be established in the majoritv of patients with incurable rectal cancer. Optimum palliatiPn entails more than substitution of colostomv bv transrectal resection. T G ALLEN-MERSH Westminster Hospital, Loindoni SWIP 2AI'
Alexander-Williams J. Advanced rcctal caniccr. Br lIed 1 1990;300:276-7. (3 Februarv.) 2 Slancv G. Results of treatment of carciinoma of the coloni and rcctum. In: Irvine WT, cd.Jodertn trentds in surgrer. Vol 3. London: Butterworth, 1971:69. 3 Cochrane JPS, Williams JIT, Fahcr R(, Slack WV. Valule of' out-patient follow-up after curative surgery tor carcinioma ot the large bowel. Br M1Ved.7 1980);280:593-5. 4 Findlav IG, Mieek DR, (iraf'f HV'. Incidencc and dctcctioni ot occult hepatic metastases in colorcctal carcinoma. Br Mled7
1982;284:803-6. 5 Wagner JS, Adson M\IA, san Hecrdcn JA, ctt a. 'I'he iattral histtrv of hepatic metastases f'roits colorectal canccr. Inni Sur,g 1984;199:502-7. 6 Heald RJ, Rvall RDH. RcCLirrctncc aind survival after total mesorectal cxcision for rectal Laiicer. Lancet 1986;i: 1479-82. 7 Ritkin MD, Wlechsler RJ. A coittparison ot computed toittographv and endorectal itltrasotiiid in staging rectal caiiccr. Ini Color Dis 1986;1: 219-23. 8 Gill PG, Morris PJ. 'The survival ot patients with colorectal cancer treated in a regional hospital. Br] Surg 1978;65: 17-21. 9 Pilepich MV, Mutuzenrider JE, 'I'ak WK, Miller HH. I'reoperative irradiation of priinmrily unresectable colorectal
carcinotna. Cancer 1978;42:1077-X1. 10 Hitgltes ESR, MicDermott FT, Masterton Jl', Cunningltam IGE, Polglase AL. Operative ntortality following excisiots of' tle rectum. Brj Surg 1980;67:49-5 1.
SIR,-In his leading article Professor J AlexanderWilliams describes the palliative treatment of patients with rectal cancer by using resectoscopes in a fluid medium. Recently I had two patients who regurgitated large quantities of glycine irrigation fluid during this procedure. The first of these patients was anaesthetised with only a bag and mask and consequently aspirated an appreciable amount of fluid, although fortunately he did not have any postoperative problems as a result. Neither patient received an excessive amount of irrigation fluid (2 9 litres and 6 litres respectively). Interestingly, both patients had incompetent ileocaecal valves on barium enema examination. Yet other patients with such radiological findings did not regurgitate. Though this is an uncommon problem (it occurred in two of 52 patients who underwent resection), it would seem prudent to consider formal endotracheal intLibation for all patients in whom this technique is to be used. J A HAGGIE Department of Surgery, Leighton Hospital, Crcwe CW'I 4QJ
recovery and crvopreservation before chemotherapy mav offer the possibilitv for some women to have their own children in future years. There have been concerns about the effects of cryopreservation on the oocyte and subsequent embryo development, but successful pregnancies have been reported. It seems possible as techniques develop that oocyte banking could become as established as sperm banking. Although assisted reproduction techniques are generally accepted by infertile patients, patients who have to undergo an arduous course of chemotherapy for a malignant disease might not welcome further interference at a time when fertility might seem the lesser issue. To assess this we interviewed 41 women under the age of 40 who had had ootoxic chemotherapy, mostly for lymphoma, and who were in complete remission. From their history and gonadotrophin concentrations, 17 had primary ovarian failure, which had occurred at a mean age of 29 years. Twenty three were married, four divorced, and 14 single. Twenty five were childless. Of the 41, 31 responded enthusiastically to the prospect of having oocyte or embryo donation or oocyte cryopreservation. Seven felt that oocyte or embryo donation was unacceptable, and only three were against donation and cryopreservation. Although oocyte cryopreservation is not yet routinely available, 37 welcomed this option and would have undergone this procedure before chemotherapy. TIwenty four of the 41 patients were sufficientlv interested in these options to indicate that they wished to be considered for them now or in the future, depending on their fertility and marital state; all 24 were childless. Our survey highlighted the fact that despite the stress of coping with malignancy fertility remains of considerable importance to women with lymphoma. They welcome and should have access to assisted reproduction techniques, particularly when there is no possibility of avoiding the ootoxic alkylating agents in their treatment. The threat of prohibiting research that would allow the development of such options will deprive these women of the opportunity to have a family when they are cured of their malignant disease. MARCIA RATCLIFFE
GILLIAN FLETT
AlU DREY DAWSON ALLAN TEMPLETON
Department of Obstetrics and (Gynaecology. Universitv of Abcrdecn, Aberdeen AB9 2ZI)
Sittger P. Should fertile people hase access to in vitro fertilisatiotn? BrAMcd_7 1990;300:167-70)1 211 January.
