Euthanasia and assisted suicide: comparison of legal aspects in Switzerland and other countries.

The purpose of this paper is to present the legal aspects associated with assisted suicide in Switzerland and compare them with those in other countries. Like euthanasia, assisted suicide is a subject that induces much discussion in many countries. While the law is very liberal in some countries, such as Belgium and the Netherlands (where both euthanasia and assisted suicide take place), these practices are very controversial in other countries, such as France, where they remain taboo subjects. In the United States of America, the laws concerning assisted suicide can differ greatly from one state to another. For example, in Oregon, assisted suicide is allowed if applied by a medical doctor; in others, this act is illegal. In Canada, it is punishable according to the Criminal Code. In Switzerland euthanasia is punishable by law. However, the penal code does not condemn assisted suicide, whether carried out by a medical doctor or another person, provided it is not carried out through selfish motives. The application of these practices has become simplified in recent years and societies for the right to die with dignity based on this principle have come into being (Exit and Dignitas). In the French- and German-speaking parts of Switzerland the association Exit assists individuals living in Switzerland with serious progressive and incurable disease in their engagement to end their life. The association Dignitas, in the German-speaking part of Switzerland, also undertakes--in the same circumstances--to assist individuals coming from foreign countries. Dignitas welcomes several such individuals every year, especially from Germany, where a similar approach does not currently exist.

Should cancer patients be informed about their diagnosis and prognosis? Future doctors and lawyers differ.

OBJECTIVES: To compare attitudes of medical and law students toward informing a cancer patient about diagnosis and prognosis and to examine whether differences are related to different convictions about benefit or harm of information. SETTING AND DESIGN: Anonymous questionnaires were distributed to convenience samples of students at the University of Geneva containing four vignettes describing a cancer patient who wishes, or alternatively, who does not wish to be told the truth. PARTICIPANTS: One hundred and twenty seven medical students and 168 law students. MAIN OUTCOME MEASURES: Five point Likert scale of responses to the vignettes ranging from "certainly inform" to "certainly not inform" the patient. RESULTS: All medical students and 96% of law students favoured information about the diagnosis of cancer if the patient requests it. Seventy four per cent of medical students and 82% of law students favoured informing a cancer patient about his or her prognosis (p = 0.0003). Thirty five per cent of law students and 11.7% of medical students favoured telling about the diagnosis (p = 0.0004) and 25.6% of law students and 7% of medical students favoured telling about the prognosis (p < 0.0001) even if the patient had clearly expressed his wish not to be informed. Law students indicated significantly more often than medical students reasons to do with the patient's good, legal obligations, and the physician's obligation to tell the truth, and significantly less often than medical students that their attitude had been determined predominantly by respect for the autonomous choice of the patient. CONCLUSION: Differences in attitudes according to the type of case and the type of studies were related to convictions about the benefit or harm to the patient caused by being given information. The self reported reasons of future physicians and future lawyers are helpful when considering means to achieve a better acceptance of patients' right to know and not to know.

Terminally ill patients and Jehovah's Witnesses: teaching acceptance of patients' refusals of vital treatments.

OBJECTIVES: To find out whether and how the teaching of medical ethics can influence attitudes on accepting treatment refusals. SETTING AND DESIGN: Anonymous questionnaires were distributed to 4 groups of students at the University of Geneva who had participated (P) or not (nP) in teaching modules on medical law and ethics. One vignette described a terminally ill patient refusing mechanical ventilation, another a Jehovah's Witness refusing a life-saving blood transfusion. PARTICIPANTS: 127 medical and 168 law students. MAIN OUTCOME MEASURES: 5-point Likert scale of responses to the vignettes reaching from certain acceptance to certain non-acceptance of the treatment refusal. RESULTS: More than 80% of law students (nP) said that a good physician should accept the terminally ill patient's refusal. 84% (P) compared to 68% (nP) of medical students (P=0.03) would accept this refusal. The acceptance of the Jehovah's Witness refusal of a life-saving transfusion was less among all students. Students from the groups (P) reported significantly more often (P < 0.001) that they would accept (76% of medical students) or that a good physician should accept (63% of law students) the treatment refusal of the Jehovah's Witness than medical students (48%) and law students (27%) from the two other groups (nP). CONCLUSION: (P) students showed significantly more acceptance of treatment refusals in the hypothetical case scenarios than (nP) students from the same faculty. Religion, cultural origin and school education of the parents had less influence on attitudes than participation in ethical teaching and type of student (medicine vs. law).

