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US courts challenge
evidence from DNA
Controversy surrounding the US National
Research Council's endorsement of forensic
DNA tests is limiting their use as evidence in
criminal cases in US state courts. Courts in                                                                 ...

California and Massachusetts and on the                                                                               .......:
island of Guam have ruled that DNA finger-
printing still lacks a scientific consensus.
   The worry is that a DNA test could give a
positive result by chance because the exact
genetics of the population are not known. On
8 September the United States Law Week             ' i
reported that "ongoing debate about the
impact of population substructure on the
statistical validity of DNA 'matches'-                                                                                                          -
noted in a National Research Council reportF
released in April-prompted the Massachu-                                                                                                    -
setts Supreme Judicial Court [on 20 July] to       Fingering the evidence: how accurate is DNA fingerprinting?
conclude there is a lack of general scientific
acceptance conceming the method Cellmark
Diagnostics laboratory and the Federal             Hospital in Baltimore, Maryland, held a                       wrong person (BM7, 18 January, p 139).
Bureau of Investigation use to calculate DNA       press conference to denounce the newspaper's                  Fisher told the BMJ that the American
profile frequencies." And two weeks ago            article and "confirm the general reliability of               Association of Crime Lab Directors-
Nature reported that the California Court of       using DNA typing in forensic science."                        Laboratory Accreditation Board, which he
Appeals and the US District Court of Guam             The New York Times corrected its error the                 chairs, would propose standards of accredita-
had also ruled "that the scientific uncertainty    next day. But the damage had been done.                       tion for forensic DNA testing to its members
over the role of population substructure in        An aid to Congressman Don Edwards, a                          at the end of this month.
calculating the chance of DNA matches is too       Democrat in California, told the industry                        Fisher said that the state's attorney general
great to pass the so-called Frye test, a           newsletter Biotechnology Newswatch that                       would appeal against the Bamey-Howard
measure of scientific acceptance needed for        the article was "clearly overstated. Unfor-                   ruling to the California Supreme Court.
legal acceptability set out in a 1923 decision     tunately, the response [by McKusick] was                      "There's a difference of opinion between
by the US Supreme Court."                          to understate the report's conclusion. The                    academics and people in the trenches,"
   The appeals decision in California affected     report is quite critical of the way DNA                       Fisher said. He noted that estimates for a
two cases-a murder (Howard) and an                 evidence has been handled up to now."                         DNA match occurring by chance ranged
attempted rape (Barney)-in which blood                Indeed, the conclusion of the National                     from 1 in 10 000 to as high as 1 in 738 million
and semen samples were the sources of DNA          Research Council's report is not clear. "DNA                  million. "I don't care," he said. "Even if it's
analysed by a crime laboratory. "Howard and        typing for personal identification is a powerful              1 in 10000 that's more than enough."-
Bamey raise almost identical issues pertain-       tool for criminal investigation and justice," it              REGINALD RHEIN,          medical journalist,
ing to the question whether there is general       says. "At the same time, the technical aspects                Washington, DC
scientific acceptance of DNA analysis and the      of DNA typing are vulnerable to error,
adequacy of the [Frye test] in each case," the     and the interpretation of results requires
court said.                                        appreciation of the principles of population
   The National Research Council's report          genetics." One of the report's main recom-
"acknowledges there is a 'substantial contro-      mendations is that "courts should require                     DNA accepted in
versy' concerning the present method of            that laboratories providing DNA typing
statistical analysis," the court said. The court   evidence have proper accreditation for each                   British courts
noted that the report "does not, however,          DNA typing method used." Another is that
choose sides in the debate, but instead            the Department of Health and Human                            DNA profiling is widely accepted in Britain's
'assumes for the sake of discussion that           Services should establish mandatory accredi-                  criminal courts, although the Court of Appeal
population substructure may exist."'               tation, in consultation with the Department                   has not so far formally considered the tech-
   The reseach council, an arm ofthe National      ofJustice.                                                    nique. Criminal lawyers could not think of a
Academy of Sciences, issued its report DNA            Despite the controversy, prosecuting attor-                case where a judge had thrown such evidence
TechnologSy in Forensic Science on 14 April.       neys are confident that forensic DNA tests                    out. The danger, according to Peter All-
That morning an article in the New York            will be accepted in all US courts eventually,                 dnidge of Cardiff Law School, writing in this
Times predicted that the council's study           said Barry Fisher, who directs the crime                      month's Criminal Law Review, is that DNA
committee would conclude that DNA tests            laboratory for the Los Angeles Sheriff's                      profiling may be considered infallible and
"should not be allowed in court in the future      Department. Several months before the                         defence lawyers may regard the evidence
unless a more scientific basis is established."    report was issued the Federal Bureau of                       as unchallengeable. "What appears to have
But the study committee's chairman, geneti-        Investigation changed the way it calculated                   happened is that the mere mention of DNA
cist Victor McKusick of the Johns Hopkins          the odds that DNA typing would identify the                   evidence for the prosecution has generated