1 Dawson K.
2 Chen C. Pregnancv after human oocyte cry'opreservation. Lancet I Alexander-Williams J. Ads-anced rectal cancer. Br MIed
I7
1990);300:276-7. (3 February.
1986;i:844-6. 3 V'an Uem JF, Sicbzehnimubl ER, Schuh B. Koch R, T rotnow S, Lang N. Birth after cryoprescrvation ot- unifcrtilized oocstes.
Lancet 1986;1:752-3.
Should fertile people have access to in vitro fertilisation?
Research ethics committees
SIR,-We would like to add further weight to Dr Karen Dawson's and Mr Peter Singer's argument that fertile people should have access to in vitro fertilisation.' While the technique has been subject to political and legal debate little attention has focused on community attitudes and on the views of those directly affected. In Grampian region we treat about 70 patients with lymphoma each year, of whom 10-15% are women aged 18-40. We expect a cure rate of well over 50%, but only with the use of gonadotoxic alkylating agents, which induce premature ovarian failure in most of the women. With the advent of assisted reproduction several options have now become available. Both oocyte donation and embryo donation are techniques that give such women the opportunity of having a pregnancy. Furthermore, oocyte
SIR,-Neither your editorial,' the draft statement that was circulated by the Department of Health,' nor the recent correspondence in the BAJ7 on research ethics committees confronted what is a major problem for social scientists working in health and health care-namely, what sort of research should be reviewed by ethical committees. In my view ethical committees should protect patients in relation to the confidentiality of their medical records and the use of invasive procedures for research. I do not think that it is appropriate for ethical committees to concern themselves with surveys that entail interviewing people who are identified from public records. The Medical Research Council, however, holds a different view. In a recent study funded by them this institute selected a random sample of death registrations of adults, and for each we wanted to
BMJ
VOLUME 300
3 MARCH 1990
interview the person who could tell us the most abotit the last vear of the deceased person's life, as was done in an earlier study.' The Medical Research Council insisted that we should seek approval from the ethical committees in all of the 19 geographic areas covered by the study. Trhe variability of their responses is illustrated by the fact that 17 approved the study and two did not. In my view once the study had been referred to them the committees should have confined themselves to ethical issues that related to the wax we protected the confidentiality of the information given to us and the disclosure to us of data relating to the people who had died that had been obtained by doctors and nurses in the professional capacity. But the two committees that did not approve our study did not raise these issues. They turned down the study because of their anxieties about the possible distress that might be caused by our interviews. Although I think that it is not appropriate for these ethical committees to adjudicate on studies based on samples drawn from public records and not entailing any medical interventions, I nevertheless think that these committees had a point. We hoped that the right to refuse to take part would mean that people could protect themselves against distress and that the people who did take part would find it helpful to talk to someone they did not know about their experiences and feelings. In the event, although many seemed to find our interviewers sympathetic and understanding, there were some informants who, in their relatives' opinion at least, had been unnecessarill distressed by taking part in the study, which revived painful memories. In spite of this I think that it is paternalistic to protect people against being asked to take part in such studies. Ethical committees are not the custodians of people's civil rights. People do not belong to their doctors, and there should be no interference with people's liberty to make up their own minds about what questions they should answer and in what circumstances. So I do not think the standpoint of the Medical Research Council is tenable. Does the council believj that the Office of Population Censuses and Surveys should seek approval from all ethical committees for its health questions in the General Household Survey? Another issue, and one over which I take issue with Drs lain Chalmers and Thomas C Chalmers,' is whether ethical committees are the appropriate bodies to determine whether research has been appropriately designed. Although I sympathise with the view that it is unethical to do poorly designed research, I do not feel that it is appropriate or realistic to expect ethical committees to have the skill and experience to make judgments on this. ANN CARTWRIGHT. Institute of Social Stuidies in Medical Carce ILondon N%C'3 2SB I ILock S. Monitoring rcsearch cthical committees. Br Mled 7 1990;300:61-2. 13 January. 2 Department of Health. Drtji health circular: local research ehtical commi'ttees. London: Do)H, 1989. 3 \arious authors. Rescarch ethics committees. Br Med 7
1990;300:395-6. 4
Cartwrigltt A, Hockc I., Ainderson JL. Life before death. London and Boston: Routledge and Kegan Paul, 1973.
