Abortion and Pills
This latter figure is a reminder of the increasing popularity of the RU-486 abortion regime (one mifepristone tablet followed, three or fours days later, by one of misoprostol) used during the first nine weeks of pregnancy.  Of course, early abortions caused by the morning-after pill (Levonelle One Step or Levonelle 1500 containing levonorgestrel and effective up to three days after unprotected sexual intercourse) and its more recently-introduced cousin, EllaOne (ulipristal acetate, effective for up to five days), are not counted in the official UK figures.  Nobody knows how many abortions they trigger.

It has often been recommended, by among others, the National Institute for Health and Clinical Excellence (NICE) just a couple of months ago, that women keep a stash of morning-after pills (MAP), just in case.  The Cochrane Database of Systematic Reviews examined data from the USA, China, India and Sweden and recently issued a report entitled, Advance Provision of Emergency Contraception for Pregnancy Prevention.  It concluded that such a strategy has no effect on pregnancy rates.  The researchers found that advance supplies of the MAP fail if – wait for it – women choose not to take them!  And that is apparently what many women decide to do.

Assisted Suicide in Switzerland
Switzerland's law on assisted suicide is certainly concise.  Since 1940, it has been permitted as long as those involved are neither selfishly nor financially motivated.  The Swiss believe that personal autonomy trumps any interference by the State.  However, this ultra-liberal thinking may be about to change.  The presence of the assisted suicide organization, Dignitas, and the unsavoury publicity created by its trade, are creating calls for greater legal controls.  During the past 12 years, Dignitas has assisted more than 1,000 people to die.  The fact that many of them have been foreigners, plus the fact that some have not been terminally ill, have begun to embarrass and worry the Swiss authorities.

These concerns peaked recently when dozens of urns containing human ashes were discovered in the bottom of Lake Zurich.  Though it has yet to be established who dumped these urns, the finger has been pointed at Dignitas because they all bore the label of the crematorium used by that organization.

Meanwhile, the Swiss government has produced two draft papers on assisted suicide.  One would ban the practice altogether.  The other would limit the practice to those who are terminally ill, with a few months to live, as evidenced by two independent doctors – it is the more likely option to be adopted.  In addition, patients would need to demonstrate that theirs were sustained and informed decisions.  Such requirements would effectively close down the Dignitas business, because the majority of its foreign patients arrive in Switzerland, see a Dignitas doctor, and die within 24 hours.  Yet herein lies the problem – once any bioethical door has been opened, shutting it, even partially, is very, very difficult.

Euthanasia and Organ Donation
Here is a pair of bioethical issues that you may not have previously conjoined – euthanasia and organ donation.  Yet the two have been approvingly coupled by a couple of bioethicists from Oxford University, Julian Savulescu and Dominic Wilkinson. Their article, Should We Allow Organ Donation Euthanasia? Alternatives for Maximizing the Number and Quality of Organs for Transplantation was published in the May edition of the journal, Bioethics.

Savulescu and Wilkinson make their utterly utilitarian case thus: ‘It is permissible to withdraw life support from a patient with extremely poor prognosis, in the knowledge that this will certainly lead to their death, even if it would be possible to keep them alive for some time.  It is permissible to remove their organs after they have died.  But why should surgeons have to wait until the patient has died as a result of withdrawal of advanced life support or even simple life prolonging medical treatment?  An alternative would be to anaesthetize the patient and remove organs, including the heart and lungs.  Brain death would follow removal of the heart (call this Organ Donation Euthanasia (ODE)).  The process of death would be less likely to be associated with suffering for the patient than death following withdrawal of LST [life-sustaining treatment] (which is not usually accompanied by full anaesthetic doses of drugs).  If there were a careful and appropriate process for selection, no patient would die who would not otherwise have died.  Organs would be more likely to be viable, since they would not have sustained a period of reduced circulation prior to retrieval.  More organs would be available (for example the heart and lungs, which are currently rarely available in the setting of DCD [donation after cardiac death]).  Patients and families could be reassured that their organs would be able to help other individuals as long as there were recipients available, and there were no contraindications to transplantation.  This is not the case at present with DCD, since many patients do not die sufficiently quickly following withdrawal of LST for organ retrieval.’

‘If we believe that we should not remove organs from patients who are still alive, even where they have consented to this and would otherwise die anyway, then one alternative would be to euthanize the donor and retrieve organs after cardiac death had been declared.  This would already be a theoretical option in countries where euthanasia is permitted.  Organ donation after cardiac euthanasia has been described in a patient in Belgium.  Organ donors could be given large doses of sedative, and cardioplegic agents (to stop the heart).  Again, this would reduce the risk of patients suffering after withdrawal of LST and make organ donation possible for some patients who would otherwise not be able to donate.  In an extreme case, they might choose to undergo euthanasia at least partly to ensure that their organs could be donated.’

So there we have it – two birds with one stone, double usefulness, euthanasia with a dual purpose, good arising from tragedy, wish fulfilment for two people.  How could anyone object?  Here is the test – can you argue the opposing case?  One day you may have to!

