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nc. Neither he nor the pro-choice groups seem willing to jdmowtedge what the statistics gathered by expert terrorist mesugaiors in both Canada and the USA have shown:1î1 1è!y, that "lone wolf ’ radicals attack abortion clinics, not instream pro-life organisations. Dr Morgentaler had spear-headed the trend towards itl1c-based abortions in this country when he opened his ::."Stoffice in Montreal, Quebec, during the 1960s. In March Statistics Canada released data for the first time on abortions s private clinics. They show clearly that Canada is following the trend in other western nations for abortions to be done in clinics rather than in hospitals. Of more than It! 000 legal abortions done in Canada during 1990, 21 443 took place in private clinics, and almost half these (10 200) in Ontario’s four private clinics, all of which were in Toronto. Further, of the 10 200,49% took place at the Harbord Street clinic. In Ontario, hospital-performed abortions declined siightly to 31224 in 1990 from 31 644 in 1989; during this time the Morgentaler clinic records indicate a 7 % increase in procedures (from 4699 to 5022), followed by a 13 % increase in 1991. Moreover, in June, 1991, Ontario’s NDP Government placed all abortions on the provincial health insurance plan. Unlike other provinces, where women continue to pay between$200-$400 for abortions at a private clinic, all Ontario abortions are now funded by taxpayers at an average cost of$500 per operation. The firebombers had chosen as their target the biggest, government-funded, private abortion clinic in Canada.

Gordon

Bagley

USA: Dioxin standards Congressional Subcommittee headed by Representative Ted Weiss of New York says that the Environmental Protection Agency’s (EPA’s) rationale for its A

risk reassessment of dioxin is based on inaccurate information from the chlorine and paper industries. At a hearing in June, Mr Weiss made public documents that he said showed that EPA administrator William K. Reilly met frequently with representatives of those industries, which are major sources of the contaminant. One of the documents was a paper industry review by the pathology firm, Pathco, of tumour slides used in the original risk assessment of dioxin. Pathologists within and outside of the EPA, Mr Weiss said, disagreed with the view of the study’s director that dioxin did not pose a cancer risk at any anticipated level of exposure. The second report came from the Chlorine Institute, which claimed that international authorities on dioxin had agreed at an Institute-fmanced meeting that a threshold for the contaminant could be identified. No such consensus, said Mr Weiss, was reached. A letter to Mr Reilly from John Georges of International Paper Co and three other paper corporation chairmen was brought up at the hearing. It read in part: "We were encouraged by what we perceived as your willingness to have the agency move expeditiously to re-examine the potency of dioxin and chloroform... We wish to underscore our strong objection to any future interference by EPA in functioning marketplaces, particularly in the absence of ’.estimate health and environmental concerns". The letter ’Aas dated Jan 25, 1991. Three months later, Mr Reilly ordered the dioxin-risk reassessment. Questioning at the hearing also revealed that Robert Scheuplein, director of the Food and Drug

of Toxicological Science, accepted industry’s data and raised what the Agency considered a safe dose by a factor of two. Testifying at the hearing, Dr Scheuplein said that more recent data have convinced him

Administration’s Office

that the risk of dioxin is greater than he previously believed. The EPA hopes to have its decision on dioxin by the end of the year. If the Agency follows the science, says Mr Weiss, the standard will be strengthened.

J. B. Sibbison

Medicine and the Law Consent, refusal, and minors On July 10, the three English Court of Appeal judges whose interim ruling in the case of J, a 16-year-old anorexic girl, was reported in The Lancet last week (p 108), delivered their reasons for compelling J to undergo treatment against her wishes. On the facts of the case, the judges questioned the High Court’s fmding that J was "a child of sufficient understanding to make an informed decision", and suggested that the High Court judge had not taken sufficiently into account the ability of anorexia nervosa to impair capacity for making an informed choice. However, the Court of Appeal chose to go further and to address the wider issue of the capacity of adolescents to refuse medical interventions. The case turned on the interpretation of the Family Law Reform Act 1969, section 8(1) of which states that the consent of a minor who has attained the age of 16 to any medical treatment "shall be effective as it would be if he were of full age" and consent from a parent or guardian is not necessary. However, section 8(3) adds that "nothing in this section shall be construed as making ineffective any consent which would have been effective if this section had not been enacted". This mysterious provision, preserving an unspecified common law right, had long been the subject of legal discussion. Who had been entitled to consent before the enactment of the statute? Lord Scarman in the Gillick case (1985) suggested one interpretation: that mature children of any age have always had a common law right "to make decisions" (and not merely "to consent"). The court in Re ∃ raised the alternative argument that, before the Act was passed, parents had the right to consent on behalf of all minor children. It was, in the court’s view, "clear and unambiguous" that Parliament, whilst giving certain limited rights to minors, had also intended to perpetuate this parental right. Section 8(1) says that parental consent is not necessary; it does not render such consent invalid. Furthermore, the "inherent jurisdiction" of the High Court, which, when invoked as it was in this case, requires the court to act in the child’s best interests, extends to all children beneath the age of majority. Lord Donaldson described consent as a sort of "flak jacket" which the child, parents, or a court could present to a doctor to protect him from the threat of legal action. In this and in his remarks about the justification for the legal requirement of consent, Lord Donaldson failed to note that the reason for making consent obligatory is not primarily to protect the doctor, but to protect the patient from undesired medical intervention. The court unflinchingly accepted the potential consequences of its distinction between consent and refusal, including the theoretical, albeit highly unlikely, possibility

