General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery.

In this article, we describe an extension of general anaesthesia - beyond facilitating surgery - to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as 'general anaesthesia in end-of-life care'. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end-of-life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end-of-life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions.

Do oncologists discuss expensive anti-cancer drugs with their patients?

BACKGROUND: In Australia, some anti-cancer drugs are only available at significant financial cost to patients. We sought the views and practices of Australian medical oncologists regarding discussion of high cost drugs (HCDs). PARTICIPANTS AND METHODS: A postal survey was mailed to all 274 members of the Medical Oncology Group of Australia. Three clinical scenarios described HCDs associated with either improved overall survival, encouraging response rate in a treatment-refractory cancer, or a scenario with improved treatment tolerability. Participants were asked about their discussion and prescription of HCDs. RESULTS: There was a 78% response rate. Most respondents were male (71%), worked in a metropolitan practice (87%) and spent more than 50% of their working time in patient care (87%). Forty-eight percent had previously prescribed a HCD. In the three scenarios, respondents would generally prescribe the drug if it were subsidised, however, between 28% and 41% (depending on the scenario) would not mention the HCD if it were not subsidised. Major reasons for not mentioning the HCD were concerns that discussion would 'worry the patient' or that the doctor would 'feel bad'. CONCLUSIONS: Despite literature suggesting that patients wish to be well informed and active participants in decision making, the practice of a significant percentage of Australian medical oncologists may prevent this.

Ethical considerations in presymptomatic testing for variant CJD.

Variant Creutzfeldt-Jakob disease (vCJD) is a fatal, transmissible, neurodegenerative disorder for which there is currently no effective treatment. vCJD arose from the zoonotic spread of bovine spongiform encephalopathy. There is now compelling evidence for human to human transmission through blood transfusions from presymptomatic carriers and experts are warning that the real epidemic may be yet to come. Imperatives exist for the development of reliable, non-invasive presymptomatic diagnostic tests. Research into such tests is well advanced. In this article the ethical implications of the availability of these tests are elaborated and comparisons drawn with predictive genetic testing for Huntington's disease and screening for HIV. Paramount to considerations is the issue of whom to test, weighing up respect for personal autonomy against obligations to benefit and protect society. A paradigm is proposed similar to that used for HIV screening but with unique features: compulsory testing of all blood/organ donors and individuals undergoing surgery or invasive procedures who have a significant risk of disease transmission.

It's only teeth - are there limits to genetic testing?

Dental genetic disorders can cause severe social and psychological effects in affected individuals. The cost of treatment can be considerable, not only in financial terms but also in time spent during treatment. In theory it is, or will soon be, possible to use advances in molecular genetics for pre-natal testing, for selection of embryos using in vitro fertilization techniques, and for gene therapy. The questions we pose are whether these approaches are appropriate. We hope that this review will stimulate debate on these issues.

"Saviour siblings".

The Victorian Infertility Treatment Authority has given permission to allow tissue typing in combination with preimplantation genetic diagnosis. This is a new application of IVF. Not only will it allow parents to select an embryo free from serious genetic disease it will allow them to simultaneously select for a match so that the umbilical cord blood of the resulting baby can provide stem cells to treat an existing sibling who has a disease.

The ethics of cloning and creating embryonic stem cells as a source of tissue for transplantation: time to change the law in Australia.

Every day, people die because there are insufficient tissues available for transplantation. The development of cloning and embryonic stem (ES) cell line technologies offers real hope for developing better sources of tissues for transplantation. Moreover, these new technologies may mean that damaged tissue (for example, after a stroke or heart attack) can be replaced with normal functioning tissue rather than scar tissue. Research into 'therapeutic cloning' and the development of ES cell lines is illegal in several States in Australia. It is time to review that legislation in order to allow destructive embryo research. My argument is that at least research should be allowed on spare embryos from assisted reproduction; that it is only one moral view (of several plausible ones) of the status of the embryo which precludes producing embryos for research; that this view is mistaken and so it is morally permissible to produce embryos for research into therapeutic cloning.

MPTP, impairment of motor performance and amine accumulation in Macaca fascicularis.

The selective neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) was injected (IV) into monkeys (Macaca fascicularis) in two different injection regimes. With the small dose regime, one monkey was injected with 0.25 mg/kg, every other day, over a 16 day period. In the large dose regime, another monkey was injected with 0.5 mg/kg every other day, over an 8 day period. While the time required for drug delivery was varied between animals, the total dose delivered was 2 mg/kg in both animals. Before, during and for 14 days after the course of drug administration both animals were assessed on several motor function tests. The animal receiving the small dose regime showed normal motor performance on all tests for the duration of the study, however, the monkey receiving the large dose regime displayed progressive akinesia, muscular rigidity, and aphagia. In fact, impairment was so severe that this animal had to be force fed and maintained with daily oral L-dopa. Fluorescent histochemical assessment of forebrain in both monkeys revealed that striatal tissue was totally devoid of fluorescence in both cases. Large, swollen axons in the internal capsule, hypothalamus and midbrain were visible only in the severely impaired animal. These results suggest that, as with other neurotoxins, degeneration associated increases in amines may be important in the aetiology of Parkinson-like motor impairment produced by selective neurotoxins.