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a fetus with Down’s syndrome.Although they were told that our usual policy was to reserve

this procedure for women over 35 years of age or for thosewho by their history were at high risk of having a baby witha detectable congenital anomaly, they were quite adamant intheir request. Amniocentesis and chromosomal analysis weretherefore carried out at 19 weeks of gestation. Cells derived byculture of amniotic fluid revealed a 47, XYY karyotype. Thepresence of two Y chromosomes was evident in metaphaseplates using quinicrine fluorescent staining. After much discus-sion, a saline abortion carried out at 23 weeks gestationresulted in the delivery of a 510 g male fetus. The patient un-derwent an elective tubal ligation and has subsequently donewell.

DISCUSSION

This case presented us with a number of difficult ethi-cal decisions. First, we had to decide if we would carryout an amniocentesis and cell culture for a woman agedless than 35 years at her request when there was noobvious increase in risk factors for a chromosomal ano-

maly in the fetus. We hesitated because if a precedentwas established by this case, and a large number ofwomen under 35 years of age requested amniocentesisand genetic studies, over-utilisation of limited facilitieswould prevent women with a greater risk of deliveringan infant with Down’s syndrome from being tested. Wewere influenced towards carrying out the procedure bythe observation that risk is always relative, and thechance of having an infant with Down’s syndromemight be acceptable to one couple but entirely unaccep-table to another. In addition, it was difficult to comparethe risk of complications from amniocentesis with therisk of having an affected child.

We, therefore, decided that since we had adequatefacilities, the only reasonable course to follow when pre-natal chromosomal studies are requested is to presentthe data and let the couple decide. On the other hand,if requests of this type became too common in relationto the facilities available, an age-limit would be reason-able and strict adherence to the 35-year-and-over agelimit would be the rule. At present each request inwomen under 35 years of age is assessed individually.A second and more difficult decision involved proper

counselling once the XYY karyotype was discovered. Ourchoices included: (1) only telling the couple that they didnot have a baby with Down’s syndrome; (2) describingthe XYY syndrome as we now understand it3 (inci-dence-1/1000-1/3000 live-born males; stature-

likely to be tall; intelligence-likely to be less than nor-mal but not severely retarded; aggressiveness-little evi-dence to support initial claims of increased aggressivebehaviour; criminality-more likely to commit minor

non-aggressive crimes than general population); or (3)something in between. The first course was rejectedbecause it involved withholding of information; the pos-sible moral and legal ramifications of this decision couldnot be determined. Nevertheless we hesitated to presentthe full description of XYY syndrome to the parents. Ifthey chose not to have an abortion, we feared that everybehavioural transgression (seen even in normal childrenfrom time to time) might be related to a possible "crimi-nal tendency" associated with the condition and a nor-mal parent-child relation would be impossible. Consider-ing the alternatives, however, we felt it better to divulgeall that we knew instead of selecting what informationwe thought might be better for the parents. Had theychosen not to have an abortion, extensive follow-up and

counselling would probably have been necessary to helpfoster a normal parent-child relation.

With the more frequent use of amniocentesis andkaryotyping for the prenatal diagnosis of Down’s syn-drome, -more fetuses with 46,XYY karyotypes as well as45,X, 47,XXY, and 47,XXX will be discovered. Thesekaryotypic abnormalities, and others as well, have incommon a phenotype often less devastating to the childand the parents than Down’s syndrome, since they aremore compatible with a normal existence. Each of thesecases will present difficult decisions for both the phys-ician and the parents.From our experience, we conclude that despite the

possibility of parental prejudice against the child if theychoose not to abort, everything that is known about thepotential physical, mental, or emotional abnormalitiesassociated with any given karotype abnormality shouldbe revealed. The parents should then have the freedomto choose the course best suited to them. Once the de-cision is made, our role is to support that decision andhelp it to be carried out.

We thank Suzzon Henderson and Pat Burgett for their help. Thecyto-genetic studies were supported in part by Project 905, Health Ser-vices Mental Health Administration, Department of Health, Educa-tion and Welfare, H.E.W., and a grant from National Foundation-March of Dimes.

Requests for reprints should be addressed to R.L.G., Department ofObstetrics and Gynecology, University of Alabama in Birmingham,School of Medicine, University Station, Birmingham, Alabama 35294.

