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Ethics briefings
  1. Martin Davies,
  2. Sophie Brannan,
  3. Eleanor Chrispin,
  4. Veronica English,
  5. Rebecca Mussell,
  6. Julian C Sheather

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Drugs used in lethal injections

In August 2012, the drug manufacturer, Fresenius Kabi, barred the sale of the anaesthetic, propofol, for use in lethal injections. The company announced that it would not accept orders for the drug from US departments of correction, and put in place similar requirements on all its wholesalers and distributors.1

Propofol is one of the world's most widely used anaesthetics. Earlier in 2012, US states began to use propofol in executions following shortages of other drugs which had previously been used in lethal injections. In May 2012, the state of Missouri decided to move to a one-drug protocol, using propofol alone for lethal injections, in place of the three-drug protocol that had been used by most states carrying out the death penalty. Missouri took this decision when supplies of thiopental sodium and pentobarbital, drugs used in the three-drug protocol, became unavailable.2

Fresenius Kabi said that it had imposed the restrictions in order to ‘prevent Propofol from being used for purposes other than its approved medical indications’ and to ensure that ‘the immediate access to Propofol needed by medical professionals’ was not hindered. The company said that it objected to the use of its products in any manner that was not in full accordance with the medical indications for which they have been approved by health authorities.3 All forms of Fresenius Kabi propofol are manufactured in Europe. A European Union (EU) Council regulation prevents products that may reasonably be expected to be used in executions from being exported from the EU. The company said that, should propofol begin to be used in executions in the USA, inadequate access to the drug in the country was a likely consequence. At the time of writing, the US Food and Drug Administration was reporting shortages of the drug in the USA for proper medical use.4

The British Medical Association (BMA) wrote to Fresenius Kabi in October, congratulating it on the steps it had taken to help secure stocks of propofol for legitimate medical use while preventing it from being diverted and stockpiled in prisons for off-label use in executions. At the BMA's 2012 conference, doctors had expressed deep concern that many executions were being carried out using pharmaceuticals produced by multinational pharmaceutical companies. The charity, Reprieve, which works closely with manufacturers and governments to prevent the abuse of medicines in executions, reported that Fresenius Kabi's action followed similar moves by Danish manufacturer, Lundbeck, which took steps to control the distribution of pentobarbital to prevent its use in executions in the USA in July 2011.5

Assisted dying appeal

As previously reported here, in August 2012, the High Court in England and Wales rejected the legal claims for assisted dying of two men suffering from locked-in syndrome.6 Fifty-eight-year-old Tony Nicklinson and a 47-year-old man, known only as Martin, had sought declarations that would enable them to end their lives. Less than 2 weeks after the judgment was handed down, Mr Nicklinson died having contracted pneumonia.

In October 2012, the High Court refused permission for Mr Nicklinson's wife to be made party to the proceedings, and therefore, she was unable to take the case forward to appeal. Martin was, however, given leave to appeal the original High Court judgment against him.7 At the time of writing, it was not known when the appeal would be heard.

South African doctor detained in UAE

In August 2012, a retired paediatric oncologist from South Africa, Professor Cyril Karabus, was detained in the United Arab Emirates (UAE) on charges of manslaughter and falsifying documents.8 The charges related to the death of a child he had treated for leukaemia in 2002 while working in Abu Dhabi. The 77-year-old, who knew nothing about the charges against him, had been convicted in absentia and was arrested at Dubai airport while in transit to South Africa from a family wedding in Canada. At the time of writing, Prof Karabus, who is in poor health, was released on bail after being detained in prison for 2 months and following six court appearances.9

Prof Karabus’ case caused alarm among the international medical community. In October, the World Medical Association passed a resolution calling on the UAE authorities to ensure that Prof Karabus was guaranteed a fair trial according to international standards, and had access to the relevant documents or information he may require to prepare his defence.10 The BMA warned doctors of the risks where a patient dies in their care in a country which is prepared to try people in absentia and not inform them of the trial and conviction. It also highlighted the dangers of an increase in the defensive practise of medicine.11 The South African Medical Association also warned its members of the medical liability risks of working in the UAE.12

Abortion: time limits

In October 2012, there was significant media coverage of UK government ministers’ views on reducing abortion time limits.