SIR,-As chairman of a local research ethics committee I would like to add to the debate taking place in the BMJ's correspondence columns. ' I think that there are serious problems associated with a national ethics committee that would consider the ethics of proposed multicentre trials. Ethics concerns arguable opinions, not indisputable facts. It is therefore not surprising that when different ethics committees consider the same proposal they do not always agree. This mav be tedious and inconvenient for researchers attempting to set up a multicentre trial, but I 607
Alexander-Williams J. Advanced rcctal caniccr. Br lIed 1 1990;300:276-7. (3 Februarv.) 2 Slancv G. Results of treatment of carciinoma of the coloni and rcctum. In: Irvine WT, cd.Jodertn trentds in surgrer. Vol 3. London: Butterworth, 1971:69. 3 Cochrane JPS, Williams JIT, Fahcr R(, Slack WV. Valule of' out-patient follow-up after curative surgery tor carcinioma ot the large bowel. Br M1Ved.7 1980);280:593-5. 4 Findlav IG, Mieek DR, (iraf'f HV'. Incidencc and dctcctioni ot occult hepatic metastases in colorcctal carcinoma. Br Mled7
1982;284:803-6. 5 Wagner JS, Adson M\IA, san Hecrdcn JA, ctt a. 'I'he iattral histtrv of hepatic metastases f'roits colorectal canccr. Inni Sur,g 1984;199:502-7. 6 Heald RJ, Rvall RDH. RcCLirrctncc aind survival after total mesorectal cxcision for rectal Laiicer. Lancet 1986;i: 1479-82. 7 Ritkin MD, Wlechsler RJ. A coittparison ot computed toittographv and endorectal itltrasotiiid in staging rectal caiiccr. Ini Color Dis 1986;1: 219-23. 8 Gill PG, Morris PJ. 'The survival ot patients with colorectal cancer treated in a regional hospital. Br] Surg 1978;65: 17-21. 9 Pilepich MV, Mutuzenrider JE, 'I'ak WK, Miller HH. I'reoperative irradiation of priinmrily unresectable colorectal
carcinotna. Cancer 1978;42:1077-X1. 10 Hitgltes ESR, MicDermott FT, Masterton Jl', Cunningltam IGE, Polglase AL. Operative ntortality following excisiots of' tle rectum. Brj Surg 1980;67:49-5 1.
SIR,-In his leading article Professor J AlexanderWilliams describes the palliative treatment of patients with rectal cancer by using resectoscopes in a fluid medium. Recently I had two patients who regurgitated large quantities of glycine irrigation fluid during this procedure. The first of these patients was anaesthetised with only a bag and mask and consequently aspirated an appreciable amount of fluid, although fortunately he did not have any postoperative problems as a result. Neither patient received an excessive amount of irrigation fluid (2 9 litres and 6 litres respectively). Interestingly, both patients had incompetent ileocaecal valves on barium enema examination. Yet other patients with such radiological findings did not regurgitate. Though this is an uncommon problem (it occurred in two of 52 patients who underwent resection), it would seem prudent to consider formal endotracheal intLibation for all patients in whom this technique is to be used. J A HAGGIE Department of Surgery, Leighton Hospital, Crcwe CW'I 4QJ
recovery and crvopreservation before chemotherapy mav offer the possibilitv for some women to have their own children in future years. There have been concerns about the effects of cryopreservation on the oocyte and subsequent embryo development, but successful pregnancies have been reported. It seems possible as techniques develop that oocyte banking could become as established as sperm banking. Although assisted reproduction techniques are generally accepted by infertile patients, patients who have to undergo an arduous course of chemotherapy for a malignant disease might not welcome further interference at a time when fertility might seem the lesser issue. To assess this we interviewed 41 women under the age of 40 who had had ootoxic chemotherapy, mostly for lymphoma, and who were in complete remission. From their history and gonadotrophin concentrations, 17 had primary ovarian failure, which had occurred at a mean age of 29 years. Twenty three were married, four divorced, and 14 single. Twenty five were childless. Of the 41, 31 responded enthusiastically to the prospect of having oocyte or embryo donation or oocyte cryopreservation. Seven felt that oocyte or embryo donation was unacceptable, and only three were against donation and cryopreservation. Although oocyte cryopreservation is not yet routinely available, 37 welcomed this option and would have undergone this procedure before chemotherapy. TIwenty four of the 41 patients were sufficientlv interested in these options to indicate that they wished to be considered for them now or in the future, depending on their fertility and marital state; all 24 were childless. Our survey highlighted the fact that despite the stress of coping with malignancy fertility remains of considerable importance to women with lymphoma. They welcome and should have access to assisted reproduction techniques, particularly when there is no possibility of avoiding the ootoxic alkylating agents in their treatment. The threat of prohibiting research that would allow the development of such options will deprive these women of the opportunity to have a family when they are cured of their malignant disease. MARCIA RATCLIFFE
GILLIAN FLETT
AlU DREY DAWSON ALLAN TEMPLETON
Department of Obstetrics and (Gynaecology. Universitv of Abcrdecn, Aberdeen AB9 2ZI)
Sittger P. Should fertile people hase access to in vitro fertilisatiotn? BrAMcd_7 1990;300:167-70)1 211 January.