BMJ VOLUME 305           24 OCTOBER 1992                                                                                                                    973
                                                    guilty pleas," he says. In one  case a legal aid
  Headlines                                         committee refused defence solicitors the cost l
                                                    of forensic work on the ground that DNA
                                                    evidence was incapable of challenge.
         Rome bns
               smoing: A Italin en-                    Even a High Court judge, Mr Justice
                                                    Alliott, confessed last year at the Old Bailey

  restaurants, and indoor markets and       samples were used as a basis for what the 9*^ ^                           _ ;     -
  willnmetake effectein w geekstieprosecution said were "very, very long odds"l
                                            against pinpointing the wrong person.                   " __
  US public health system fails to            The judge threw out the case, which_t
  attack diseases: A report from the        involved a 37 year old Mghan, beeause        rap
  N ational    Academy of Science urges     of "incompetence" by the prosecution un-
  health officials to be aware of the |Hrelated to the DNA tests. He said he wasl
  potential for epidemics. The report       disappointed that there would be no resolu-                   i
  says that public health surveillance      tion of a problem about DNA evidence which
  systems are unable to detect threats      he had not been aware of before reading the
  from either new diseases such as AIDS     defence material._
  or the re-emergence ofubereulosis.           In Britain new forms of scientific est M                                 iu w
                                            whceh prove to have forensic appleations are
  British government relaxes adoption       introduced in the courts on an ad hoc basis.
  rules: Local authorities will no longer   The only test is that they must be relevant Tandem IQ. The controversy over the effects
  be allowed to impose upper age limits     andhelpful. IntheUnitedStates,bycontrast, of supplements on children's IQs, which
  on adoptive parents under changes         any new scientific te               u h  o pass the dates from a study in 1988 by Dr David
  to the adoption law proposed by a         "Frye test" of general acceptance in the Benton, a research psychologist at the Uni-
  government working party. Racially        scientifioeommunity.                                 versity College of Wales at Swansea, was
  mixed adoptions will also be allowed.       Mr Alidridge points out that DNA evi- thrashed out over five days at Shrewsbury
  Preference will still be given to         dence is not proof against human error, and magistrates'court.
  married couples. Children over 12 ean     challenges may be mounted on two grounds:               Shropshire trading standards department,
  vetoiany adoptiondplans.                  technical errors in carrying out the test and which brought the case, alleged that the
                                            the inferences to be drawn from the results packaging of Tandem IQ, which showed two
  German controversy over dead              based on population geneties. But statistical ehildren reading, gave the impression that
  mother's fetus: In an attempt to save     arguments about whether pattens un- the product could improve the intelligence of
  her 14 week old fetus an 18 year old      common in the general population might be all children, not just those who were poorly
  dental nurse is being artificially venti- common in the defendant's ethnic group nourished. David Roberts, chief trading
  lated after a car accident. The case has  have not had much play in Britain, and Home standards officer, said: "We're pleased with
  aroused controversy in Germany since      Office forensice sientists regard the question the outcome. It vindicates the view that the
  the aecident on 5 October. News-          of ethnieity as a tred        herring.               experts advising us took, that this was too
  papers have accused doetors of being         DNA profiling and scientifie evidence general a claim. It ats as a wamring to others
  perverted in their judgment.              generally is one of the subjects under to make sure they use scientific evidence
                                            review by the Royal Commission on Criminal carefully."
  University staff's reduced pay rise:      Justie, set up in the wake of a series of               The stipendiary magistrate, Harry
  University staff in Britain, including    misariages of justice. Mr Alldridge argues Hatchard, said he accepted that the
  medically qualified preclinical teachers, that a new scientific technique should have to company's paekaging was not a deliberate
  will receive a salary rise of 412%,       go through some test to ensure reliability hoax. Its chairman, Dr Robert Woodward,
  backdated to April, with an extra         of the evidence produced. He suggests an genuinely believed the producteould en-
  willperohbi O-75%/t available
              thae           41ofbigedients
  discretionary acsaedotr for per-             DN       rfln-n cetfceiec                                      li. IQs. sawmn offence
                                            independent committee that would have to hance children's Itat The company'soohr
  formance related pay. The payment is      validate a new technique before it was used lay in not taking sufficient care to limit the
  2ot less than a~ anward agreed by
          clnes~ ~         ~ ~~~~~~usie upe inscourt.
                                                scts inv the waeobeerenf                         claimsaforritsmproduct. Th mistelsaid he
  employers but vetoed by ministers,                                                                Th         tpniay mgsrae
                                               The committee would lay down was satisfied that there was reliable evidence               ar

  who refused independent arbitration.      standards for the the the test was performed, that only children with a dietary deficiency
                                            and the court would have to decide in each were likely to benefit from vitamin and
  Fated prob vrs ndrugAdministrainc
      eF ood andro 415 drug. igedients:       individual OUt.LARE DYER, legal s ineral,supplements.      r
                                            properly carriedwhether the test had been m Tandem IQ and two similar products,
  The prohdibt tnh sale Adof4 Ningsredient  correspondent, BMJ                                   Vitachieve and Boost IQ, became best-sellers
  contained in over the . counter medi-
                                . .       .                                                     ~~~~~~~~~~~~~~~~after
                                                                                                        the TV science programme QED publi-
    cines. because theyvhaveanotobeen                                                            cised Dr Benton's study. He had tested two
                                            miscamages of justice.MrAlldridgearguhgroups of 12 year olds and then gave one
    University staff in Britain, including
  shown to be effective for their stated
  aim   .Peppr    main pwill no teonher be
                 to April
     backdated a digestion aid. anextra     ofthviaenuceturers fined . mixture of vltamin and mineral contanlng
                                                                                   H sss         placo s and athe o r lls                  a
  available as
                                                        T                                        Those given the supplement gained seven
                                            forpvitamin claims
                                            c e
                                                                                                 IQ points on average.
  More medical schools? New univer-                                                                 The prosecution will cost Larkhall nearly
  sities in Britain, such as Brighton       A health food company last week became the £100 000. The company put its own costs-
  and Plymouth, are considering estab-      third vitamin pill manufacturer to be fined inldng the expense of flying in expert
  lishing medical schools, the Times        for making exaggerated claims that their witnesses-at around £70 000. The other
  Higher Education Supplement reports.      products could boostchildren's IQs. Larkhall two maufacturers Seven Seas and Raw
  They are encouraged by the suggestion     Natural Health was fined £1000 and ordered Power pleaded guilty earlier and were each
  that the Department of Health might       to pay £35 000 prosecution costs after being fined £4000 for making false claims about
  increase the quota of medical students    found guilty on three charges under the their respective products, Boost IQ and
  by 0o.
  s                                         Trade Descriptions Act over the packaging Vitachieve.bLAe DYER, legal correspon-
  aims._Peppermint_will_no_longer     beanufacturersfined
                                                       vitamin mineral supplement, dent, BMJ