Inhibition of the calcium-dependent tyrosine kinase (CADTK) blocks monocyte spreading and motility.

Freshly isolated peripheral blood monocytes lack focal adhesion kinase (p125(FAK)) but activate a second member of this kinase family, calcium-dependent tyrosine kinase (CADTK; also known as Pyk2/CAKbeta/RAFTK/FAK2), upon adhesion or stimulation with chemokines. To study the role of CADTK in monocyte adherence and motility, we performed immunocytochemical localization that showed CADTK at the leading edge and ruffling lamellipodial structures in freshly isolated, adhered human monocytes. We next introduced CADTK/CAKbeta-related non-kinase (CRNK), the C-terminal noncatalytic domain of CADTK, into monocytes by electroporation and showed that it inhibited CADTK autophosphorylation. Introduction of the fusion protein glutathione S-transferase (GST)-CRNK also reduced (i) cell spreading, as reflected in a reduced cell area 30 min after adhesion, (ii) adhesion-induced phosphotyrosine increases and redistribution into lamellipodia, and (iii) adhesion-induced extracellular signal-regulated protein kinase (ERK) activation. In control experiments, introduction of GST or GST-C3 transferase (an inhibitor of RhoA GTPase activity) by electroporation did not affect these parameters. Monocytes adhered in the presence of autologous serum were highly motile even after introduction of GST (83% motile cells). However, only 26% of monocytes with introduced GST-CRNK were motile. In contrast, GST-CRNK-treated monocytes were fully capable of phagocytosis and adhesion-induced cytokine gene induction, suggesting that CADTK is not involved in these cellular activities and that GST-CRNK introduction does not inhibit global monocyte functions. These results suggest that CADTK is crucial for the in vitro monocyte cytoskeletal reorganization necessary for cell motility and is likely to be required in vivo for recruitment to sites of inflammation.

Human rights law in the field of mental health: a critical review.

The 'centrepiece' of international human rights law in the field of mental health is often said to be the United Nations Principles for the Protection of Persons with Mental Illness of 1991. Some observers appreciate the symbolic importance of these principles in providing visibility to the needs of the mentally ill, in stressing the right of access to adequate mental health care and in establishing the principle equivalence between psychiatry and the rest of medicine. However, the Principles appear basically flawed in several respects: (1) they do no have the status of a formal international treaty; (2) States are not required to adopt the Principles as 'minimum standards' for the protection of mentally ill persons; (3) in some respects, notably on the issue of consent to treatment, the Principles remove patients' rights rather than reinforce them; (4) the Principles do not provide for redress nor for any form of monitoring, inspection or supervision by an independent international body. Thus, it appears that even at an international level the deep-seated societal ambivalence towards the mentally ill has taken root and that so called 'human rights' principles have little material effect on the lives of psychiatric patients and create double standards in the exercise of choice.

Testing adolescents for a hereditary breast cancer gene (BRCA1): respecting their autonomy is in their best interest.

The testing of individuals before the age of 18 years for hereditary late-onset diseases has been judged ethically not acceptable in guidelines and directives published by medical professional organizations. However, there are not enough best interest arguments to deny genetic testing to an adolescent at risk of carrying a BRCA1 mutation, even if the competence of adolescents for medical decisions is considered to be lower than the competence of adults. The adolescent's decision is not irrational or of very high risk. Respecting adolescents' autonomous choices concerning genetic testing has positive consequences for their self-esteem and psychological health. Geneticists and other professionals should clearly differentiate between children and adolescents in regard to BRCA1 gene testing and recommend giving decision autonomy about the test to all psychologically "normal" adolescents.

Inhibition of chronic rejection of aortic allografts by dietary glycine.

