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Jul-Sep2002-10(3)
FROM OTHER JOURNALS
An obsolete oath?
Does Hippocrates have noth ing to say to the modern
health professional? This writer argues that developments in medical technology,
the growing importance of public health, the growth of private insurance, and a
range of social changes all combine to challenge the principles contained in the
Hippocratic oath. Powerful new interventions often do some harm; the absolute
regard for life has been challenged by the dilemmas posed by high-tech
techniques, and private insurance and public health demands have together eroded
the notion of privacy. He suggests that doctors and society must get to grips
with the ethical consequences of the medical revolution.
Imre Loefler.
Why the Hippocratic ideals are dead. BMJ
2002;324:1463
Publication ethics
The writers looked at whether medical journals have
improved their standards requiring researchers to describe the protection given
to participants in clinical trials, in terms of mentioning whether informed
consent was taken from participants, and whether ethics committee approval was
sought and obtained. They compared 60 articles in each of five major general
medical journals, for 1995-1999. While these journals improved their reporting
of these two ethical requirements, 9% of studies still report neither informed
consent nor ethics committee approval.
Veronica Yank,
Drummond Rennie. Reporting of informed consent and ethics committee
approval in clinical trials JAMA. 2002;287:2835-2838.
All about the kidney trade…
The fortnightly Frontline has carried a number of
investigations on the kidney trade. The site (www.flonet.com) now has a collection
of articles on the subject, which make up an excellent reference source
(www.flonnet.com/ktrade.htm), with
reports on networks in various parts of the country, a feature on a 'one-kidney
community' of donors, articles on the law and on cadaver programmes. In an essay
on the case for a 'regulated kidney trade', the writer gives a brief outline of
perspectives of the World Medical Association and other international and
national bodies, and non-governmental organisations. She presents the arguments
in support of organ sale, and the response to these arguments, drawing from
academic debates, decisions of the World Medical Association and other
organisations, and the experiences of medical professionals. She concludes:
"New-fangled arguments for a paid-donor system cannot override its proven
negative social and ethical consequences and implications."
Vidya Ram.Ethical
and moral considerations. Frontline 2002 March 30-April 12; 10 (7).
Trying to bridge the 'donation gap'
The kidney trade in India sabotages efforts at
establishing a cadaveric organ transplant programme. The USA has a cadaveric
programme, but although three out of four people asked say they would wish to
donate, when actually asked for consent for donation of a relative's organs,
only half of those asked agree. The US still faces a crisis in donations,
resulting in about 4,300 deaths in 2001. This leads to desperate patients buying
organs from outside the country. Efforts to promote donation include improving
public awareness, scrutinising existing approaches to getting consent from
relatives, incentives and even payments. This report discusses efforts to
improve the manner in which patients' relatives are approached for consent. A
study of 420 families found that those who spent more time discussing donation
with organ procurement organisation staff were more likely to consent, as were
families who were asked to make a decision only after such discussions. The more
radical approach of presumed consent, in which all deceased patients become
potential donors, has not been taken up at the policy level.
Brian Vastag.Need for donor
organs spurs thought and action. JAMA 2002; 287 (19).
Ethical incentives to organ
donation
n This essay considers the possibility of giving
incentives to promote organ donation. This suggestion is made in the context of
a growing reliance on living donation - and the attendant risk of financially
motivated donation. The authors argue that both presumed consent and mandated
choice (requiring all citizens to state whether or not they will donate) have
limitations in a country such as the US. The existing shortage also leads people
to the black market for organs. Though the National Organ Transplant Act
prohibits the selling/buying of organs, for-profit companies have already become
processors of other transplantable tissues. Many bills are in the pipeline to
promote donation; some effectively legalise payment for organ donation. They
suggest other ethical incentives to increase organ donation - from both, living
donors and from cadavers - which would not amount to payment. These could
include some kind of public honour, a small reimbursement for funeral expenses,
medical leave for organ donation, and life and disability insurance for donors.
Tax credits or refunds - both suggestions made in proposed legislation - are
effectively payments, which the authors oppose.
Delmonico, F L et al. Ethical incentives - not
payment - for organ donation. N Engl J Med 2002 346 (25): 2002-2005
Unequal medical care
"In almost every nation in the world, increased
burdens of morbidity and mortality afflict racial and ethnic minorities and new
immigrant populations." While poverty and poor access play a role in this
situation, the author also points to research findings that minorities who do
use the system are also treated differently- from the quality of work-up, to
getting specific procedures, or medications - even when factors such as age,
sex, economic status and insurance coverage were taken into account. There is
evidence in some studies that the patients who were denied appropriate or
necessary care included some who were at greatest risk, and who suffered
accelerated mortality consequently. This goes against the commitment to equal
care for all. Of the many possible reasons for this disparity, the writer argues
that physician bias affecting clinical decision-making, and cultural
incompetence, are the most directly remediable. Both the US and the UK have
taken steps to address racism in health care. Medical students are also being
trained to work in multi-cultural settings. Most examples of uneven treatment
are not to do with conscious bias, but the indirect results of time pressures
and the complex nature of the job. Also, health care workers will reflect the
biases in mainstream society and the culture of medicine. Reducing racially or
culturally based inequity in medical care is a moral imperative.
H Jack Geiger.
Racial stereotyping and medicine: the need for cultural competence
Commentary. CMAJ 2001; 164 (12).