REFERENCES

1. Nadler, H. L., Gerbie, A. Obstet. Gynec. 1971, 38, 789.2. Levy, D. L., Holland, J. B. ibid. 1976, 48, 233.3. Witkin, H. A., Mednick, S. A., Schulsinger, F., et al: Science, 1976, 193,

547.

Round the World

From our CorrespondentsAustralia

MEDIBANK DISMANTLED

THE austerity Budget ("stringent and anti-inflationary" wasthe official description) introduced by Mr Malcolm Fraser’sGovernment on Aug. 15 included the disappearance of auto-matic health insurance for all and thus the almost total des-truction of the great Health Insurance Program launched byMr Whitlam’s Administration on July 1, 1975. The provisionsknown as Medibank Standard are to be withdrawn, thoughMedibank Private survives as a competitor for the privatelyoperated voluntary insurance funds. In the early days of hisGovernment, Mr Fraser had promised to retain Medibank andmake it operate efficiently. In going back on his word, he mayblame inflation and the eagerness of some doctors to drainMedibank for all it was worth.

In announcing earlier changes in Medibank,’ which tookeffect on July 1, the Federal Minister for Health, Mr RalphHunt, included the end of "bulk-billing", except on behalf of"entitled pensioners", for whom doctors were still permitted toclaim 85% of the scheduled fee direct from Medibank. (Bulk-billing was the procedure whereby doctors were allowed toclaim accumulated fees due to them-a system described byMr Hunt as providing doctors "with a pipe-line to the mint".)At once there was an outcry (now being repeated with greatervehemence) that the "socially disadvantaged" would beexcluded from health care if on-the-spot payment was

demanded from them. If, on the other hand, such patients

1. See Lancet, May 13, 1978. p. 1036.

467

were to be billed by the doctors, the probability of the "sociallydisadvantaged" claiming the 75% rebate from Medibank tosend with the 25% personal contribution to the doctor, in fullpayment, was so remote that doctors in "under-privileged"areas could foresee the ruin of their practices. A compromise,now of theoretical interest in the face of the Budget’s drasticchanges, was proposed by the Government at Mr Hunt’s sugges-tion. Each doctor would have the right to determine which ofhis patients was unlikely to be able to pay his fee, and for such"disadvantaged" individuals he would be allowed to bulk-billfor 75% only of the scheduled fee. The onus of determiningwhich patients were "socially disadvantaged" would havefallen on the doctor, who, it was thought, would be unlikelyto extend a concession- made at his expense-to other thanthe genuinely needy. The hope (now, it seems, to be con-

founded) was that all patients in need would continue to haveaccess to free health care.

AGGRESSION

THE Australasian Pacific Forensic Sciences Congress onaggression, held last month in Sydney, was attended by repre-sentatives of Australia’s Asian neighbours and a few delegatesfrom Germany, Israel, and the United States. During the dis-cussion on juvenile violence evidence was advanced to showthat in Australia the increasing frequency of assaults, robbery,and malicious damage by male juveniles (although consider-ably less than in the U.S. and the U.K.) had continued its un-interrupted growth for nearly two decades. One possibility wasthat over-reporting by the mass media and sensationalising ofacts of juvenile violence had caused unwarranted public con-cern. Without adequate comparative data, who could say? Thepresent Australian picture of juvenile aggression could well beanalogous to the New South Wales illicit drug-abuse scene ofthe ’60s when, because of publicity, there was much publicanxiety, although only 503 narcotic abusers under the age of30 had been listed by 1969 on State police and Health De-partment files.’ Nevertheless, the mounting seriousness of theproblem was on record at that time, despite the difficulties ofidentifying narcotic abusers in the early stages; and so also wasthe fact that narcotics were in increasing use by ever youngerpersons. According to the State Health Commission, there arenow (1978) an estimated 10 000 narcotic abusers in N.S.W.A comprehensive attempt to discover common features

among young N.S.W. delinquents likely to become and toremain violent (as opposed to those likely to remain propertyoffenders) yielded nothing apart from a slight associationbetween lack of supervision and juvenile violence. So far thereappeared to be no psychologically distinct minority group hav-ing a monopoly on juvenile violent behaviour, nor a particularsocial class from which the aggressive young emerged. Whilethe violent young recidivists studied in Sydney had admittedlycome from unskilled or semi-skilled backgrounds, anothergroup-self-disclosed "unconvicted" equally aggressivejuveniles-had come uniformly from all social strata, indicat-ing that juvenile violence and social background had little con-nection with each other, and that the current Australian judi-cial system was funnelling off for conviction only a smallsocially definable section of juvenile delinquents.New research data from the U.S., presented by Prof. M. E.