BACKGROUND: Chronic rejection is influenced by a variety of risk factors, including histoincompatibility and ischemia. Glycine, a cytoprotective agent, has been shown to protect against ischemia-reperfusion injury in the liver, inactivate hepatic resident macrophages, minimize cyclosporin A-induced nephrotoxicity, and exhibit immunosuppressive properties in vitro. The aim of this study was to investigate whether dietary glycine could reduce development of chronic rejection. METHODS: Lewis recipients of Fisher-344 abdominal aortic allografts received diets that contained either 5% glycine plus 15% casein or 20% casein as control for 10 weeks. Vascular lesions of aortic isografts and allografts were evaluated quantitatively with image analysis and cell counting. RESULTS: No significant vascular changes were observed in isografts (mean medial areas of 3.3 +/- 0.3x0(5) microm2). However, dramatic intimal thickening (neointimal area 2.1+/-0.3) and medial thinning (1.5+/-0.3) were observed in allografts from rats fed control diet. In contrast, glycine significantly reduced the neointima by 45% (1.2+/-0.3) and protected the media (3.5+/-0.2). This led to intima to media area ratios almost twice as large in the control group as in glycine-fed rats (2.2+/-0.4 vs. 1.1+/-0.3, P<0.05). Moreover, infiltrating leukocytes, especially macrophages, were reduced significantly in the adventitia by glycine. In addition, glycine inhibited proliferation and migration of rat aortic smooth muscle cells in culture by 45 and 60%, respectively. CONCLUSION: These results indicate that dietary glycine minimizes histopathological changes of chronic rejection by reducing the immune response and, in part, by minimizing proliferation and migration of smooth muscle cells.

A mechanism for trabecular meshwork cell retraction: ethacrynic acid initiates the dephosphorylation of focal adhesion proteins.

Ethacrynic acid (ECA) increases aqueous humor outflow facility in human and animal model systems, and causes cellular retraction in cultured trabecular meshwork (TM) cells. ECA-induced retraction, a possible correlate to the opening of spaces in the outflow pathway in vivo, takes place coincident with disruption of cell-cell attachments and actin stress fibers. Tyrosine phosphorylated proteins are located predominantly where actin filaments terminate at sites of cell-to-cell and cell-to-substrate adhesion, and are understood to regulate cellular adhesions and filamentous (F) actin organization in many cell types. In the present study we investigated whether ECA might affect cell adhesions and F-actin in TM cells by altering levels of phosphotyrosine. We analysed levels of phosphotyrosine in cultured human TM and calf pulmonary artery endothelial cells after exposure to ECA. Using immunoflourescence microscopy and antibodies to phosphotyrosinated proteins we found a rapid decrease in phosphotyrosine levels at the focal contacts of cells treated with ECA. Immunoblots of whole cell extracts showed a decrease in phosphotyrosine predominantly in a band running at about 120 kD, with a more subtle decrease in a band about 65 kD. Reprobing the blot with antibodies to pp120 focal adhesion kinase (FAK) or paxillin indicated that the 120 kD band was FAK and the 65 kD band was likely paxillin. Immunoprecipitation of FAK or paxillin and probing the resulting blot with antibodies to phosphotyrosine confirmed that these proteins were rapidly dephosphorylated after ECA addition. Loss of FAK and paxillin proteins in cells was then confirmed using immunofluorescence microscopy. Dephosphorylation of these proteins was detected before the onset of retraction, stress fiber disruption, or complete disruption of focal adhesions. A pure microtubule inhibitor (colchicine), did not cause stress fiber disruption or decrease focal adhesion phosphorylation. We postulate that dephosphorylation of FAK and paxillin by ECA disrupts signaling pathways that normally maintain the stability of the actin cytoskeleton and cellular adhesions, and that this action leads both to cell shape change in culture, and to facility changes in vivo.

[AIDS prevention in European prisons]. / La prévention du SIDA dans les prisons européennes.

