1270
postoperative chemotherapy and radiation therapy improves local control and survival in stage II and III patients and is recommended. The most effective regimen seems to be 5-FU plus methyl-CCNU and high-dose pelvic irradiation (45 to 55 Gy), but because of the possibility of chronic toxicity with methyl-CCNU this regimen should be used outside clinical trials. Current clinical trials of combined modality therapy are designed to improve the prognosis of stage IIand III patients. Entry of patients into these clinical trials is highly encouraged. not
What are the recommendations for future research? The
highest priority for future adjuvant trials in colon should build on the results achieved with 5-FU/J levamisole and should examine the use of modulators of 5-FU, modulators of host response, and new regimens of proven efficacy in advanced disease. The highest priority for future adjuvant trials in rectal cancer will be to integrate radiation therapy with newer 5-FU-modulated regimens such as 5-FU/levamisoIe, 5FU/leucovorin, or other combinations with demonstrated activity in advanced disease. Other areas that deserve attention include: the identification of new determinants of risk for selecting early-stage patients likely to benefit from adjuvant therapy; the incorporation into intergroup trials of the appropriate basic laboratory investigations required to define mechanisms of drug action, especially in trials with modulators of host immune response; quality of life and the cost-benefit of adjuvant therapies; and trials that address questions of differences in disease and outcome observed in various ethnic and socioeconomically disadvantaged groups. cancer
Jehovah’s Witness to refuse treatment without having the risks of doing so explained, and the concept is inherent in another US case.’ It seems that it is fear of litigation and the possibility of punitive damages which have encouraged doctors and hospital administrators to continue to give life-sustaining treatment against patients’ wishes. Judge Terry did not rule out all possibility of the courts overriding the wishes of a pregnant woman: "We do not quite foreclose the possibility that a conflicting state interest may be so compelling that the patient’s interest must yield, but we anticipate that such cases will be extremely rare and truly exceptional. This is not such a case". (In his dissenting view Judge James A. Belson said that the majority had failed to give adequate weight to "the state’s interest in preserving human life and the viable unborn child’s interest in survival". The decision has been hailed by the American Civil Liberties Union as a major victory providing a solid authority for rejecting the notion that fetal rights can be used to deny women the right to control their own bodies and lives.3
In British law, where there is a conflict between the interests of the fetus and the mother, the interests and wishes of the mother must prevail.
Diana Brahams 1. Brahams D. A baby’s life or a mother’s liberty. Lancet 1988; i: 1006. 2. Annas GJ. She’s going to die: the case of Angela C. Hastings Center Rep, Feb/March, 1988: 23. 3. Greenhouse L. Forced surgery to save fetus is rejected by court m capital. N Y Times, Apnl 27, 1990. 4. Brahams D. Unwanted life-sustaining treatment. Lancet 1990; 335: 1209.
Heat-illness in the Royal
Navy: conviction
quashed On Feb 21, 1990,
Royal Navy lieutenant instructor (and under the Naval Discipline Act 1957 with ex-marine) charged ill-treating an officer who had collapsed from heat illness during a training exercise.’ He was convicted and dismissed from his ship (but seems subsequently to have been appointed to another). On May 16, it emerged that the Admiralty Board had quashed his conviction on the basis that the court-martial might not have found him guilty if it had been directed on the question of "recklessness" in accordance with a Court of Appeal decision in R vs Newington (Times Feb 27, 1990). The Board decided that the verdict was unsafe. At the time it seemed that the instructor had been made a scapegoat for the repeated failures of the armed forces to take account of heat illness in training. The chain of responsibility begins at the top. The court-martial of this junior officer was an exercise in passing the buck over the shortest distance-but the Admiralty has now passed it right out of sight. a
was
Medicine and the Law Enforced
US appeal In June, 1987, in the United States, a judge ordered doctors to do a caesarean section on a 27-year-old dying woman, to give her 26-week fetus a chance of life. The patient’s doctors refused because the woman did not give her consent, but other doctors agreed. The judge gave no weight to the woman’s wishes because of her impending death. Mother and baby died within a few hours of the operation.12 The caesarean
section:
a
national scandal. The woman’s parents appealed, arguing that the operation had violated their daughter’s right to bodily integrity, and they were supported by the American Medical Association, several women’s and religious groups, and the American Civil Liberties Union, among others.3 Even though the dispute was by then academic (or "moot" in US parlance) the Appeals Court in Washington, DC, agreed to take the case because the issue could come up again and because the family was suing the George Washington University Hospital. On April 26,1990, the Appeals Court decided by 7 to 1 that a pregnant woman may not be forced to undergo a caesarean section to save her fetus. case
caused
a
Judge John A. Terry, who wrote the majority opinion, stated that patient, if competent, has the right to an informed choice, to accept or to forego treatment. This doctrine of informed consent is ingrained in the common law, he declared. The right to informed consent encompasses a right to informed refusal but "A fetus cannot have rights in this respect superior to a person who has already been every
born". The issue of informed refusal Canadian
appeal
on
the
rights
of
an
was also discussed in a unconscious card-carrying
Diana Brahams 1. Brahams D. Heat illness in the navy. Lancet
1990; 335: 529.