Wolfgang, professor of sociology and law in the University ofPennsylvania, could be helpful to Australia and other coun-tries having, by American standards, a low homicide-rate. Inthe U.S., police statistics had shown that although this ratehad increased annually, the figures for spouse killing spousehad remained steady at 12%, while murder within the familyhad made up 25% of all murders. For countries with low homi-cide-rates, such as Australia, records showed a much higherpercentage of homicide resulting from domestic violence, andefforts to control or to reduce their overall homicide rates-

1. LeFevre, C. G. Med. J. Aust. 1971, i, 395, 1292.

particularly when such efforts were limited by lack of finance-should prove most effective if concentrated on family vio-lence. The "emergency domestic quarrel team" of specialists2was working successfully in Kansas City, where "with appro-priate intervening, counselling, referral and treatment of

family disturbance cells, there is a probability of reducing notonly domestic homicide but family violence in general".

Further, the idea that crime was committed by the emo-tionally disturbed-an approach which, to quote Professor

Wolfgang, resulted in the "coercive, manipulative control andthe psychic invasion of prisoners, as in the Clockwork Orange"-was now questioned because few or none of the rehabili-tation programmes introduced in the U.S., Sweden, Finland,England, and Norway had made much or any difference to therates of recidivism in those countries. The available data fromall sources now suggested that criminal aggression should bepunished by law and punished according to the extent to whichthe aggression has been inflicted on individuals and on society.The papers presented will appear in the Journal of the A us-

tralian Academy of Forensic Sciences.

United States and CanadaMETRICATION

WHILE Britain decided several years back to go metric andhas already taken the initial steps, the U.S. considered the ad-visability of doing likewise, agreed that it would probably bebeneficial in the long run, and then promptly decided to let itrest. When "metrication" was broached on television and theother media, industry rose up in arms, declaring that the modi-fications necessary would cost many billions of dollars-whichis probably true. But more importantly it would be unethicaland un-American to make nuts and bolts whose dimensionshad to be stated in centimetres rather than inches and to sellbeer by the cubic centimetre. Moreover, to go metric wouldrender useless all the wrenches (spanners) already in use in theU.S. But the general public protested even more, and since allmembers of the House of Representatives have to stand forelection every two years, they tend to heed the admonitionsthey receive from their constituents. Only in the scientific andmedical world does the metric system prevail, but even herethere are isolated pockets of resistance, as exemplified by adrug company which devised and distributed free a pocketnomogram to convert degrees Centigrade back to Farenheit.

North of the border, and perhaps partly because of the in-fluence of French Canada, the Government has decided to gometric even if the majority of their constituents are undecided.Distances and speeds are all given in kilometres and kilometresper hour. Those U.S. citizens who come to Canada on holidayare often unaware of the change, and their eyes light up whenthey see the speed limit of 100. Having been restricted to 55m.p.h. in the States, they see the Canadian signs as marvel-lous, and many go on to assume, often to their financial embar-rassment, that kilometres is just the French word for miles.But Canada has only gone half-hog; one still buys petrol (orgaz in Quebec) by the gallon, and this has led to some outra-geous anomalies, such as the hybrid by which car performanceis expressed in kilometres per gallon. SI units are still a Euro-pean disease, but doubtless some North American scientist orphysician with an obsessional neurosis and with too much timeon his hands will sooner or later develop the evangelistic urge.There are those who feel that the urge to go metric is not onlybarbaric but is also responsible for most of the world’s prob-lems, including Britain’s past and present economic predica-ment. As a British colleague so aptly remarked, "in the goodold days of pounds, shillings, and pence, no foreigner could un-derstand the system, and any enterprising Briton could shortchange them-but now!"

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2. Wolfgang, M. E. Youth and Violence, U.S. Department of Health and Edu-cation and Welfare. Washington, D.C. 1970.