Informations on HIV/AIDS in prisons which include 32 prison-systems in 17 European countries have been collected. The principle of equivalence of preventive measures and health care between prisons and the outside community, prison authorities should strive to prevent HIV transmission in prisons. There have been major developments in effective prevention programmes in the community, there has been less progress within the prison-systems. Information on AIDS is provided to prisoners in almost all prison-systems. While condom distribution is practiced in a growing number of systems, no prison systems have adopted syringes/needle distribution or exchange during incarceration. A few system have accepted distribution of a disinfectant (diluted bleach) with instruction on cleaning injection materials. Despite clear recommendations made by international bodies in 1987/88, it must be concluded that discrimination and segregation (restriction from access to workshops, specially work in kitchens) remain widespread in 1992.

"Not worth powder and shot". A reappraisal of Montagu Lomax's contribution to mental health reform.

Dr Montagu Lomax worked as an assistant medical officer at Prestwich Asylum for two years from 1917. His book, The Experiences of an Asylum Doctor, was published in 1921. He was condemned by the psychiatric establishment for his description of inhuman, custodial, and antitherapeutic conditions. Access to previously confidential official papers, to the archives of Prestwich Hospital, and to Professor George Robertson's correspondence has permitted a reconstruction of the Lomax affair. Lomax was a dedicated and sincere clinician. Senior Ministry of Health officials regarded Lomax's book as "temperate", "well founded", and an opportunity to secure public support for long needed legal and administrative reforms. Through his book, Lomax made a lasting contribution to the cause of mental health reform.

The application of the European Convention of Human Rights to the field of psychiatry.

The European Convention of Human Rights enumerates a set of individual rights and fundamental freedoms and defines supra-national legal procedures whereby individuals, who believe themselves victims of human rights abuses and are unable to gain redress through domestic courts, can petition the European Commission of Human Rights.

Knowledge and attitudes of primary health care personnel concerning mental health problems in developing countries: a follow-up study.

Within the context of a World Health Organization coordinated collaborative study health workers in six developing countries were assessed 18 months after their training for improvement in their knowledge and attitude towards mental health problems and their management. The approaches to training varied between study areas, but the degree of improvement following the training, was of equal magnitude in all countries. The training process has formalized the recognition by the health workers that treatment of mental health problems is an integral part of their work.

[The symptoms questionnaire for problem detection in adults]. / El cuestionario de síntomas para la detección de problemas en adultos.

This questionnaire has been designed considering transcultural differences. Its validation includes an approximately 400-patient sample, with their relatives as control sample population. Such populations come from General Health Centers located in Colombia, India, the Philippines, and Sudan. In each area, different cut-off points were used on the calculation of sensitivity and specificity. This instrument is currently used in different parts of the world: It is demonstrating to be valuable and sensitive a tool for identifying mental disorders among individuals seeking treatment at General Health Services. At the same time, it is being used in a training manual for Psychiatry primary care workers. Even though the instrument does not diagnosticate, it nonetheless identifies individuals suffering from psychological disrupting symptoms. Both its simplicity and high sensitivity help in a practical approach to Psychiatry primary care strategies.

Prevention of torture and inhuman or degrading treatment: medical implications of a new European convention.

A new European convention creates a mechanism for the prevention of torture and inhuman or degrading treatments of detained people through visits by outside, independent teams with unlimited access to places of detention. The convention has important implications for the medical profession: firstly, visits to psychiatric hospitals will be included and, in particular, to secure facilities, where the risk of human rights abuses is well established; and, secondly, the adequacy and ethics of medical care in prisons will be a key issue in assessing the protection of prisoners' human rights. The convention should be welcomed by the medical profession as a stimulus to the improvement of medical care for detained people.

El cuestionario de síntomas para la detección de problemas en adultos. / [The symptoms questionnaire for problem detection in adults]

This questionnaire has been designed considering transcultural differences. Its validation includes an approximately 400-patient sample, with their relatives as control sample population. Such populations come from General Health Centers located in Colombia, India, the Philippines, and Sudan. In each area, different cut-off points were used on the calculation of sensitivity and specificity. This instrument is currently used in different parts of the world: It is demonstrating to be valuable and sensitive a tool for identifying mental disorders among individuals seeking treatment at General Health Services. At the same time, it is being used in a training manual for Psychiatry primary care workers. Even though the instrument does not diagnosticate, it nonetheless identifies individuals suffering from psychological disrupting symptoms. Both its simplicity and high sensitivity help in a practical approach to Psychiatry primary care strategies.