Obituary Kenneth Wyatt Newell Professor Newell, who died in March, aged 64, played a major role in developing and shaping community health programmes in many regions of the world. After graduating from Otago Medical School he served as medical officer in Te Araroa Maori Area before spending 2 years as epidemiologist in the Public Health Laboratory Service, Colindale, then teaching preventive medicine in Belfast. In 1958 he joined the World Health Organisation (WHO) in Indonesia as epidemiologist and 2 years later, aged 35, he was appointed professor of epidemiology in Tulane University Medical School, from where he directed field studies at the International Center for Medical
postoperative chemotherapy and radiation therapy improves local control and survival in stage II and III patients and is recommended. The most effective regimen seems to be 5-FU plus methyl-CCNU and high-dose pelvic irradiation (45 to 55 Gy), but because of the possibility of chronic toxicity with methyl-CCNU this regimen should be used outside clinical trials. Current clinical trials of combined modality therapy are designed to improve the prognosis of stage IIand III patients. Entry of patients into these clinical trials is highly encouraged. not
What are the recommendations for future research? The
highest priority for future adjuvant trials in colon should build on the results achieved with 5-FU/J levamisole and should examine the use of modulators of 5-FU, modulators of host response, and new regimens of proven efficacy in advanced disease. The highest priority for future adjuvant trials in rectal cancer will be to integrate radiation therapy with newer 5-FU-modulated regimens such as 5-FU/levamisoIe, 5FU/leucovorin, or other combinations with demonstrated activity in advanced disease. Other areas that deserve attention include: the identification of new determinants of risk for selecting early-stage patients likely to benefit from adjuvant therapy; the incorporation into intergroup trials of the appropriate basic laboratory investigations required to define mechanisms of drug action, especially in trials with modulators of host immune response; quality of life and the cost-benefit of adjuvant therapies; and trials that address questions of differences in disease and outcome observed in various ethnic and socioeconomically disadvantaged groups. cancer
Jehovah’s Witness to refuse treatment without having the risks of doing so explained, and the concept is inherent in another US case.’ It seems that it is fear of litigation and the possibility of punitive damages which have encouraged doctors and hospital administrators to continue to give life-sustaining treatment against patients’ wishes. Judge Terry did not rule out all possibility of the courts overriding the wishes of a pregnant woman: "We do not quite foreclose the possibility that a conflicting state interest may be so compelling that the patient’s interest must yield, but we anticipate that such cases will be extremely rare and truly exceptional. This is not such a case". (In his dissenting view Judge James A. Belson said that the majority had failed to give adequate weight to "the state’s interest in preserving human life and the viable unborn child’s interest in survival". The decision has been hailed by the American Civil Liberties Union as a major victory providing a solid authority for rejecting the notion that fetal rights can be used to deny women the right to control their own bodies and lives.3
In British law, where there is a conflict between the interests of the fetus and the mother, the interests and wishes of the mother must prevail.
Diana Brahams 1. Brahams D. A baby’s life or a mother’s liberty. Lancet 1988; i: 1006. 2. Annas GJ. She’s going to die: the case of Angela C. Hastings Center Rep, Feb/March, 1988: 23. 3. Greenhouse L. Forced surgery to save fetus is rejected by court m capital. N Y Times, Apnl 27, 1990. 4. Brahams D. Unwanted life-sustaining treatment. Lancet 1990; 335: 1209.
Heat-illness in the Royal
Navy: conviction
quashed On Feb 21, 1990,
Royal Navy lieutenant instructor (and under the Naval Discipline Act 1957 with ex-marine) charged ill-treating an officer who had collapsed from heat illness during a training exercise.’ He was convicted and dismissed from his ship (but seems subsequently to have been appointed to another). On May 16, it emerged that the Admiralty Board had quashed his conviction on the basis that the court-martial might not have found him guilty if it had been directed on the question of "recklessness" in accordance with a Court of Appeal decision in R vs Newington (Times Feb 27, 1990). The Board decided that the verdict was unsafe. At the time it seemed that the instructor had been made a scapegoat for the repeated failures of the armed forces to take account of heat illness in training. The chain of responsibility begins at the top. The court-martial of this junior officer was an exercise in passing the buck over the shortest distance-but the Admiralty has now passed it right out of sight. a
was
Medicine and the Law Enforced
US appeal In June, 1987, in the United States, a judge ordered doctors to do a caesarean section on a 27-year-old dying woman, to give her 26-week fetus a chance of life. The patient’s doctors refused because the woman did not give her consent, but other doctors agreed. The judge gave no weight to the woman’s wishes because of her impending death. Mother and baby died within a few hours of the operation.12 The caesarean
section:
a
national scandal. The woman’s parents appealed, arguing that the operation had violated their daughter’s right to bodily integrity, and they were supported by the American Medical Association, several women’s and religious groups, and the American Civil Liberties Union, among others.3 Even though the dispute was by then academic (or "moot" in US parlance) the Appeals Court in Washington, DC, agreed to take the case because the issue could come up again and because the family was suing the George Washington University Hospital. On April 26,1990, the Appeals Court decided by 7 to 1 that a pregnant woman may not be forced to undergo a caesarean section to save her fetus. case
caused
a
Judge John A. Terry, who wrote the majority opinion, stated that patient, if competent, has the right to an informed choice, to accept or to forego treatment. This doctrine of informed consent is ingrained in the common law, he declared. The right to informed consent encompasses a right to informed refusal but "A fetus cannot have rights in this respect superior to a person who has already been every
born". The issue of informed refusal Canadian
appeal
on
the
rights
of
an
was also discussed in a unconscious card-carrying
Diana Brahams 1. Brahams D. Heat illness in the navy. Lancet
1990; 335: 529.
Obituary Kenneth Wyatt Newell Professor Newell, who died in March, aged 64, played a major role in developing and shaping community health programmes in many regions of the world. After graduating from Otago Medical School he served as medical officer in Te Araroa Maori Area before spending 2 years as epidemiologist in the Public Health Laboratory Service, Colindale, then teaching preventive medicine in Belfast. In 1958 he joined the World Health Organisation (WHO) in Indonesia as epidemiologist and 2 years later, aged 35, he was appointed professor of epidemiology in Tulane University Medical School, from where he directed field studies at the International Center for Medical
