- Email: [email protected]
VOLUNTARY EUTHANASIA
691 his senior lecturer, Mrs Savage. He gave no indication here of any such intention. I had long discussions with him, just before and after he took up his appointment, about the academic unit and the Tower Hamlets NHS department of obstetrics and gynaecology. We talked about the many problems confronting such university units, especially one serving two medical schools. Professor Grudzinskas expressed no desire to be rid of Mrs Savage and was confident they would work well together. He later had long discussions about the unit with Sir John Ellis, a previous dean who had been closely involved in establishing the unit jointly with St Bartholomew’s Hospital Medical College. Again, he made no mention of Mrs Savage, and, when asked, said that the staff were working well together and that he hoped to provide her with the greater opportunities for research she was seeking. It has also been alleged that Professor Grudzinskas spoke disparagingly in public about Mrs Savage’s professional competence. The only occasion that I can recall when he commented publicly on her competence was during his evidence to the Beaumont inquiry; he asked on several occasions to be allowed to give evidence in private but the chairman insisted that the inquiry remain public. I am not aware of any specific allegation as to when or to whom Professor Grudzinskas made such remarks publicly. This college expresses its confidence in Professor Grudzinskas’ integrity and in his clinical and academic excellence. The achievements of the department and academic unit were noted in a letter in your columns last week (p 633). The college also expects that, despite the recent problems, Mrs Savage will, after her return, continue to make an important contribution both clinically and
academically. A panel chaired by Dame Alison Munro has been asked by the district health authority to advise us on the organisation of obstetric and gynaecological services. We will do all we can to help her team in this difficult task. Passions have been high of late and there are many wounds to heal. It would help if everybody-medical colleagues, journalists, and others, most of whom know little about the complex problems of the obstetrics department in this hospital, which go back many years-would refrain from comment in the press or on radio and television until Dame Alison’s work is done. London Hospital Medical London El 2AD
M. A. FLOYER,
College,
Dean
VOLUNTARY EUTHANASIA
SIR,—Having just finished a review of the public discussion in Holland on the need for new legislation on voluntary euthanasia,1 I was very interested in Dr Brewin’s comments (May 10, p 1085). The statement that the "administration of euthanasia in Holland is no longer a serious criminal offence in contrast with most other countries" is misleading. There have been three bills designed to change the Dutch penal code on killing on request and assistance in suicide. The bill introduced by a left-liberal member of the Dutch Parliament and then by a state commission assigned to advise the government both would leave euthanasia punishable, unless it can be justified as "careful assistance" (defmed by hopeless circumstances of bodily or mental suffering and requiring wellinformed voluntarily expressed will, consultation with a second, independent physician [to be designated by the Minister of Health] and a written account and subsequently a report to the authorities). The commission was criticised for not applying the requirement of prior expressed will to patients in irreversible coma. From the beginning the government dissented and stated in a third bill that a change in the law should be limited to the introduction of a reason precluding guilt. The act of euthanasia would remain punishable but those who administer it may be not guilty, and therefore not punishable, where the patient is suffering insupportably, death is imminent, and further treatment is
meaningless. The Dutch State Council, the highest advisory organ of the government, has lately decided that there is no need for legislation on euthanasia at present and it is unlikely that euthanasia will soon cease to be a criminal offence. In Holland there are no juries, who could refuse to convict, but the Public Prosecutor can dismiss a
charge if prosecution is not in the public interest, and in cases of euthanasia an assembly of the five attorneys-general decides whether a prosecution should proceed. The most important criteria are that euthanasia has been administered by a physician at the repeated request of a well-informed, hopelessly suffering patient and after consultation with a second physician. About 18 % of cases brought to the attention of the Public Prosecutor are prosecuted. Prison sentences can range between 1 day and 12 years in cases of killing on request or 3 years in cases of assistance in suicide, and there is an equivalent range in fines. The verdict can be guilty but with no punishment. In general, punishments in Holland are not heavy but in no case of proven euthanasia has the accused been declared not guilty. Department of Biopharmacy, University of Amsterdam, 1018 TV Amsterdam, Netherlands 1.
J. SAGEL
Sagel J. Die Sterbehilfediskussion in den Niederlanden. Z Rechtspolitik (in press).
MEASLES AND THE IMMUNOSUPPRESSED CHILD
SIR,-Dr Eden and colleagues (Aug 2, p 283) urge the community health services to increase measles immunisation. These services have been trying to do that for many years, but with limited success. The finding that some deaths from measles are in children who may well have survived cancer and its treatment should spur them on; however, it would be helpful if more were known about the natural history of the illness in immunosuppressed children. In particular, does measles vaccination or natural measles infection provide any protection for children in whom leukaemia develops later? Are such children less at risk in America? If, in the USA, they are spared measles, do other life-threatening infections come to the fore? These are not reasons for not aiming to eradicate measles, but are matters which need to be considered when asking parents or health workers to change their immunising habits. Department of Child Health, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH
DAVID HULL
**This letter has been shown to Dr Eden and colleagues, whose reply follows.-ED. L. SIR,-For the individual with previous measles infection who subsequently develops measles there appears to be adequate residual immunity, although measles titres rapidly fall after chemotherapy begins. After vaccination there is less absolute guarantee of immunity although the current vaccines appear to be more protective than those in use a decade ago. As for so many infections, vaccination programmes in America have provided such good herd immunity that contact risk for the immunosuppressed child has almost disappeared. In the Medical Research Council UKALL VIII leukaemia trials 6 deaths in 829 patients entered were due to measles, whilst in a directly comparable American trial from which we adapted our therapy, there were no recorded measles infections or deaths from 1215 patients entered into the trial. The morbidity and mortality from infection were slightly lower (not significantly in the American
series) and no single other infection emerged as the measles risk disappeared. As our chemotherapy programmes are intensified to maximise early leukaemic cell kill the consequent risk of myelosuppression and immunosuppression increases. In the UK measles appears to be the greatest single infectious risk to life during prolonged immunosuppression-hence our enthusiasm for increased immunisation.