The Abortion Act 1967 only applies to England, Scotland and Wales, not Northern Ireland. The 1967 Act permits abortion under certain specific medical criteria. Under the Act, there is a time limit, of 24 weeks where ‘the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family’. A pregnancy may lawfully be terminated up to birth for serious fetal abnormality; to prevent grave permanent injury to a pregnant woman; or if continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated. Of all the abortions in England and Wales in 2011,13 91% of abortions were carried out at under 13 weeks’ gestation and 78% at under 10 weeks. Only 2% of abortions, including for fetal abnormalities, were carried out at 20 weeks and over; and less than 0.1% of abortions were carried out at over 24 weeks.

Parliament last debated abortion time limits in 2008 when a reduction in 24 weeks was rejected. At that time, as parliamentary debate on the 24-week time limit tends to focus on fetal viability, the BMA, the British Association of Perinatal Medicine, the Royal College of Nursing and the Royal College of Obstetricians and Gynaecologists (RCOG) informed MPs that ‘it is important that evidence-based factual information informs parliamentary debate … there is no evidence of a significant improvement in the survival of preterm infants below 24 weeks’ gestation, in the UK, in the last 18 years. The major development since 1990 has been an improvement in the survival of babies born at 24 weeks and over, but not below this gestation.’14

This latest debate around time limits began with the new minister for Women, and secretary of state for Culture, Media and Sport, Maria Miller, stating that it was ‘common sense’ to reduce the 24 week time limit to 20 weeks to ‘reflect the way science has moved on’.15 This was followed by Jeremy Hunt, the newly appointed health secretary, saying ‘Everyone looks at the evidence and comes to a view about when they think that moment is, and my own view is that 12 weeks is the right point for it … It's just my view about that incredibly difficult question about the moment that we should deem life to start. I don't think the reason I have that view is for religious reasons’.16 In response to Jeremy Hunt's comments, the RCOG issued a press statement17 stating that ‘lowering the time limit will not result in a lower abortion rate. Women who are desperate to have an abortion will look for the means to have one, and this includes seeking access to an illegal and unsafe abortion. This would be a huge backward step for women putting them at serious risk of psychological and physical complications, reminiscent of the situation prior to the passage of the Abortion Act of 1967.’

The prime minister, David Cameron, also expressed his personal opinion that the 24-week limit should be reduced to 20 weeks, but stressed that the government had no plans to lower the time limit.18 This was confirmed by a statement in the House of Lords by Earl Howe (parliamentary under-secretary of state, department of health) which made clear that ‘the Government have no plans to review the Abortion Act 1967’. He went on to say ‘there is currently no call from the main medical bodies for a review of the Act in relation to time limits, and the BMA and the Royal College of Obstetricians and Gynaecologists support that view’.19

Non-therapeutic male circumcision: Germany

In October 2012, the German government announced it was backing legislation which would make it clear that non-therapeutic male circumcision is legal under certain circumstances. The German parliament felt compelled to respond after a doctor was prosecuted in 2011 for circumcising a 4-year-old Muslim boy, at the request of his parents, for religious reasons. As a result of the surgery the boy suffered bleeding which resulted in him attending the emergency department 2 days after the procedure. There was no suggestion that the doctor was negligent in the way he performed the procedure, and the doctor was acquitted by the courts. Despite this, the Cologne regional court concluded that circumcision for religious reasons was a violation of the child's bodily integrity, and the child could decide for himself later if he wanted circumcision as a visible sign of belonging to Islam.

The ruling caused outrage among religious groups. The president of the Central Council of Jews in Germany, Dr Dieter Graumann, called the court decision ‘an outrageous and insensitive act’ stating that the ‘circumcision of newborn boys is an inherent part of the Jewish religion and has been practised worldwide for centuries. This religious right is respected in every country in the world’.20 The Central Council of Muslims in Germany (ZMD) stated that the judgment was a flagrant and unacceptable interference with the self-determination of religious communities and parental rights.21

Although the Cologne court's ruling is not binding on the rest of Germany, it was likely to be influential in future cases. As a consequence of the judgment, the German Medical Association told doctors to stop performing non-therapeutic circumcision.22 Chancellor Angela Merkel was quick to respond saying ‘I do not want Germany to be the only country in the world where Jews cannot practise their rituals. Otherwise we will become a laughing stock’.23

The German Government's new legislation was expected to become law before the end of 2012.24 The German Medical Association welcomed the draft Bill.25


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