974                                                                                                    BMJ VOLUME 305      24 OCTOBER 1992
Labour's policy for                                and people eat a lot
                                                                                 of   shellfish in Hong these pollutants40 years and that's howinlong
                                                                                                        developing for have been building up the
London s health                                      Half of Hong Kong's daily sewage and
                                                   waste water stream is untreated, and a further
                                                                                                                                                "At the
                                                                                                            bottom sediments," said Mr Morritt.dredging
                                                                                                            moment there is a great deal of
                                                   40% undergoes only primary' treatment to                 going on for land reclamation and the sedi-
                                                   remove solids. "Just 1O0% receives proper                ments are being disturbed. These dangerous
London's health services last week, support-       treatment," according to Ms Joanna Ruxton,               pollutants -are being spread throughout
ing a shift of resources into primary health       marine conservation officer for the World                the marine ecosystems."-FRED LENIHAN,
care and the development of community              Wide Fund for Nature in the colony. "People              freelance journalist, Bangkok
health centres. But Labour states that no          are increasingly concerned. It became a big
hospitals should be closed until alternative       issue recently when the colony's sewage
services have been set up under the super-         strategy was shelved, and we decided to
vision of a special task force that will report to collate all the existing information on water
a new regional health authority for London.                                                             Drug com anies
   In a statement of principles Mr David poluion into one report. It's been well                        pusay
Blunkett, shadow health secretary, says that areceivedgand we u eristnth auto i oi
change must be managed carefully over Rextang
an adequate timescale. He warns against Rton.          It is estimated that it would cost $3-2 bn Canada c s t.
hospital closures being based on financial
                                                                      opoieHn ogwt
gain from sales of prime sites. But he also fentralised ntreatment system for sewage and The latest evidence of the flourishing partner-
wants to ensure that "vociferous advocates"' ewaste water. The new governor, Chris Patten, ship between university research and the
                                          wants to
of a particular hospital do not override the recently allocated HK$3 bn for the project, pharmaceutical industry is the announce-
interests of local people.
                 Leondon' health crisis
   Labour attributes London's health cnlsis. although
                                                               overall..financing  remains              ment.that Canada's first Centre for
                                                     Mr Morritt explained: "Because the public Medicine and Therapeutics will be estab-
to consistent underfunding and suspects the                                                             lished at the University of British Columbia
                                                                           are so large it does require
goverment of using Sir Berard Tomlinson's expenditure figures
report on health care in London to implement
                                                     a great deal of thought, but the colony is         with theFrosst aCanada million grant from
                                                                                                                  aid of Can$15
                                                  freaching    a crisis point."                         Merck                       Incorporated. The
                                           furthr cs aIn addition to heavy organic pollution in the grant is the largest for extramural research
of new NHS trusts and general practitioner colony's coastal waters, figures show increas- Merck has ever made worldwide, and the
                    besueed andv key spe
fundholders to be suspended andkey spe- ingly serious heavy metal contamination in biggest made by any drug firm to research
cialtistihospitals reoedfomtevaaie
                                                  fsediment layers in the bays. Much of this based in a Canadian university.
   com Labour.also proposes greater integra
                                                     stems from Hong Kong's many thousands                The new centre will be dedicated to under-
                                                     of small metalworking factories, which standing the genetic causes of disease and
of medical training with the capital's academic discharge their untreated, toxic wastes developing clinical strategies and new drugs.
institutions, possibly leading to the establish- directly into storm drains. Activists claim Scientists will interact with the more than
ment of a London medical science park.- that heavy metal pollution will pose another 4000 scientists in Merck's laboratories
JOHN WARDEN, parliamentary correspondent, serious health threat.                                        around the world.
BMJ                                                    The Hong Kong Environmental Protection              The director will be a specialist in Hunting-
                                                     Department's own statistics show bottom ton's disease, Dr Michael Hayden, professor
                                                     sediment readings in Kowloon Bay at 8800 of medical genetics at the University of
                                                     mg/kg for copper, 680 mg/kg for chromium, British Columbia. He is also director of the
                                                     9-6 mg/kg for cadmium, and 620 mg/kg for Canadian Genetic Diseases Network, a
 Untreated sewage                                    zinc. The sediment contamination that the consortium of Canada's leading genetics
                                                     authorities use as a benchmark for action is researchers linked with universities and
brings hepatitis to                                  recorded at 65, 80, 1-5, and 200 mg/kg industry.
                                                     respectively. "The level of heavy metal and           Prime minister Brian Mulroney's govern-
Hong Kong                                            toxic pollution in some of the bays is another ment has strongly encouraged research by
                                                     real health worry. Hong Kong has been the pharmaceutical industry. In 1987 it
 A dramatic rise in the incidence of hepatitis A
 and gastrointestinal disorders in Hong Kong
 in the first half of this year has been linked to
 the daily discharge of two million tonnes of'
 mainly untreated sewage and waste water
 into the colony's heavily polluted coastal
 waters. A report published jointly this month
 by three environmental action groups claims
 that 2242 cases of hepatitis A were reported
 to the public health department in the first six
 months of this year-70% above the total of
  1297 for the whole of last year. Water Pollution
 in Hong Kong: A Time to Act states that "the
 population is at greater risk of. general
 stomach disorders, as well as eye infections,
 ear infections and skin rashes."

