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Press releases Saturday 26 May 2007
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(1) Is presumed consent the answer to organ shortages?
(2) Cosmetic genital surgery may be fuelling women±s insecurity about their bodies
(4) Hypnotherapy may help patients with irritable bowel syndrome
(1) Is presumed consent the answer to organ shortages?
(Head to Head: Is presumed consent the answer to organ shortages?)
http://www.bmj.com/cgi/content/full/334/7603/1088
The supply of organ donors cannot keep up with demand. Two experts in this week±s BMJ debate whether presumed consent " assuming people want to donate unless there is evidence to the contrary " is the answer.
Surveys show that 90% of the UK population support organ donation, yet only 23% have registered their wish to donate, writes Veronica English, Deputy Head of Medical Ethics at the British Medical Association.
Research indicates that countries with presumed consent have 25-30% higher donation rates than those with informed consent. So by changing the default position to presumed consent we can help save and transform more lives whilst respecting the wishes of those who want to donate and protecting the rights of those who do not, she says.
Spain has a presumed consent system which portrays a positive attitude towards donation, together with major financial investment and good organisation. It also has the highest recorded donor rate in the world, at 35.1 donors per million population, compared with 12.8 in the UK.
"We cannot afford to wait another five years before beginning to consider alternatives because the longer we procrastinate the more lives are lost unnecessarily," she warns. "Now is the time for a public debate about presumed consent."
But Linda Wright, a Bioethicist at the University of Toronto, believes that no single strategy is likely to solve the organ shortage.
She points out that donation rates vary even between countries that practice presumed consent and suggests that presumed consent will not work unless it is accompanied by the necessary equipment, trained personnel and intensive care beds.
She also says encouraging people to talk to their families about their wishes on donation, engaging communities to help build the necessary trust to favour organ donation, and increasing our knowledge of what influences donation rates are also important.
Finally, meeting the demand for organs may require not only increasing organ supply but also optimising disease prevention and recipient selection, she adds.
"Given the multifactorial nature of the problem, presumed consent alone will not solve the organ shortage," she concludes.
Contacts:
Veronica English, Deputy Head of Medical Ethics, British Medical Association, London, UK
Email:
pressoffice@bma.org.uk
Linda Wright, Bioethicist, University of Toronto, Toronto General Hospital, Ontario, Canada
Email:
linda.wright@uhn.on.ca
(2) Cosmetic genital surgery may be fuelling women±s insecurity about their bodies
(Requests for genetic genitoplasty: how should healthcare providers respond?)
http://www.bmj.com/cgi/content/full/334/7603/1090
Cosmetic genital surgery may be fuelling women±s insecurity about their body and their body parts, argue two senior doctors in this week±s BMJ.
They believe that women should be warned about the risks of cosmetic genital surgery, and that alternative solutions to concerns about the appearance of their genitals should be developed. More and more women are said to be troubled by the shape, size, or proportions of their vulvas, write Lih Mei Liao and Sarah Creighton from the UCL Elizabeth Garrett Anderson Institute for Women's Health. Demand for cosmetic genital surgery (genitoplasty) is increasing and the number of labial reductions in the NHS has doubled in the past five years,
But decisions about surgically altering the genitalia may be based on misguided assumptions about normal dimensions, they warn.
Surgery carries risk, such as loss of sensitivity and the long term benefits are unclear, they say. Some doctors even align the practice with "female genital mutilation." So what makes women take such risks when their genital characteristics fall within typical ranges?
They interviewed healthy adults who had undergone surgical reduction of normal labia.
Some patients cited restrictions on lifestyle as reasons for their decision, including inability to wear tight clothing, ride a bicycle comfortably, or avoidance of some sexual practices. The authors noted that men with similar problems seek alternative solutions.
Patients consistently wanted their vulvas to be flat with no protrusion beyond the labia majora, even though there is nothing unusual about protrusion of the labia minora or clitoris beyond the labia majora, say the authors. Some women brought along images to illustrate the desired appearance, usually from advertisements or pornography that may have been digitally altered.
The increased demand for cosmetic genitoplasty may reflect a narrowing social definition of normal, or a confusion of what is normal and what is idealised, they write. And the provision of genitoplasty could narrow acceptable ranges further and increase the demand for surgery even more.
Surgery is an extreme and unproved intervention in this instance, and it should be thought of as the last resort, not the first port of call, they argue.
"Initiatives involving health agencies, educational bodies, the voluntary sector and the media are needed to help women and girls deal with feelings of insecurity about their genitals and about their bodies in general, they say. "We also need more commitment and investment in research as well as innovative interventions in the community to help women and girls to approach concerns about their appearance skilfully and imaginatively."
