was particularly concerned to monitor the end-diastole velocity of blood flow through the easily located arteries, since a decrease had been shown to be linked with a higher rate of caesarean section and a lower Apgar score. Using this technique Professor Campbell was able to predict at 17 weeks which babies were at risk, and, as a result, stillbirths in his unit were rare. He predicted that in future end-diastole velocity would come to be seen as the most crucial factor in the assessment of the wellbeing of the fetus. Another area of lively discussion concerned the manipulation of in-vitro human embryos. Professor Thomsen posed the difficult questions. What should happen to the surplus of embryos not required for transfer? Should they be destroyed, or used for medical experiments? Indeed, whose property were they? In his view, embryos were in a legal vacuum, although he concluded that legal provisions alone would not overcome all the difficulties. Dr Robert Edwards (Cambridge, UK) pointed out that six European Parliaments were now debating the legal and ethical implications of embryo use. He believed there was an urgent need for continued research on embryos; and he emphasised the value of work on embryo metabolism, which, in his view, could be done without harm by examining the surrounding medium. As a result of work already done it had been possible to reduce pyruvate levels in the medium by one-third, and probably increase the survival rate. Dr Edwards said that two infants with Down’s syndrome had been born after in-vitro fertilisation. He wondered whether handling the oocyte wrongly could cause trisomy. Trisomy must be investigated in long-term research, including also other genetic analyses, post-implantation assessment, and the possible use of embryo material for grafting in the treatment of adult diseases. Although only mouse studies were so far being conducted, Dr Edwards hoped that the potential for grafting embryonic haemopoetic tissue in the treatment of leukaemia might-reduce the need for tissue typing and avoid risk and inconvenience to donors.
United States TOO FEW POSTMORTEM EXAMINATIONS?
THE Institute of Medicine is concerned about the decline in the number of necropsies performed; since 1945 the number has dropped from 50% of all deaths to 14%, and over half those performed are on infants and children. For deaths over 70 the rate has dropped to about 5%. Pathologists speak of the many occasions when the necropsy findings are at variance with clinical diagnosis or when additional lesions are found, and of the large proportion of necropsies which are significant to patient care. This decline has been accentuated by the reluctance of clinicians to seek permission for necropsy, by fears of malpractice ("it is better to bury mistakes promptly"), or by a belief that with all the modern techniques available their diagnoses are invariably complete and exact. Additional factors are the increasing expense and the fact that hospitals can be accredited without the performance of a certain percentage of necropsies. There is also the boredom factor: with the decline in many infectious diseases, the commonplaces of necropsy practice are cancer, heart disease, and stroke. In fact, more (and more thorough) necropsies would provide evidence on the effects of new drugs, on iatrogenic disease, and on new diagnostic methods. Indeed, some would argue, forensic necropsies have become more interesting-and needed (since many homicides may go undetected).
developments of existing aspects of Cuban life. The new purpose-built housing will be the ground level of "microbrigade" others are
blocks-self built homes which workers can choose to erect instead of doing their regular work as long as their colleagues agree to cover for them at work and output does not fall. The ground floors of these blocks will be constructed for use by the elderly, with shared laundry and dining facilities but private rooms for around 40 people who will generally be cared for under the supervision of the committees for the Defence of the Revolution. Some existing blocks will be converted. The network of day centres-Casas de los Abuelos or houses of the grandparents-is the extension of a pilot project which has already established 10 such centres in Cuba. They are large houses which have been taken over for the social and minor medical needs of the neighbourhood’s elderly. Around 60 people can attend on weekdays with a half day on Saturdays to meet friends, play dominoes, read, and benefit from visiting entertainers. Other plans for the elderly in Cuba include giving a 30 peso a month bonus to nurses who work with psychogeriatric patients, setting up at least one geriatric hospital, and designating the third Sunday of every month as the Day of the Homes of the Elderly when special community support should be forthcoming. Mednel, 18 St Ann’s Road, London W 11 4SR
1. Ubell RN.
JAD ADAMS
High-tech
medicine
in
the Caribbean: 25 years of Cuban health
care.
N Engl J Med 1983; 309: 1468-72. 2 Werner D. Health care in Cuba: A model service or a means of social control or both? In:
Morley D, Rohde J, Williams G, eds. Practising health for all. Oxford: Oxford University Press, 1983. 3. Oliva M. Old age can be enjoyable Gramma (weekly review). Dec 9, 1984: 12. Havana. 4. Perez EA, Macfadyen DM. Report of WHO/PAHO mission to Cuba on technical cooperation in health of the elderly March 25-30 1984. Copenhagen. WHO, 1984. 5. Adams J, Shenton J. The time bomb of old age. Who cares series, Channel 4. May, 31 1985. 6. Asamblea Nacional Sobre
del Poder Popular—Estudio la
al Anciano 3. Government
West
Atencion Institucional:
of Cuba, 1984.