Royal Hospital for Sick Children, Department of Paediatric Haematology, Edinburgh EH9 1LF
O. B. EDEN SHARON GLASS M. GRAY I. HANN
academically. A panel chaired by Dame Alison Munro has been asked by the district health authority to advise us on the organisation of obstetric and gynaecological services. We will do all we can to help her team in this difficult task. Passions have been high of late and there are many wounds to heal. It would help if everybody-medical colleagues, journalists, and others, most of whom know little about the complex problems of the obstetrics department in this hospital, which go back many years-would refrain from comment in the press or on radio and television until Dame Alison’s work is done. London Hospital Medical London El 2AD
M. A. FLOYER,
College,
Dean
VOLUNTARY EUTHANASIA
SIR,—Having just finished a review of the public discussion in Holland on the need for new legislation on voluntary euthanasia,1 I was very interested in Dr Brewin’s comments (May 10, p 1085). The statement that the "administration of euthanasia in Holland is no longer a serious criminal offence in contrast with most other countries" is misleading. There have been three bills designed to change the Dutch penal code on killing on request and assistance in suicide. The bill introduced by a left-liberal member of the Dutch Parliament and then by a state commission assigned to advise the government both would leave euthanasia punishable, unless it can be justified as "careful assistance" (defmed by hopeless circumstances of bodily or mental suffering and requiring wellinformed voluntarily expressed will, consultation with a second, independent physician [to be designated by the Minister of Health] and a written account and subsequently a report to the authorities). The commission was criticised for not applying the requirement of prior expressed will to patients in irreversible coma. From the beginning the government dissented and stated in a third bill that a change in the law should be limited to the introduction of a reason precluding guilt. The act of euthanasia would remain punishable but those who administer it may be not guilty, and therefore not punishable, where the patient is suffering insupportably, death is imminent, and further treatment is
meaningless. The Dutch State Council, the highest advisory organ of the government, has lately decided that there is no need for legislation on euthanasia at present and it is unlikely that euthanasia will soon cease to be a criminal offence. In Holland there are no juries, who could refuse to convict, but the Public Prosecutor can dismiss a
charge if prosecution is not in the public interest, and in cases of euthanasia an assembly of the five attorneys-general decides whether a prosecution should proceed. The most important criteria are that euthanasia has been administered by a physician at the repeated request of a well-informed, hopelessly suffering patient and after consultation with a second physician. About 18 % of cases brought to the attention of the Public Prosecutor are prosecuted. Prison sentences can range between 1 day and 12 years in cases of killing on request or 3 years in cases of assistance in suicide, and there is an equivalent range in fines. The verdict can be guilty but with no punishment. In general, punishments in Holland are not heavy but in no case of proven euthanasia has the accused been declared not guilty. Department of Biopharmacy, University of Amsterdam, 1018 TV Amsterdam, Netherlands 1.
J. SAGEL
Sagel J. Die Sterbehilfediskussion in den Niederlanden. Z Rechtspolitik (in press).
MEASLES AND THE IMMUNOSUPPRESSED CHILD
SIR,-Dr Eden and colleagues (Aug 2, p 283) urge the community health services to increase measles immunisation. These services have been trying to do that for many years, but with limited success. The finding that some deaths from measles are in children who may well have survived cancer and its treatment should spur them on; however, it would be helpful if more were known about the natural history of the illness in immunosuppressed children. In particular, does measles vaccination or natural measles infection provide any protection for children in whom leukaemia develops later? Are such children less at risk in America? If, in the USA, they are spared measles, do other life-threatening infections come to the fore? These are not reasons for not aiming to eradicate measles, but are matters which need to be considered when asking parents or health workers to change their immunising habits. Department of Child Health, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH
DAVID HULL
**This letter has been shown to Dr Eden and colleagues, whose reply follows.-ED. L. SIR,-For the individual with previous measles infection who subsequently develops measles there appears to be adequate residual immunity, although measles titres rapidly fall after chemotherapy begins. After vaccination there is less absolute guarantee of immunity although the current vaccines appear to be more protective than those in use a decade ago. As for so many infections, vaccination programmes in America have provided such good herd immunity that contact risk for the immunosuppressed child has almost disappeared. In the Medical Research Council UKALL VIII leukaemia trials 6 deaths in 829 patients entered were due to measles, whilst in a directly comparable American trial from which we adapted our therapy, there were no recorded measles infections or deaths from 1215 patients entered into the trial. The morbidity and mortality from infection were slightly lower (not significantly in the American
series) and no single other infection emerged as the measles risk disappeared. As our chemotherapy programmes are intensified to maximise early leukaemic cell kill the consequent risk of myelosuppression and immunosuppression increases. In the UK measles appears to be the greatest single infectious risk to life during prolonged immunosuppression-hence our enthusiasm for increased immunisation.
Royal Hospital for Sick Children, Department of Paediatric Haematology, Edinburgh EH9 1LF
O. B. EDEN SHARON GLASS M. GRAY I. HANN