 for Frieds of the Eart in Hong Kiong, said,                                                                                                               z

 Hepatitis A is transmitted through sewage in __-S <srXXiIu
 the coastal waters, and because so much of it                                                              _0i_5
 is now being dumped untreated in the bays               -_-g                                                                                              z
 the marine ecosystem is suffering heavier ||
 problem because they become contaminated            Untreated water is ruining Hong Kong's health

 BMJ VOLUME 305            24 OCTOBER 1992                                                                                                          975
       passed Bill C-22, extending market exclu-                                   dex Leluk questions the board's methods.       that the winter is democratic. It will kill the
       sivity for drugs for 7-10 years in return for                                  Leluk points out that provincial health     children from all sides."
       promises of increased research and develop-                                 ministries face rising drug costs-close to       Unicef are putting out adverts 12 times
       ment expenditures by the drug companies.                                    $900 million this year in the case of Ontario. a day on Croat and Serbian television-
       The companies responded by more than                                        There the rise has been close to 20% annually, promoting the week of tranquillity. "If it fails
       doubling such expenditures. Last January                                    in Alberta 18%, and in Quebec 17-5%. Pro-      then there will be scenes like the siege
       the government endorsed a General Agree-                                    vincial health ministers have set up a task    of Leningrad-with hundreds of thousands
       ment on Tariffs and Trade (GATT) proposal                                   force to study how to reduce costs-DAVID       of children and elderly dying" said Edith
       that extended patent protection by a further                                SPURGEON, medical journalist, Canada           Simmons. "The television cameras will be
       three years on average. The industry in-                                                                                   there to record it and the world will find it
       creased its research and development invest-                                                                               unbearable to watch."
       ments to about Can $400 million. Last June                                                                                    There are now over 1 350 000 refugees in
       the government introduced Bill C-91, which                                                   g                             Bosnia-Herzegovina-most of them women
       follows the GATF proposals.
          British Columbia's government is expected
                                                                                   Unicef gets ceasefire                          and children, according to Unicef s latest
                                                                                                                                  figures. Unicef estimates that over 317000
       to pay for the new centre's building, and                                   In fo            er       Yugoslavia           children, pregnant women, and nursing
       hopes that this will lead to establishment of a                                                                            mothers in Bosnia-Herzegovina urgently
       pharmaceutical industry on the west coast.                                  Unicef have received a firm promise from all need supplenmentary feeding. The numbers
       So far, most of the industry is centred around                              the political leaders in the former Yugoslavia are higher in Serbia and Croatia, where
       Toronto and Montreal.                                                       for a one week ceasefire beginning on 1 crowded collective shelters increase the risk
          Merck Frosst Canada said that it will only                               November. The ceasefire will allow convoys of epidemics, which are now more likely with
       go ahead with the new centre if Bill C-91 is                                to reach up to one million children, bringing the onset of winter. Sarajevo is trying to
       passed into legislation. But the bill is strongly                           them winter clothes, blankets, medicines, restore its electricity and water supplies.
       opposed to generic drug manufacturers, who                                  and vaccines. "We have talked to every Hospitals in most of the former Yugoslavia
       claim that it will lead to a rise in drug prices.                           political leader in this conflict," said Edith are already short of basic drugs, vaccines,
          Nicholas Leluk of the generics' Canadian                                 Simmons, Unicef s liaison officer in former and medical equipment. A quarter of all
       Drug Manufacturers Association maintains                                    Yugoslavia. "We have got a military under- the working space of hospitals and health
       that prices of new drugs are now higher than                                taking that they will stand down for a week of centres has been destroyed.
       before as a result of Bill C-22. But the Prices                             tranquillity for the children. We believe that    Unicef says that 1417 children have
       and Medicines Review Board, set up to                                       it will work where other ceasefires have not been killed and 29 169 wounded in Bosnia-
       monitor prices after Bill C-22, claims that                                 because we have looked these people in the Herzegovina since the war started. Unicef
       between 1987 and 1990 prices of existing                                    eyes and asked them how much they care predicts that if the ceasefire is unsuccessful
       patented drugs remained consistently below                                  about their children. If someone shoots-the children will be dying of starvation within
       its guidelines and the Consumer Price In-                                   whole world will see it. We have told them three weeks.

          Abortion: How available is it for women around the world?