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that a girl of 16 or 17 could be forced to have an abortion against her wishes if it were "truly in the best interests of the child". However, all three judges took the view that, although parents and courts had the power to intervene in

adolescents’ decisions about medical treatment, that power was not to be exercised lightly. Lord Justice Balcombe ruled that there should be a "strong predilection" to give effect to the wishes, whatever they might be, of the mature adolescent. But there came a point where the child’s refusal would "in all probability lead to the death of the child or to severe permanent injury". At that point, the court could override that refusal in the child’s interests. Lord Justice Nolan added that, in cases of conflict between adolescent refusal and parental consent, the court’s jurisdiction should always be invoked. These conclusions, while arguably sensitive to the position of adolescence, leave open glaring inconsistencies in the law. The first problem is the potential conflict between the House of Lords’ interpretation of the common law in Gillick and the ruling in this case. The second problem is that if the consent/refusal discrepancy is retained, it will result in a situation in which teenagers are permitted to make certain serious, even irreversible decisions, but not others, merely because some decisions are classified as "refusals", and others as "consents". For example, there would seem to be no obstacle in law to a 16 or 17 year old having irreversible transsexual surgery. Lord Donaldson, departing from the facts before him, specifically stated that the common law (but not the narrower Family Law Reform Act) would seem to entitle a mature child to consent to donate an organ (although Lord Justice Nolan took the view that all such matters should come before a court). And in hundreds of clinics and surgeries every day, very young teenagers are permitted to obtain contraception. The solution proposed by the court in Re J was to refer to the "theoretically limitless" powers of the court’s inherent jurisdiction in protecting minors. Lord Donaldson held that, although such power was not available to parents, the court might overrule any decision of a minor, including consents by mature children and those over 16. This suggests a conflict between the powers of the court and the rights granted to minors by the statute and is an issue that reauires further discussion.

Elizabeth Roberts

Conference Epidemiology

in central and eastern

Europe

To say that epidemiology did not exist in the countries of central and eastern Europe (CCEE) under their former communist regimes would be an exaggeration, but only just.

Epidemiology was regarded by the communists as unsound, unnecessary, and in later years unwelcome. Unsound because it was inherited from a capitalist past, was popular in the west, and emphasised the differences between groups within the population; unnecessary because faith in the socialist ideology meant that improved health would follow as a matter

of course; and unwelcome because of the wish to on the true state of health of the

suppress information

population and the factors that influenced it. Where epidemiology survived, often in departments of social medicine or hygiene, the approaches used were almost entirely descriptive rather than analytical. The World Health Organisation is committed to the strengthening of epidemiology worldwide and is particularly concerned about the consequences of the virtual neglect of the subject tentative step towards an epidemiology and health information systems was held in Dobogoko- a small town in the hills outside Budapest-organised jointly by the WHO, the International Epidemiology Association, and the Hungarian Government. Participants from 11 different post-communist countries including Byelorussia, Romania, Bulgaria, Yugoslavia, Albania, and Latvia gathered to discuss their interests with experienced epidemiologists from western Europe and the USA. A paternalistic approach on the part of western "experts" would be as inappropriate as it would be ineffective. It is help rather than advice that is needed. The Dobogoko workshop was planned, therefore, to provide training and guidance in modern epidemiological methods and their application. Intensive teaching of theoretical epidemiology was combined with an introduction to the design of information systems and use of epidemiological data in health promotion and disease prevention. The material was well received and was generally thought highly relevant to tasks currently being undertaken in the CCEE. In Byelorussia a register of haematological malignant diseases is being used to assess the impact of Chernobyl. In Romania the effects of Chernobyl are also being investigated by analysis of a wide range of routine information. Follow-up studies are being conducted on a large cohort of young diabetic patients in Bulgaria. Diabetes has been studied in the Baltic states and the Latvians are planning to include epidemiology in the undergraduate medical syllabus. In Lithuania a system of national health indicators and a related software package has been developed in collaboration with WHO. In most of the CCEE vital statistics are collected reliably and about half the countries have accurate population registers. Analysis tends to be limited more by lack of training in epidemiology and health services research than by lack of electronic information systems. The enthusiasm for epidemiology may in part be due to the promotion of public health and its related disciplines by outside observers from the World Bank and other potential donor agencies. The meeting in Dobogoko has made a contribution to the resurrection of epidemiology, but formidable obstacles remain. Firstly, the lack of a critical mass of individuals trained in epidemiology in any one country limits the possibilities for both research and training without considerable input from abroad: some of the Baltic states are not much larger than an English regional health authority. Secondly, those already working in epidemiology have to contend with the extreme difficulty of obtaining published material and of travelling to other countries to exchange ideas and research findings. It may be some time before the first school of public health is established in a previously communist country in central or eastern Europe. Meanwhile any epidemiologist or public health physician prepared to contribute to the development of epidemiology in the CCEE will find it a in these countries. As

improvement,

a

a

workshop

on

rewarding experience. Unit of Health-Care Epidemiology, University of Oxford

John Newton

Consent, refusal, and minors.

In the British case of Re J, the Court of Appeal ruled that a 16-year-old anorexic girl could be compelled to undergo treatment against her wishes. Ro...
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