1 Dawson K.
2 Chen C. Pregnancv after human oocyte cry'opreservation. Lancet I Alexander-Williams J. Ads-anced rectal cancer. Br MIed
I7
1990);300:276-7. (3 February.
1986;i:844-6. 3 V'an Uem JF, Sicbzehnimubl ER, Schuh B. Koch R, T rotnow S, Lang N. Birth after cryoprescrvation ot- unifcrtilized oocstes.
Lancet 1986;1:752-3.
Should fertile people have access to in vitro fertilisation?
Research ethics committees
SIR,-We would like to add further weight to Dr Karen Dawson's and Mr Peter Singer's argument that fertile people should have access to in vitro fertilisation.' While the technique has been subject to political and legal debate little attention has focused on community attitudes and on the views of those directly affected. In Grampian region we treat about 70 patients with lymphoma each year, of whom 10-15% are women aged 18-40. We expect a cure rate of well over 50%, but only with the use of gonadotoxic alkylating agents, which induce premature ovarian failure in most of the women. With the advent of assisted reproduction several options have now become available. Both oocyte donation and embryo donation are techniques that give such women the opportunity of having a pregnancy. Furthermore, oocyte
SIR,-Neither your editorial,' the draft statement that was circulated by the Department of Health,' nor the recent correspondence in the BAJ7 on research ethics committees confronted what is a major problem for social scientists working in health and health care-namely, what sort of research should be reviewed by ethical committees. In my view ethical committees should protect patients in relation to the confidentiality of their medical records and the use of invasive procedures for research. I do not think that it is appropriate for ethical committees to concern themselves with surveys that entail interviewing people who are identified from public records. The Medical Research Council, however, holds a different view. In a recent study funded by them this institute selected a random sample of death registrations of adults, and for each we wanted to
BMJ
VOLUME 300
3 MARCH 1990
interview the person who could tell us the most abotit the last vear of the deceased person's life, as was done in an earlier study.' The Medical Research Council insisted that we should seek approval from the ethical committees in all of the 19 geographic areas covered by the study. Trhe variability of their responses is illustrated by the fact that 17 approved the study and two did not. In my view once the study had been referred to them the committees should have confined themselves to ethical issues that related to the wax we protected the confidentiality of the information given to us and the disclosure to us of data relating to the people who had died that had been obtained by doctors and nurses in the professional capacity. But the two committees that did not approve our study did not raise these issues. They turned down the study because of their anxieties about the possible distress that might be caused by our interviews. Although I think that it is not appropriate for these ethical committees to adjudicate on studies based on samples drawn from public records and not entailing any medical interventions, I nevertheless think that these committees had a point. We hoped that the right to refuse to take part would mean that people could protect themselves against distress and that the people who did take part would find it helpful to talk to someone they did not know about their experiences and feelings. In the event, although many seemed to find our interviewers sympathetic and understanding, there were some informants who, in their relatives' opinion at least, had been unnecessarill distressed by taking part in the study, which revived painful memories. In spite of this I think that it is paternalistic to protect people against being asked to take part in such studies. Ethical committees are not the custodians of people's civil rights. People do not belong to their doctors, and there should be no interference with people's liberty to make up their own minds about what questions they should answer and in what circumstances. So I do not think the standpoint of the Medical Research Council is tenable. Does the council believj that the Office of Population Censuses and Surveys should seek approval from all ethical committees for its health questions in the General Household Survey? Another issue, and one over which I take issue with Drs lain Chalmers and Thomas C Chalmers,' is whether ethical committees are the appropriate bodies to determine whether research has been appropriately designed. Although I sympathise with the view that it is unethical to do poorly designed research, I do not feel that it is appropriate or realistic to expect ethical committees to have the skill and experience to make judgments on this. ANN CARTWRIGHT. Institute of Social Stuidies in Medical Carce ILondon N%C'3 2SB I ILock S. Monitoring rcsearch cthical committees. Br Mled 7 1990;300:61-2. 13 January. 2 Department of Health. Drtji health circular: local research ehtical commi'ttees. London: Do)H, 1989. 3 \arious authors. Rescarch ethics committees. Br Med 7
1990;300:395-6. 4
Cartwrigltt A, Hockc I., Ainderson JL. Life before death. London and Boston: Routledge and Kegan Paul, 1973.
SIR,-As chairman of a local research ethics committee I would like to add to the debate taking place in the BMJ's correspondence columns. ' I think that there are serious problems associated with a national ethics committee that would consider the ethics of proposed multicentre trials. Ethics concerns arguable opinions, not indisputable facts. It is therefore not surprising that when different ethics committees consider the same proposal they do not always agree. This mav be tedious and inconvenient for researchers attempting to set up a multicentre trial, but I 607