                                  ........   .....~~~
                                                                                                                     OJBU1            *                                                   4&X
...   .......................~ ~ ~~ ~ ~ ~ ~ ~ ~                            ~       ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~4

                                                      ~ ~ ~~       ~   ~       ~    ~   ~   ~    ~   ~   ~   ~   ~    ~   ~   ~   ~
                     Convention       em.

                                                                           976                                                                              BMJ     VOLUME     305.24.OCTOBER 1992


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         Cot'nto o teehintonofalfrm f isrmiaongainstwmn.

        976                                                                                                                                                   24 CTOBER 1992~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
                                                                                                                                                            BMJO305 VOLUME
                                                    the right and duty to raise with their employ-       of providing oxygen concentrators at home
                                                    ing authority or trust any matter of concem          for people with chronic bronchitis might
                                      X   ^   i     they may have about health service issues.           seem too high if researchers did not wait to
                                     t;;      _E    Stating that the interests of patients are           see the long term benefits. To avoid throwing
                                                    paramount, the guidance,says that employees          out such valuable interventions a thorough
                                                    have a duty to draw to the attention of              system of assessment is needed.
                                                    managers any matter they consider to be                 Firstly, all possible outcomes of introduc-
                                                    damaging to patient interests and to put             ing a new technology should be considered.
                                                    forward suggestions for improvement.                 These may include clinical, administrative,
                                                       Each NHS employer' should draw up                 financial, and social implications. For
                                                    policies and procedures locally to enable the        example, the widespread introduction of day
                                                    rights and duties of staff to be fully and fairly    surgery has required many changes for
                                                    met. Under no circumstances are employees            surgical units and more work for relatives
                                                    to be penalised for using the procedures.            and district nurses-all outcomes that need
                                                    If grievances cannot be resolved informally          to be assessed.
                                                    they can be formally referred all the way up to         When randomised trials are impossible or
                                                    the chairman of the health authority or NHS          inappropriate, large observational studies
                          _;;                       trust.                                               can provide useful data. Once the data have
                                                             The main constraints relate to confiden-    been collected they can be used by other
                                                          tiality. Unauthorised disclosure of personal   researchers (particularly before protocols
                                                        f information about any patient will always      for further study are drawn up) and, in
                                                          warrant disciplinary action. Under common      accessible forms, by clinicians, purchasers.
                                                          law employees also have an implied duty of     politicians, and patients.
                                                       : confidence and fidelity to their employer.         To assimilate data of high quality the NHS
                                                       2 A breach of this duty may also result in        should appoint special staff, says the report.
                to se          militavaluechldren
The world waits to see how the military value children    disciplinary action whether or not there
                                                          .                                              The advisory team proposes that a proper
                                                          is a clause to that effect in a contract of    career structure for health technology assess-
   The agency estimates that 900 000 children employment.                                                ment is created, along with specialist centres
have been traumatised by the war. "I visited                 As a last resort an employee may "contem-   for collecting data. Someone wanting to
children who had been living in cellars for six plate the possibility of disclosing to the media         know about a new treatment for schizo-
months. They had gone without fresh fruit a matter of genuine concem"-but should                         phrenia, for example, should be able to
and had not been to school for six months," first consider the possible consequences of                  contact a centre where all relevant domestic
said Edith Simmons. "I interviewed one such an action. Any unauthorised disclosure                       and international psychiatric research (both
child who had been sitting on his mother's of matters relevant to the employer's                         published and unpublished) has been
lap on a bus that was attacked by snipers. His responsibilities might represent a serious                subjected to meta-analysis and stored in an
mother was shot dead trying to protect him." breach of contract. Employees are advised to                electronic database.
  To help children come to terms with their seek advice from their professional or repre-                   Such databases already exist for certain
experiences Unicef has set up workshops for sentative bodies.                                            diseases, including breast cancer and peri-
local psychologists, teachers and for parents                The guidance states that all staff must     natal problems. Dr lain Chalmers, chairman
to learn "first aid trauma." "We ask the retain the right to consult their professional                  of the Advisory Group on Health Technolo-
children to draw a picture of their village organisation or trade union. Comments on                     gies, which prepared the report, asserts
before and after the war or write an essay on the guidance are invited by 13 November to                 that "there is an appetite for this sort of
what they would do if they were president," Peter Hall, NHS Management Executive,                        information, not only among doctors." For
explained Ms Simmons. "These children are Room 234, Quarry House, Quarry Hill,                           example, many NHS purchasers have
confused. They cannot understand why their Leeds LS2 7UE.-JOHN WARDEN, parlia-                           already used the database of the National
friends and neighbours have turned against mentary correspondent, BMJ                                    Perinatal Epidemiology Unit in deciding
them. They are all terrified of grenades.                                                                how to spend their budgets. Dr Chalmers
Many have seen their fathers killed. Adults                                                              was director of that unit for 14 years and
prefer to think that children haven't taken                                                              has just taken up directorship of the new
these things in-but there is a need for                                            *                     Cochrane Centre, where he will help to set up
children to talk about their experiences. It is Technologies need to                                     and disseminate a register of controlled trials
hard for adults to hear it. You feel so be tested
ashamed. "-LUISA DILLNER, BMJo
                                                    Doctors would not prescribe a drug that had
                                                    not been tested but they offer other health
                                                    interventions that have never been rigorously
                                                    evaluated. With limited money and a nation s
New guidance for                           health at stake this haphazard approach is no
 wf Healh.Isfiebowoses'frs and effectlv    walonger good enough, says a report from the
localhproceduresbthrougheascenin levels ofNHS Research and Development Division.
                                              In future, says the report, all new health
The right of NHS staff to freedom of speech         technologies offered to the NHS should first
about health service issues and the care            be evaluated to see if they make people
ofpatiwens a isformallytrecognised dora
                              iS                    shealtier ateasonae cst. Te terhealth

loalrcdresthrounghtaslendewingtlevelsf"ofwae"rsuc ais healtehihdcation, culical n hw_

 anser giallegsatios that alNHS employer             shourreld bale bandon ted." BThsoentia xenoelO-
                                                                  a                   i                    ye thm- otyotauaufroeae