Contact:
Lih Mei Liao, Consultant Clinical Psychologist, UCL Institute for Women±s Health, Elizabeth Garrett Anderson and Obstetric
Hospital, London, UK
Email: lih-mei.liao@uclh.nhs.uk
(3) New reforms could cut the number of unexplained infant deaths and will reduce the trauma for all involved
(Sudden Infant Death: Protection for the Innocent)
http://www.bmj.com/cgi/content/full/334/7603/1083
Reforms introduced as a result of the Sally Clark case could lead to a halving in the number of cases of unexplained infant deaths and a positive legacy emerging from tragedy, says a feature in this week±s BMJ .
Sally Clark was arrested in 1998 for the murder of her two infant sons. She was imprisoned but won her appeal in 2003. She died in March this year. The consequences of the case, says Jonathan Gornall, have been devastating for her family and far reaching for the medical and other professions involved.
Protocols introduced as a direct result of the case will be obligatory by April 2008 - the statutory process allowing this to happen has been astoundingly fast says the writer. Peter Fleming, a professor of infant health in Bristol, who implemented a structured system in Avon which will form the template of what will become nationwide protocol, says:
"(this) reflects huge concern within the professions that professionals and families were being let down by the system because nobody knew quite what was required of them."
The reforms establish a standard routine for a collaborative multi-agency response to every sudden unexpected infant death, detailing what is expected from ambulance crews, A&E staff, child protection co-ordinators, coroners, GPs, midwives, paediatricians, pathologists, police and social workers.
Two key changes are that police should visit the home with a paediatrician and a paediatric pathologist should always carry out the examination.
Professor Fleming believes the protocol will ensure more robust and reliable investigations and it could lead to a substantial reduction in the number of deaths from sudden infant death syndrome. When he and his colleagues introduced structured arrangements in Avon in 1984 the benefits soon became apparent - every one of the major risk factors for cot death was first identified there in the 1980s, he says.
The reforms mean new local boards will have to collate information on all deaths in their regions, which will feed into a national enquiry and that can draw nationally applicable conclusions.
However, the article does raise concerns about whether there will be adequate staffing to carry out these new protocols. Child protection has become something of a "poisoned chalice" for paediatricians and pathologists, says the writer, as they are increasingly the target of complaints. Yet, says Professor Fleming:
"Now at least we will be (protecting children) within a recognised and accepted framework, so in theory we can be criticised only if we have failed to do what we should have done, rather than merely for being there."
Contact:
Jonathan Gornall, freelance journalist
Email: jgornall@mac.com
(4) Hypnotherapy may help patients with irritable bowel syndrome
(Clinical Review: A psychological approach to the management of irritable bowel syndrome)
http://www.bmj.com/cgi/content/full/334/7603/1105
Antidepressants and psychological treatments such as hypnotherapy have the potential to help patients with severe irritable bowel syndrome (IBS), say researchers in this week±s BMJ.
IBS is a very common disorder, but conventional ±physical± treatments often do not work very well and patients can feel that their symptoms are being ignored, downplayed or misunderstood.
Patients with IBS are more likely to suffer from depression and have ±abnormal± behaviour patterns including anxiety and somatisation (conversion of an emotional, mental, or psychosocial problem to a physical complaint). This has led to the idea that IBS has a psychological as well as a biological basis and a growing body of evidence supports the use of antidepressants for IBS, write the authors.
However, many doctors are reluctant to prescribe such agents to patients who are clearly not depressed.
Other "psychological" therapies exist that patients with IBS should be made aware of, they say. For example, ±talking therapy± (known as cognitive behavioural therapy) is as effective as antidepressant treatment and its benefits last longer.
Hypnotherapy has also been reported to be an effective intervention for IBS in small trials, although a recent review of hypnotherapy trials found insufficient evidence to recommend its widespread use and suggested that this treatment option should be restricted to specialist centres dealing with more severe cases of the syndrome.
Nevertheless, hypnotherapy has the potential to help those patients whose IBS is severe, say the authors.
The choice of treatment will depend on the individual patient and, inevitably, will be limited by local availability, they add. However, IBS is undeniably very common and many patients are probably denied help by lack of access to therapists with the appropriate psychological skills.
They believe that increasing provision of primary care services for patients with IBS will provide an avenue for effective and early psychological treatment for a condition in which real improvement can be achieved.
Contact:
Ian Forgacs, Consultant Physician, Department of Gastroenterology, Kings College Hospital, London, UK
Email: ian.forgacs@kcl.ac.uk
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