US physicians debate capital punishment

Congress renews fight

over

Dormant for most of the past two years, the political issue of abortion is again taking centre stage in congress, where the opposition to Dr Henry Foster’s nomination as US Surgeon General (see p 41) is the highest profile but not the only abortion debate now raging. The election of 1994 that gave Republicans control of Congress heralded for the first time a majority in both the House and Senate who oppose legal abortion in most circumstances. But with Congress unlikely to muster the votes to outlaw abortion completely, the Republicans have adopted a two-pronged, incremental strategy-to reverse some of the gains abortion-rights advocates have made since President Clinton took office in 1993, and to spotlight new issues that could help win the support of an electorate deeply ambivalent about abortion. It is these new issues that are of the most concern to physicians. One effort is to outlaw what lawmakers have labelled "partial birth abortions", a reference to a variant of the dilation and extraction procedure done after the first trimester of pregnancy. A bill approved on June 21 by

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abortion subcommittee of the House Judiciary Committee defines the procedure as "an abortion in which the person performing the abortion partially vaginally delivers a living fetus before killing the fetus and completing the delivery". Under the bill physicians performing such a procedure could face a 2-year prison sentence and be sued by the patient. But physicians testifying at a June 15 hearing on the measure took exception. "Medically, we do not do ’partial birth’ abortions. There is no such thing", testified DrJ Courtland Robinson of the obstetrics and gynaecology faculty at the Johns Hopkins University Hospital. Furthermore,’ Robinson added, "Telling a physician that it is illegal for him or her to adapt his or her surgical method for the safety of the patient is, in effect, legislating malpractice". Anti-abortion legislators last week also introduced a bill that would overturn a policy change adopted in February by the Accreditation Council on Graduate Medical Education requiring most obstetric and gynaecology residents to be trained to do induced abortions. Residents with a

physicians debate capital punishment

Nearly half a century after the Nurem- : consider physician complicity in capital berg Doctors’ Trial, ethical concerns : sentences to be grounds for disciplinary about physician involvement in state- : proceedings, including revocation of ordered executions were aired at the : licensure. Following this, some individual American Medical Association’s annual : physicians and the Physicians for Human meeting in June. The focus was not some Rights challenged the Illinois law, arguing far-off land noted for human-rights viola- : that doctors who participate in executions tions, but Illinois, the AMA’s own back- : should lose their licences for performing yard, site of its head quarters and annual : unethical acts. But Illinois legislators : passed a law, signed by the governor this meeting. to some are involved Physicians degree : March on the day of the double execuin executions in 36 American state, typition, changing the medical practice act to cally to pronounce death. At Statesville : say that physicians involved in carrying Correctional Centre in Joliet, Illinois, : out the capital sentence were not practisfour prisoners, including mass-murderer : ing medicine and so were exempt from John Wayne Gacy, have been put to death : being disciplined for ethical violations. Dr Ann Marie Dunlap, a prison physiwith lethal injections since 1990 with the : cian and campaigner against physician assistance of physicians. In this state, involvement reportedly has included set- : involvement in executions, said the Illiing up the intravenous portals for delivery : nois law is more brazen than any official of the execution drugs, monitoring vital : steps taken during the Nazi era in Gersigns, and pronouncing death. During a : many. She said American physicians are double execution in March, the doctors : split on whether capital punishment are reported to have administered the : should be performed, but the great intravenous drugs. No-one knows for cermajority agree physicians should not viobecause a state law tain, however, passed : late the social contract by being part of in 1991 allows anonymity of the physi- : the killing process. cians and orders that they be paid in : have State-employed physicians untraceable cash. Despite strong ethical : shunned the killing process. But Illinois prohibitions from the AMA and other : Department of Corrections has had no professional bodies against physician problem finding physicians willing to involvement, no disciplinary actions have : perform executions. been taken against doctors who have : The American College of Physicians, taken part in executions in Illinois or in : the American Public Health Association, : and the American Nurses Association any other place. In March, 1994, the AMA and other : called on the AMA to condemn the Illigroups called on licensing boards to . nois law. The AMA’s policy-setting House

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"moral or religious objections" would be excused from the requirements, and residency programmes with "a religious, moral or legal restriction" prohibiting abortions would have to refer residents for abortion training elsewhere. All residents would be required to receive training in managing complications of abortions. Anti-abortion lawmakers, however, argue that the religious and moral exceptions are insufficient. "This policy is forcing medical training programmes in obstetrics and gynaecology to teach abortion techniques against their will", said Representative Pete Hoekstra (Republican, Michigan). Other abortion fights are expected to play out this summer during consideration of the 13 annual government-spending bills. This House has already voted to bar abortions in military hospitals for servicewomen and military dependants, even if the woman pays for the procedure herself. Efforts are also expected to allow states to deny funding for abortions in cases of rape or incest, and to ban research using tissue from aborted fetuses. All are previous restrictions lifted since President Clinton’s term began.

Julie Rovner of

Delegates did just that. Dr Palma Formica, an AMA Board member, said a resolution the body adopted reaffirmed the AMA’s 1980 position against physician involvement and also censured the Illinois statute. Now Dunlap said she hopes the AMA will join in an expected challenge of the new law in the courts. Meanwhile, Illinois officials have said that there could soon be an execution a month.

Howard

Wolinsky

Los

Angeles County’s hospitals dilemma Angeles County administrators are considering closing the 63-year-old County-University of Southern California Medical Center, long the symbol of life and death for millions of Los Angeles poor. As protestors crowd hearing rooms, county administrators see shutting the hospital and four regional health centres as one way to correct a major share of the budget deficit, which has grown to Los

US$1.2 billion-$655 million of it in health-care costs. The proposal would eliminate some 12 000 county health workers, 9000 of them at County-USC. If the big hospital is kept open, the fate of four of six other county hospitals would be jeopardised, the county administrative officer said. In contrast with health layoffs, only 1132 law-enforcement and court-related jobs would be eliminated.

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