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Commercial or compensated surrogacy involves providing payment for a woman to gestate a fetus to term and then hand over the child to commissioning parent(s). Compensated surrogacy is currently restricted by law or regulation in all Australian states and territories. New South Wales, Queensland and the Australian Capital Territory also restrict commissioning transnational compensated surrogacy, although there is evidence that this is not acting as a deterrent. Ethical issues arising in transnational compensated surrogacy include concerns relating to exploitation, commodification and welfare. The current status quo is unsatisfactory on legal, ethical and practical grounds. It is time to openly debate how Australia should balance the desire for childbearing through surrogacy with the limited domestic availability of women willing to act as surrogates.

The protracted and costly investigations into Camden and Campbelltown hospitals (New South Wales), The Canberra Hospital (Australian Capital Territory), and King Edward Memorial Hospital (Western Australia) recently uncovered significant problems with quality and safety at these institutions. Each investigation arose after whistleblowers alerted politicians directly, having failed to resolve the problems using existing intra-institutional structures. None of the substantiated problems had been uncovered or previously resolved by extensive accreditation or national safety and quality processes; in each instance, the problems were exacerbated by a poor institutional culture of self-regulation, error reporting or investigation. Even after substantiation of their allegations, the whistleblowers, who included staff specialists, administrators and nurses, received little respect and support from their institutions or professions. Increasing legislative protections indicate the role of whistleblowers must now be formally acknowledged and incorporated as a "last resort" component in clinical-governance structures. Portable digital technology, if adequately funded and institutionally supported, may help to transform the conscience-based activity of whistleblowing into a culture of self-reporting, linked to personal and professional development.

Objective: To determine the incidence of congenital heart defects (CHD) in Aboriginal and non-Aboriginal infants in Central Australia and to compare this with the incidence elsewhere in Australia. Design and setting: Data on cases were obtained from patient records of the Alice Springs Hospital, Central Australia, the sole referral centre for paediatric and initial cardiac diagnostic services for the region. Participants: Patients with CHD proven by echocardiography reported between 1 January 1993 and 30 June 2000. Main outcome measures: Incidence of CHD using all live births in Central Australia as the denominator. Results: 108 patients with CHD were detected among 6156 live births (incidence, 17.5 per 1000; 95% CI, 14.9–21.7 per 1000); 57 of 2991 were Aboriginal (19.0 per 1000; 95% CI, 14.4–24.6 per 1000) and 51 of 3165 were non-Aboriginal (16.1 per 1000; 95% CI, 12.0–21.1 per 1000). The difference between the two groups was not statistically significant (relative risk, 1.18; 95% CI, 0.81–1.72). CHD incidence in Central Australia was significantly higher than that reported for other parts of Australia (4.3 per 1000 live births in New South Wales and the Australian Capital Territory, 1981–1984; 7.65 and 12 per 1000 total births in Western Australia, 1980–1989, and South Australia, 1993–2000, respectively). Conclusions: The high rates of CHD in Central Australia may partly reflect the high utilisation of echocardiography for assessing minor lesions. However, the incidence of both major and minor types of CHD was significantly higher than previously reported from other regions of Australia. The role of socioenvironmental factors in this high

Objectives: To investigate the relationship between access block in the emergency department (ED) (defined as total time from arrival to transfer from the ED over eight hours) and inpatient length of stay (LOS). Design and setting: Retrospective cohort study of all admissions through the ED to a tertiary hospital in Canberra, Australian Capital Territory, during 1999. Main outcome measures: Total time in the ED and LOS, calculated in days from ED departure to hospital discharge (non-overnight admissions were assigned LOS of one day, and all LOS were truncated at 10 days). Results: 11 906 admissions were included, and 919 experienced access block (7.7%). Mean LOS was 4.9 days in those who experienced access block (95% Cl, 4.7-5.1), compared with 4.1 days in the no-block group (95% Cl, 4.0-4.2; P < 0.0001). Subgroup analysis showed that this access block effect occurred across different severities of illness and diagnoses. A strong relationship was found between longer LOS and arrival of access-block patients on the inpatient ward outside office hours (0800-1600 weekdays). Conclusions: This is the first study to show an association between access block and a measure of outcome outside the ED. If the effect of access block on LOS is reproduced in other settings, there are major implications for hospital management.