Racism in medicine
This book review of Racism in medicine, by a UK
physician of Asian descent, presents another facet to the issue of racism in
medicine, relevant to India. The author states that the book provides ample
evidence of racism within the health services - directed at patients by health
professionals, at students by teachers, at health professionals by their
colleagues as well as by patients. The profession cannot afford to be complacent
about the problem; nor can it wait for more research. What is needed now is a
sense of responsibility to change the situation, and action to implement
existing legislation.
Raj Bhopal. Racism in medicine: the spectre
must be exorcisedwww.studentbmj.com/back_issues/0801/editorials/262.html
Doctors in conflict
A UK doctor on his way to volunteer in the
emergency department of a Palestinian hospital for the Palestine Red Crescent
Society was denied entry 'for security reasons' and deported from Tel Aviv
airport. He wrote on the wall of the holding cell: "I was denied entry because I
came to give humanitarian assistance... My duty as a doctor is to give help to
those in need, irrespective of race, nationality, religion, or political
beliefs. That includes Palestinians." As a result of the Israeli government's
policy, 2,000 humanitarian aid workers and human rights activists were barred
from entering Israel in a month; 50 were deported.
Ben Alofs.Occupied
Territories: entry denied. BMJ 2002;324:1225
Health care workers and
war
What can health care workers do about the threat of
war? This is certainly an urgent task before the medical profession in this
region. The writers believe that doctors can support efforts to prevent the use
of certain weapons (such as nuclear or biological weapons), draw public
attention to the health effects of war; support efforts at peace-making. Also,
they can support the rehabilitation of all those affected by war, by building an
equitable, accessible healthcare system. Doctors should use their skill "in
maintaining the well being of humans, as well as our legitimacy as healthcare
workers, to seek medical, social, and political solutions that help eradicate or
limit this disease that afflicts humanity."
Salim Yusuf, et al.
Can medicine prevent war? Imaginative thinking shows that it might. BMJ
1998;317:1669-1670.
Case studies on health and human
rights
The skills of physicians, medical and forensic
scientists, and other health workers are uniquely valuable in human rights
investigations and documentation, producing evidence of abuse more credible and
less vulnerable to challenge than traditional methods of case
reporting.
This article presents case studies from the field
missions of Physicians for Human Rights on investigation and documentation of
violations of medical neutrality, refugee health crises, use of indiscriminate
weapons, torture, deliberate injury, rape, and mass executions. Participation of
health workers in the defense of human rights now includes investigation and
documentation of health effects in threatened populations as well as individual
victims.
Geiger HJ, Cook-Deegan RM.
The role of physicians in conflicts and humanitarian crises. Case studies
from the field missions of Physicians for Human Rights, 1988 to 1993. JAMA 1993;
270(5): 616-20.
Doctors at the time of Apartheid
This report documents the role of white health
professionals in South Africa during a time of state-supported racism ignored.
It finds that they supported Apartheid in violation of international medical
standards, by refusing treatment; falsifying medical records to cover up
evidence of torture; turning over wounded political demonstrators, without
treatment, to the security forces, and violating patient confidentiality to
cooperate with security forces. "The conduct of the leaders of health
professional organisations was in many respects the most egregious of all," the
report concludes.
Human rights and health: the legacy of
Apartheid. American Association for the Advancement of Science and Physicians
for Human Rights, in conjunction with The American Nurses Association and the
Committee for Health in Southern Africa, Washington, DC, December 1998.
Changing responsibilities
Health professionals can "apply their skills and
knowledge in many increasingly complex emergency settings," write the
editorialists. They have documented the health consequences of human rights
violations, to establish criminal responsibility and to prevent them from being
repeated, usually through case testimonies.This editorial comments on a study to
establish patterns of human rights violations among Kosovar refugees by Serbian
forces.
Iacopino V, Waldman RJ.
Editorial. From Solferion to Kosovo: the evolving role of physicians.
JAMA 1999; 282 (5).
FILLER
Nepal doctors in a
bind
Since the declaration of a state of emergency in
Nepal on Nov 26, 2001, freedoms of expression, association, and movement
have been suspended. Security forces have arrested many civilians…On March 16,
2002, Mahesh Maskey, a member of Physicians for Social Responsibility, Nepal,
was arrested on his way to attend a conference in New Delhi, India… and was
released only after pressure by national and international human rights groups.
More than 2,850 people have been killed in the
6-year conflict between rebel Maoist groups and the government. Since
mobilisation of the army, there has been a high casualty rate among government
security personnel, members of the armed rebel groups, and civilians. Health
professionals are under pressure and scrutiny since both sides want to use their
skills to treat their wounded. In addition, the ethical right of health
professionals to practise medicine without prejudice has come under threat
through a recent government directive which requires all health professionals
and institutions to immediately inform Security Officials about any wounded
individuals seeking medical assistance. If treatment is provided without
appropriate notification, they will be regarded as supporters of terrorists and
be prosecuted. Jeetendra Mahaseth of Nepalgunj Medical College Hospital was
arrested and kept in isolation for 19 days because he had provided treatment to
at least one wounded member of the Communist Party of Nepal (Maoist). The
directive violates international ethical standards set by the World Medical
Association…
Medical professionals are in an impossible
situation: ...they are at risk of encountering armed groups demanding treatment
for their wounded; but providing treatment might lead to subsequent government
prosecution.
Nepal Medical Council, the only national body
ensuring medical ethics, has remained silent. Nepal Medical Association, the
national professional organisation of medical doctors, so far has written only
one letter of concern…
G K Sharma et al.
Physicians persecuted for ethical practice in Nepal. The Lancet, April
27, 2002.