Doctors and Assisted Suicide
In the wake of the publication, in February 2010, of the Director of Public Prosecutions (DPP) definitive guidelines concerning the prosecution of those involved in assisting suicide, the British Medical Association (BMA) has issued a two-page guidance for doctors facing such requests from patients.

Thankfully, it is firm and clear, as the following quotation demonstrates: ‘The BMA advises doctors to avoid all actions that might be interpreted as assisting, facilitating or encouraging a suicide attempt.  This means that doctors should not:
• advise patients on what constitutes a fatal dose;
• advise patients on anti-emetics in relation to a planned overdose;
• suggest the option of suicide abroad;
• write medical reports specifically to facilitate assisted suicide abroad; nor
• facilitate any other aspects of planning a suicide.’

That other doctors’ body, the General Medical Council, has also recently issued guidance urging doctors to begin discussing end-of-life care with their terminally-ill patients well in advance of their final days.  With some caveats, that advice makes good sense and should enable more patients to die well.

Euthanasia and the Near Future
Despite what seems to be sustained opposition to legalising euthanasia, there is no room for complacency.  We must not be lulled into believing that all is quiet on the euthanasia front.  Its advocates are busy, everywhere.  For example, in Germany, a landmark ruling by its Federal Court of Justice has given approval for what some call ‘passive’ euthanasia of terminally-ill patients.  The Court overturned a conviction of attempted manslaughter by a lawyer, Wolfgang Putz, who advised a woman to cut the intravenous feeding tube keeping her comatose mother alive.  In Belgium, a recent study has shown that during 2007, five years after the practices were legalised, euthanasia (voluntary and non-voluntary) and assisted suicide accounted for 2.0% of all deaths in Flanders, the Dutch-speaking part of that country.  And the latest figures from Holland should further alarm us.  During 2009, the number of reported Dutch deaths by euthanasia rose by 13% to 2,636, following an increase of 10% in 2008.  These rises have led a concerned Dutch health ministry to launch an official inquiry into their euthanasia laws.  Meanwhile, in the UK, pro-euthanasia groups, such as Dignity in Dying with its now claimed 25,000 supporters, are actively recruiting and planning.  A apparent lull in the battle is never the time to relax.

The wonders of stem cell technology, in particular those of the non-embryonic variety, continue to astound.  Let the following examples amaze you.

Tracheal Construction
Remember Claudia Castillo, the Spanish mother of two, who in 2008 had the remarkable world’s first operation to insert a ‘new’ trachea section built from her own stem cells?  Now a 10-year-old British boy has become the first child to undergo a whole windpipe transplant constructed from his own stem cells.  He was born with a condition known as Long Segment Congenital Tracheal Stenosis, resulting in a very narrow trachea.  Doctors at Great Ormond Street Hospital used a donor trachea, stripped it to its collagen scaffolding, and then injected it with stem cells taken from the boy’s bone marrow – so the organ is being regenerated inside the boy’s body over the coming months.  And it seems to be working.

Stems Cells from Amniotic Fluid
Yet another source of stem cells has been reported.  Scientists at the Wake Forest Institute for Regenerative Medicine, North Carolina have discovered them in human amniotic fluid.  While team leader, Anthony Atala, would not yet claim these cells were truly pluripotent, he said they were versatile and non-tumour forming when tested in animals.  This latter characteristic may prove advantageous in their usefulness in clinical trials, compared with tumour-causing embryonic stem cells.

Stem Cells and the Heart
Jean-Paul Tremblay, a 59-year-old construction worker from Montreal, recently had a routine coronary artery bypass operation.  But before the surgical team closed him up they added a little extra – stem cells purified from his bone marrow that they had removed from his pelvic bone earlier that day.  Mr Tremblay’s condition had caused him to become weak and fatigued, but post-operatively his heart was almost normal and his health had dramatically improved.  It is thought that the stem cells will work by regenerating the patient’s blood vessels and heart muscles.  The task now is to assess how much of the patient’s improvement was caused by the bypass operation and how much by the added stem cells.  Fascinating!

On 20 May, the maverick biologist and flamboyant entrepreneur J Craig Venter and his research team announced in the journal Science that they had created a world first – a synthetic life form, predictably nicknamed, Synthia.  It has taken them 15 years of trying at a cost of $40m.  This triumph of synthetic biology was hailed by some commentators as an achievement as profound as the production of the first atomic bomb, and as 'a defining moment in biology'.  Others hailed it as the progenitor of better drugs, less thirsty crops, greener fuels, and so on.  But, despite all of this media hype, all is not quite as it seemed.  Sure, it was an important technological achievement, but scientists already possess the know-how to, for example, alter bacterial genes to order.

What Venter and his colleagues had actually done in this proof-of-principle study was to synthesize chemically an artificial genome, which had been computer designed, and put it in the ‘shell’ of Mycoplasma mycoides, a well-known, simple bacterium.  The result was a functioning, replicating new bacterial species with no ancestors.  But Venter’s ‘new species’ is not an entire, new creation, rather it merely carries a new set of artificial genes – all its other cellular components are from another bacterial strain.  Artificially creating all of these other components is currently beyond the means of scientists.  And anyway, DNA, genes, a genome, whether produced artificially or naturally, are not life – the latter is almost unimaginably more complex.