Objectives: To compare rates of mortality from coronary heart disease (CHD) between populations living within and outside Australian capital city statistical divisions. Design and setting: Descriptive epidemiological study based on data for all residents of Australia aged 30-69 years who died between 1986 and 1996 in all States and Territories of Australia. Main outcome measures: Standardised mortality rates from all causes and coronary heart disease as coded by the Australian Bureau of Statistics, and estimated excess deaths in populations living outside capital city statistical divisions. Results: Between 1986 and 1996, mortality from CHD declined by 46% in men and 51% in women, and accounted for 61% of the decline in mortality from all causes in men and 48% in women. More deaths than expected from acute myocardial infarction resulted in mortality rates from CHD up to 30% higher in men and 21% higher in women living outside the capital city statistical divisions, and accounted for an overall estimated excess of 3835 deaths from CHD in men (32% of excess deaths from all causes), and 1385 deaths from CHD in women (27% of excess deaths from all causes) over the 11-year study period. Conclusions: Although there were impressive declines in coronary mortality in all Australian States and Territories from 1986 to 1996, populations living outside capital cities continue to have higher death rates from CHD. These differences in mortality rates indicate a need for further research into factors which may influence mortality rates for CHD in rural and remote areas, and immediate measures to ensure optimal treatment of coronary risk factors and acute coronary events in such populations.

The Australian National Liver Transplantation Unit carried out 251 multiple organ-retrieval procedures between January 1986 and December 1994: 53% were in the Sydney metropolitan area, 22% in country New South Wales and the Australian Capital Territory, 21% interstate and 4% in New Zealand; mean total procurement times were, respectively, 4 hours 57 minutes, 6 hours 58 minutes, 9 hours 20 minutes and 12 hours 20 minutes. Donor operation times steadily decreased over the nine years. One-year patient and graft survival rates were 77.1% and 70.3%, respectively; primary non-function occurred in only one case. The importance of coordination of donor organ procurement and efficient organ retrieval to the success of transplantation programs is discussed.

Objective To record doctors' attitudes towards, and practice of, active voluntary euthanasia (AVE) and physician-assisted suicide (PAS) in New South Wales and the Australian Capital Territory. Methods A postal survey was sent to a random sample of 2000 practitioners on the Medical Register of NSW (which includes medical practitioners in the ACT). Results Almost half the practitioners had been asked to perform euthanasia, of whom 28% had complied. Of practitioners asked to assist with suicide, 7% had complied. There was majority support for changes to the law concerning euthanasia. Conclusions There are relatively high levels of support for, and practice of, AVE and PAS by medical practitioners in New South Wales and the ACT, suggesting that the current legislation should be reviewed.

OBJECTIVE: To determine the accuracy of death certificates in the Australian Capital Territory (ACT) by comparison with autopsy reports. DESIGN: A retrospective study of 495 deaths occurring from 1979 to 1987, excluding coronial deaths and deaths of infants under one year of age. The main cause of death on the death certificate was compared with the main cause of death recorded on an autopsy-supported death certificate created for the study. SETTING: The deaths occurred in both major institutional hospitals in the ACT. These hospitals are government-funded and administered, catering for both private and public patients. PATIENTS: There were 495 autopsies recorded in the ACT over the study period. The age data were lost in two cases. MAIN OUTCOME MEASURES: To find a simple measure of death certificate accuracy and compare the results with previous work. RESULTS: The accuracy of death certificates was 77%. Age, sex and length of hospital stay made little difference to the accuracy. Neoplastic diseases were accurately reported in 90% of cases, digestive and cardiovascular diseases in 81%. CONCLUSIONS: There is a need for practical methods and standard criteria to evaluate accuracy of death certificates.