BMJ VOLUME 305                 24 OCTOBER 1992                                                                                                      977
as part of the NHS research and development
programme. (3 October, p 787.)
   Doctors who lack the appetite for such
data are warned in the report: "Health
professionals want to do the best for their
patients, but their training often leads them
to be more certain than is justified about--A .+
what is best. "-TRISH GROVES, BAl

British court orders                                                                                                            I         I

caesarean section
An emergency caesarean section was camed-
out at a London hospital last week after the
High Court overrode the mother's objections
on religious grounds. In the first case of its
kind to reach court in Britain, Sir Stephen_
Brown, president of the court's family divi-      N       y e
sion, granted a London health authority a
declaration that the operation would not be
unlawful, despite the mother's refusal.           an out of court settlement and an agreement       greater emphasis on health promotion activi-
   In a 23 minute court application, Sir          from the hospital that it would set up an in      ties encouraged by the -1990 general prac-
Stephen was told that the 30 year old mother,     house ethics committee to safeguard pregnant      titioner contract, the introduction of general
Mrs S, had been in labour for two days. The       women's rights and would "virtually never"        practice fundholding, and the proposals in
fetus was full term, in transverse lie, with an   take such cases to court in future.               The Health of the Nation. One in six practice
elbow projecting through the cervix. The            Mr Levy said it seemed that Mrs S could         nurses had changed their employment in the
only means of saving the lives of the mother      also bring a civil action, for assault, if the    past six months, most moving from an NHS
and her unbom child was to carrv out a            Appeal Court ruled that the High Court            hospital post. Practice nurses were most
caesarean, and it was a case of "minutes          declaration was wrongly made. But the             satisfied with their work. One nurse com-
rather than hours," Sir Stephen was told.         damages would be likely to be minimal, he         mented, "Before being employed as a practice
The operation was carried out, but the baby       added.-CLARE DYER, legal correspondent,           nurse I worked as a district nurse. I moved
died. The mother is recovering.                   BMt                                               because of the management and lack of
   Medical lawyers believe the case should go                                                       flexibility in what nurses were allowed to do.
to appeal, since-as Sir Stephen, England's                                                          I am now treated with more respect and am
senior family judge, conceded-there is no                                                           encouraged to train to develop other nursing
authority in English law for a competent                          s                                 skills."
patient's refusal of treatment to be over-        Nurses          st'll feel                           The survey was submitted to the nurses'
ridden, even if the result is certain death. In                                                     review body to back up its claims for an 8-7%
addition, earlier cases have established that a   overworked and                                    pay rise. The college's secretary, Ms Christine
fetus has no rights under English law.                                                              Hancock, commented, "There is clearly a
   Sir Stephen said there was "some American      Unaerpald                                         high level of unpaid, unchosen overtime
authority" which suggested that a declaration                                                       being worked." She believed that the survey
should be made in the circumstances of the        Many nurses believe that working above            confirmed anecdotal evidence of growing
case. However, the case he cited, that of         their normal hours is an inevitable part of       pressures on nurses.-LINDA BEECHAM, BMJ
Angela Carder, established that mothers           their job but fear that it makes them unable to   Motivation,the 1990sand publishedAby the Institute of
                                                                                                                 Morale     Mobility: Profile of Qualified
should be forced to undergo caesareans            provide patients with the kind of care they       Nurses in            is
against their will only in "extremely rare"       need. A survey of 3000 qualified nurses, by       Manpower Studies, Mantell Building, Falmer,
and "truly exceptional" cases. The case, the      the Institute of Manpower Studies, finds that     Brighton BN1 9RF, price £15.
first to go to a fully argued appeal, is widely   they are still struggling to complete essential
credited with having stemmed the tide of          tasks, paperwork, and other duties. Less
caesareans ordered by American courts,            than half of the respondents thought that
which were numbered in dozens.                    they were paid fairly considering their level
  Margaret Puxon, a QC and former ob- of responsibility. Two thirds of nurses                       Royal Society calls
stetrician, said that the decision would          thought that career prospects were becoming
probably be overruled by the Court of Appeal
if Mrs S appealed. Allan Levy QC, who has
                                                  less attractive, and almost half said that they
                                                  could eam more money for less work if they
                                                                                                    for career
                                                                                                    for scientists
appeared in most of the leading cases on          left the profession.
consent to treatment, said: "I hope it goes to       Despite these findings the proportion
appeal-it's too important not to. It should       leaving nursing has fallen to under 7% from       Poor conditions and career prospects for
go to the House of Lords."                        1 1% in 1986-7. The report says, "Most            researchers were the commonest issues raised
   Angela Carder, a patient at George             nurses have spouses, and in most cases their      by themore than300 peopleandorganisations
Washington University Medical Center in           nursing jobs will be seen as more secure          who responded to the Royal Society's
Washington, DC, was dying ofcancer and 26         than jobs outside the health care sector."        20 month inquiry into the science base in
weeks into her pregnancy when the hospital        When asked about job satisfaction only 9%/        Britain published this month. "As profes-
won a court order permitting a caesarean          were negative about nursing. Three quarters       sional scientists we believe that an inadequate
against her will and over the objections of her   of the nurses were working in the NHS and         number are being trained for the next genera-
family and the doctors caring for her. Mother     most were working in acute specialties.           tion . .. the majority of lively, young people,
and baby died. The appeal court ruled that           Since the early 1980s the number of nurses     with the necessary intellectual gifts, seek
the order should never have been granted.         employed by general practitioners has risen       training in other careers from an early age,
After the appeal Ms Carder's parents sued         from nearly 4000 in 1984 to over 13000            and we have difficulty in persuading young
the hospital and won undisclosed damages in       in 1990. The increase has been due to the         science graduates to embark on a research