Germany ETHICAL ISSUES IN GYNAECOLOGY AND OBSTETRICS
THE German
formed
Society for Gynaecology and Obstetrics, which was
a century ago, acted as host in West Berlin last month to the 1 lath World Congress on Gynaecology and Obstetrics. In his opening address, Prof Klaus Thomsen questioned whether, in attempts to prolong life and to develop new techniques, we had strayed too far from the principles of humanity which should govern the practice of medicine. In particular the use of aggressive treatment in advanced malignant disease must be reassessed. Was it justified to continue the treatment of hopelessly ill patients with new and increasingly aggressive combinations of cytotoxic agents until death came? If highly sophisticated and expensive treatments could merely postpone death for a few days or weeks during which the patient lived nothing but a miserable life, such treatment had to be called an act of inhumanity. One of the themes which attracted much attention was that of "the fetus, our patient". Prof John Hobbins (Yale) discussed the issues which arose when a fetus was obviously abnormal. Using hydramnios as an example, he pointed out that, despite the clear physical abnormality, normal or even superior intelligence was a possible outcome. The consequences of hydramnios could depend more on the aetiology of the condition than on the extent of the damage. For example, in obstructive nephropathy, intrauterine surgery or delivery and immediate operation was possible. But in such conditions as anencephaly or trisomy 18, Professor Hobbins thought that termination was often advisable, though only when diagnostic procedures showed that the defects were incompatible with survival. In order to identify such defects, advanced scanning techniques were required, although present anxiety about the safety of ultrasound was not conducive to the development of this work. Prof Charles Martin (Wisconsin) reported that his studies had shown that it was now possible to identify a fetus in which hypoxia, growth
exactly
retardation, and other defects were affecting general development. He had used in combination a tocograph and two scanners, one to detect facial movement and one body movement. Pregnant women in his centre were observed for a period of two hours at intervals of two weeks during late pregnancy. Also supporting the case for scanning, Prof Stuart Campbell (King’s College Hospital, London) described how he used a combination of ultrasound, Doppler-shift analysis of blood flow in the fetal arteries and in the arcuate arteries of the placenta, and imaging and computer analysis to determine with considerable accuracy the condition of the fetus. He was particularly concerned to monitor the end-diastole velocity of blood flow through the easily located arteries, since a decrease had been shown to be linked with a higher rate of caesarean section and a lower Apgar score. Using this technique Professor Campbell was able to predict at 17 weeks which babies were at risk, and, as a result, stillbirths in his unit were rare. He predicted that in future end-diastole velocity would come to be seen as the most crucial factor in the assessment of the wellbeing of the fetus. Another area of lively discussion concerned the manipulation of in-vitro human embryos. Professor Thomsen posed the difficult questions. What should happen to the surplus of embryos not required for transfer? Should they be destroyed, or used for medical experiments? Indeed, whose property were they? In his view, embryos were in a legal vacuum, although he concluded that legal provisions alone would not overcome all the difficulties. Dr Robert Edwards (Cambridge, UK) pointed out that six European Parliaments were now debating the legal and ethical implications of embryo use. He believed there was an urgent need for continued research on embryos; and he emphasised the value of work on embryo metabolism, which, in his view, could be done without harm by examining the surrounding medium. As a result of work already done it had been possible to reduce pyruvate levels in the medium by one-third, and probably increase the survival rate. Dr Edwards said that two infants with Down’s syndrome had been born after in-vitro fertilisation. He wondered whether handling the oocyte wrongly could cause trisomy. Trisomy must be investigated in long-term research, including also other genetic analyses, post-implantation assessment, and the possible use of embryo material for grafting in the treatment of adult diseases. Although only mouse studies were so far being conducted, Dr Edwards hoped that the potential for grafting embryonic haemopoetic tissue in the treatment of leukaemia might-reduce the need for tissue typing and avoid risk and inconvenience to donors.
United States TOO FEW POSTMORTEM EXAMINATIONS?
THE Institute of Medicine is concerned about the decline in the number of necropsies performed; since 1945 the number has dropped from 50% of all deaths to 14%, and over half those performed are on infants and children. For deaths over 70 the rate has dropped to about 5%. Pathologists speak of the many occasions when the necropsy findings are at variance with clinical diagnosis or when additional lesions are found, and of the large proportion of necropsies which are significant to patient care. This decline has been accentuated by the reluctance of clinicians to seek permission for necropsy, by fears of malpractice ("it is better to bury mistakes promptly"), or by a belief that with all the modern techniques available their diagnoses are invariably complete and exact. Additional factors are the increasing expense and the fact that hospitals can be accredited without the performance of a certain percentage of necropsies. There is also the boredom factor: with the decline in many infectious diseases, the commonplaces of necropsy practice are cancer, heart disease, and stroke. In fact, more (and more thorough) necropsies would provide evidence on the effects of new drugs, on iatrogenic disease, and on new diagnostic methods. Indeed, some would argue, forensic necropsies have become more interesting-and needed (since many homicides may go undetected).