Objective: To describe the experiences of people with bipolar disorder with primary care and specialist mental health services. Design and setting: Focus groups and indepth interviews were conducted in seven Australian capital cities between July 2002 and April 2003. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data. Participants: Forty-nine people with bipolar disorder participated in the focus groups and four participated in the interviews. Results: Thematic analyses highlighted eight key themes. Most notably, respondents identified a lack of awareness and understanding about bipolar disorder within the Australian community, which contributed to apparent delays in seeking medical assessment. The burden of illness was exacerbated by difficulties experienced with obtaining an accurate diagnosis and optimal treatment. The healthcare system responses were described as inadequate and included inappropriate crisis management, difficulties accessing hospital care, inappropriate exclusion of carers and families from management decisions, and frequent discontinuities of medical and psychological care. Conclusions: People with extensive experience of bipolar disorder report barriers to optimal care because of lack of community understanding and healthcare system shortcomings. These barriers exacerbate the social

OBJECTIVE To determine the likelihood of pregnancy for couples entering the New Reproductive Technology (NRT) programs in Australia and New Zealand, by combining the data from nearly all the practising units. DESIGN All units practising in-vitro fertilisation (IVF) and/or gamete intrafallopian transfer (GIFT) were contacted and asked to provide data on patients treated and pregnancy rates. These figures were then combined to produce life tables to determine the likelihood of pregnancy with repeated attempts. SETTING IVF/GIFT units in five States of Australia, the Australian Capital Territory and New Zealand. Eighteen of the 22 units provided data to be analysed. PATIENTS Data were available for analysis on 18,089 cycles of IVF resulting in 3034 clinical pregnancies, and 6308 cycles of GIFT resulting in 1724 clinical pregnancies. MAIN OUTCOME MEASURES This was either "clinical pregnancy" (the presence of products of conception on ultrasound examination), or "viable pregnancy" (a pregnancy developing to at least 20 weeks of gestation). RESULTS After four attempts at IVF, half the couples achieved a pregnancy, whereas four attempts at GIFT resulted in two-thirds of the couples achieving pregnancy. CONCLUSION Both IVF and GIFT are effective and successful options for infertile or subfertile couples. New Reproductive Technology should be readily available in every advanced clinic dealing with subfertile couples in the 1990s.

No data are available on the incidence of breast cancer for the whole of Australia. Review of published incidence data from 1972 to 1978 from New South Wales, South Australia, and Tasmania shows that the incidence of breast cancer in women aged 25 years and over ranged between 97.8/100 000 and 106.5/100 000 of these women. These rates are similar to those in other countries with high rates. Comparison of mortality rates in Australian States between 1968 and 1978 for women aged 25 years and over showed rates from 28.3/100 000 in Victoria and 44.1/100 000 in the Australian Capital Territory. The rates for Victoria and the Australian Capital Territory were significantly higher than those in the other States. Trends in mortality in Australia for women aged 25 years and over were studied in the period from 1907 to 1977. Initially, the mortality rate was 28.5/100 000 and increased to reach a peak of 41.5/100 000 in 1940-1944. Thereafter, rates fell to 37.1/100 000 in 1960-1964, but have begun to rise again since 1970. The 1940-1944 peak was largely confined to women over the age of 50 years, and further analysis of the age-specific mortality rates showed the peak to be cross-sectional in type (that is, affecting each age group in the same calendar period). The rise after 1970 occurred mainly in women aged between 30 and 44 years and 60 and 79 years.

A case-finding survey yielded 58 persons with transfusion-dependent homozygous beta-thalassaemia who lived either in New South Wales or in the Australian Capital Territory. Of those born between 1961 and 1976 in New South Wales, nearly 70% were of Greek or Greek-Cypriot origin and 18% of Italian origin. The New South Wales incidence rates for homozygous beta-thalassaemia were estimated as follows: one in 934 births, Greek origin; one in 264 births, Cypriot origin and one in 3441 births, Italian origin.