978                                                                                                     BMJ     VOLUME 305           24 OCTOBER 1992
career," says one fellow of the Royal Society Indian                                dam p                     now colleges have mushroomed-there are
 in the report.                                                     courts                                    117 recognised and 27 unrecognised medical
    One reason why the young leave science is down on private                                                 colleges in India. Many have lobbied for
that they are most likely to be employed on                                                                   recognition after opening, sometimes exert-
fixed term contracts. Between 1977-8 and medical schools                    -                                 ing political and industrial pressure through
1990-1 short term researchers in science and                                                                  strikes.
engineering in universities increased by 6000, In the past few months India's highest courts                     A further examination of medical training
rising from 22% to 44%/ of total academic have condemned the spreading privatisation                          will be carried out by a special ministerial
staff. Between 1979-80 and 1989-90, 1100 of medical and dental education in several                           committee set up by the National Develop-
permanent posts. Were lost, although 300 states The controversy started when the                              ment Council on Medical Education and led
were restored in 1990-1. Another problem Andhra Pradeshstate governmentintroduced                             by Professor J S Bajaj. The committee will
for young scientists is the constraint placed an amendment to an act on educational                           review the standards required for entry to
on research by having to spend time raising funding, thus allowing medical and dental                         medical school and the quality of education
money, teaching, and administering.                 colleges to charge private fees for up to half of         and will attempt to predict future needs for
    Salaries have also been reduced relative to alltheirplaces                                                medical manpower in India-ZAKA IMAM,
others, and Sir Michael Atiyah, president of           The state's High Court ruled against the               medical writer, Lucknow, India
the Royal Society, said that many PhD amendment sigh it wuld contr e
                                                     equalitycau in the Ind onstitution
students lived below the poverty level. "That equ alilty clauses in 'the Indi an ccontittin
makes me very makes meveryangy,"headded. O
                     angry," he d. Other and lead to a two tier system of education.
causes of the young not wanting to enter The High Court also quashed two orders
careers in research are the "perceived reduc- by the state government that would have                         Launch of Official
tion in the prestige of science and scientists allowed the opening of 12 more medical and
and the reported lowering of morale."               eight more dental 'private colleges in the                Health Statistics
    But science remains a wonderfully reward- state.                                                          w
ing career for those who make it through,.             In tur the Supreme Court ruled that                                  Group
said Sir Michael, ' report proposes ~~~~~~Andhra Pradesh had a fundamental obliga-
                      .and the
changes at every level of the present structure.
Firngest athev                                 *ch education and a choice of (non-private)
Firstly, those beginning a careerirese research tion provideasked all state governments,
                  beg         a aee in          r         to                                                  "A whole paradigm shift is needed, not
                                                                                                              just in Britain but elsewhere," said Bill
should be advised -that many will not be able the Medical and Dental Councils of
to make a lifetime career in science. "People and the University Grants Commission to
                                                                                              India,          McLennan, the newly appointed head of the
thoumak arlifetognimecareeri
                        cidfen. "Peopey
         should recognise,
                                                    submit plans on college funding. Chief
                                                                                                              Government Statistical Service. "Statistics
                                                                                                              should be collected according to the needs of
professor of geology at Oxford and a member Justice M H Kania observed that racketeering                      the users rather than the needs of collectors."
of the committee that produced te    d the. report,
of"thetscomitcedoesn hate
                    t       prod rporat,            in private colleges must be stopped.                      Mr McLennan was giving his backing to the
"thatescencge doesain'tngn
                        hveno            vation. Andhra Pradesh is not the only state where
                                      e and
                                                    private medical- education -has been proli-
                                                                                                              newly launched Official Health Statistics
                                                                                                              Users Group at a meeting in London this
go and do something else." Sir Michael
                           reseacher     adferating.inInfees are collected annually 1000m
                                  career advice all
added that researchers "need career                 rupees
                                                                 Karnataka approximately
                                                                                              and a
                                                                                                              month. Similar groups have been set up
                                                                                                              by users of statistics on trade, the labour
the way through." One problem, says the single place to study medicine costs up to                            market, transport, and housing under the
report,   is that many researchers "are funded 1 .2m rupees. In Maharashtra state in 1988 the                 auspices of the Statistics Users' Council.
by one organisation and employed by another, government banned the collection of
with neither .taking an interest in their educational fees but continued to private
                                                                                                                 Users at the meeting must have felt that
                                                                                               allow          they were pushing at an open door. Providers
  A major recommendation of the report is                "donations" to colleges.                             of statistics from the Office of Population
                                                           In response to the controversy the central         Censuses and Surveys, Department of
that about five years after taking their PhDs
                                           Indian government has decided that no new                          Health, and Health and Safety Executive
researchers should be able to compete for  medical and dental colleges should open                            described how much more customer oriented
contracts guaranteeing their. salary e as
                               ctt g aeg and
                                           without the prior approval of the Medical                          they had become recently, giving the audience
research expenses for at least five years. Ifthe.
researchexpenses foredatilstfivetion yhearsand Dental Councils and has passed new
                                           legislation ' to ensure that this happens.
                                                                                                              details of the statistical series that' they
                                                                                                              collected. In addition, the Department of
contracts would go with them. The Royalle
concits wouldeves gtwthis             thet
Society believes that this them. that Roya
                           means      more
                                           Without such restrictions on approval until                        Health provided a directory of relevant
resources would be allocated by genuine
competition, researchers would have more
independence, and universities would have
to compete to attract good researchers.'
  Those who proved unsuited to a research
career would be helped to transfer to different
employment, but the report also proposes a
research officer path for those who want to
stay in research but who will not become
leaders in it. Eventually some high fliers
would be given permanent posts. But, says
the report, "the old system of awarding
tenure was imperfect ver few respondents
to the inquiry advocated continuing it."'

Michael saidthat if changeswere nost mdee Sin
science policy in Britain then in 10 years'                          (i                  °i       S_                                                1    1
time Britain would be firmly in the second                                                     1jBe                    -    i    ,    f
tions on the PorganisaOtionand fu°mnding 0of
science and on European and international .* .Z
iSSueS.-RICHARD SMITH, BMJ                               _e_
The Futur of the Scee Bas is available from the h..-............ :,_3
Royal Society, 6 Carlton House Terrace, London
  SWY A, price £ 1.50u.                            India 's medical education is under governmnent scrutiny

BMJ     VOLUME 305           24 OCTOBER 1992                                  .979
names and telephone numbers for its statistics        nity pay set at 80% of the woman's average       two years in full time employment or five
division.                                             earnings rather than the level of sick pay.      years in part time employment before they
   To be fair, the user unfriendliness of             This had also been called for by Ms Joanna       are entitled to six weeks' leave at 900/, pay,
government statistics over the past decade            Foster, chairman of the Equal Opportunities      followed by a flat rate payment for 12 weeks.
has hardly been the providers' fault. It dates        Commission and leader of the EC's advisory       The Equal Opportunities Commission has
from the Rayner report of 1981, which laid            committee on equal opportunities. Italian        complained that the criteria in Britain are so
down that government statistics should be             women now receive 100% of their normal pay       restrictive that one pregnant woman in five
collected primarily to fulfil the government's        when pregnant. So the government in Rome         does not receive any benefit. Allowances vary
needs and not those of other interested               argued that the new proposals would mean         across the community. Luxembourg gives 16
parties. Swingeing cuts followed in both              a step back for Italian women, but it is         weeks on full pay, Denmark 28 weeks at 90%
staff numbers and the volume of statistics            reassured to some extent by the fact that the    of pay, and Ireland 14 weeks at 70% of pay.
collected.                                            Council of Ministers will review the directive   In France and Germany women receive 1 00%
   The current poor quality of economic               after five years.                                of salary for 16 and 14 weeks respectively.-
forecasts by the Treasury has been blamed                Women in Britain currently have to spend      LINDA BEECHAM, BM7
on these cuts; the omission of an adequate
commentary to the last decennial supplement
on mortality and socioeconomic status
published by the Office of Population Cen-
suses and Surveys was the most notorious
casualty in health and social security statistics.
   Mr McLennan arrived from the Australian
government's statistical service six months
ago with a reputation for making government
statistics more user friendly and for marketing
them. The prospect of putting a price on
government statistics, however, leaves some
providers aghast. "Charge a reasonable price
and you'll soon find out whether you're giving
value for money," responded Mr McLennan.

For more details about the users group contact Klim
McPherson, Department of Public Health and Policy,
London School of Hygiene and Tropical Medicine,
London WC1E 7HT. The next meeting is on 27
  For more information about the Department of
Health's statistics division phone 071 972 2000.

EC reaches
compromise on
maternity benefits
The European Community (EC) has agreed
on rules to guarantee a minimum level of
maternity leave and pay. In a last minute
compromise the deadlock was broken and a
new directive agreed in Luxembourg on
19 October. Britain's employment secretary,
Mrs Gillian Shephard, has welcomed the
compromise and at a meeting of social affairs
ministers last week offered to include a clause
making it clear that the directive was not
"equating pregnancy with sickness."
  The directive, which will come into
force in just over a year, will give women
throughout the community a guaranteed 14
weeks' leave with pay at the minimum rate of
their country's statutory sick pay as soon as
they start work. The directive will also give
pregnant women a compulsory two week rest
period before birth and outlaw the sacking
of women because they are pregnant. The
social affairs commissioner, Mrs Vasso
Papandreou, had originally proposed a mini-
mum of 14 weeks' leave on full pay. Mrs
Shephard resisted this proposal because it
would have placed too heavy a burden on
British employers.
   Italy had been the stumbling block. The
Italian government, backed by the European
Commission and parliament, wanted mater-

980                                                                                                       BMJ VOLUME 305           24 OCTOBER 1992

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