BIOETHICS
"When you dance with the Devil, the devil doesn't change; the Devil changes YOU"

Bioethics consists of obligations of a moral nature relating to biological research and its applications. It is a branch of applied ethics arising from technological and scientific developments (e.g. tissue engineering, assisted reproduction techniques, life support techniques, ...)

Defensive bioethics looks for limits to tutelate

  • academic freedom of clinical faculty :
  • "I expect most doctors use the drink-drive rules--one drink when things are sorted is probably OK when you are on call. I don't think you will find many people who would discuss it openly: a bit of a taboo subject. I expect questions in surveys are not answered completely accurately." Thus said one senior UK doctor to The Lancet last week. 3 recent surveys show the extent of drinking by doctors on call, and some cultural differences between the UK and the USA, although the above caveat about honesty must be borne in mind. John Storrs found that nearly a half of UK consultants he questioned said that social drinking on call was acceptable. But a staggering fifth reported colleagues impaired by alcohol on callref. In the USA, however, James Peterman and Norman Desbiens found that 86% of physcians they surveyed disagreed that "social" drinking on call is acceptable. 27% had seen on-call colleagues impaired by drinking, a bit above the UK response ref. Clearly, doctors with alcohol problems or dependency need professional help. But what about social drinking of a drug that is so widely and legally available? Is the doctor safe to practise? The individual response to alcohol varies greatly, depending on sex, body size, eating food, taking other drugs (eg, antihistamines), and the complexity of the impending task. Because of the unpredictability of the response, no alcohol in the blood when on call must become the norm. Indeed, other professions face that stricture. For example, UK pilots are not meant to fly for at least 8 h after drinking even small amounts. US pilots face stricter rules: no drinking within 8 h of take-off. Some UK hospitals provide a bizarre watering-hole: the hospital bar. Actually, the bar provides a necessary social, learning, and debriefing environment. But it is crazy to sell alcohol to doctors on duty, and the practice must cease. Patients, and professional colleagues, must be able to trust that a doctor is not impaired to any degree by alcohol. In Peterman and Desbiens' survey, half the respondents felt they should inform their patient if they had had a drink on call, but only 12% had done so. The researchers refute the liberal argument that private actions are allowable if they do not harm others. That argument, they say, "ignores the role related obligations of physicians to put their own interests second to their patients' interests and the need to practice medicine with sobriety". No doctor should be practising, even after that single glass of cold Chardonnayref.

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  • Work-related sleep loss and fatigue in medical training has become a source of increasing concernref1, ref2, ref3, ref4. Although some studies demonstrate post-call performance deficitsref1, ref2, ref3, ref4, other studies do notref1, ref2, ref3, ref4. These mixed findings have been attributed to methodological limitationsref1, ref2, such as low power, absence of objective sleep measurement, outcome measures insensitive to sleepiness or lacking ecological validity (having little relevance to real-world demands), absence of control for circadian factors or stimulant use (caffeine), and questionable rested control groups (>4 hours of sleep)ref. The serious consequences of resident sleep loss have been demonstrated in an intervention study that found that interns obtained 5.8 hours less sleep, had 50% more attentional failures, and committed 22% more serious errors on critical care units while working a traditional schedule compared with a schedule of reduced hoursref1, ref2. On self-report measures, residents express concern about occupational and interpersonal difficulties stemming from sleep lossref1, ref2, ref3, ref4, ref5. Of particular concern, self-reported lifetime rates of motor vehicle near-misses and crashes among residentsref are 2.5 and 3 times those of nonresident drivers, respectivelyref. One survey found that compared with faculty members over the previous 3 years, more pediatric house officers reported falling asleep behind the wheel (49% vs 13%) and having motor vehicle crashes (20% vs 11%) during residencyref. A prospective study found that for every extended work shift, the monthly risk of a motor vehicle crash increased by 9.1%ref. Despite the heightened risk, only 2 small studies have examined resident driving impairment experimentally. Both found impairment of simulated driving post-call, but neither provided objective on-call sleep durationref (Risser MR, Manser TJ, Cain CL, Morewitz CL, Ware JC. Effects of call and gender on medical resident driving simulator performance [abstract]. Sleep. 2001;24:A125) and 1 study used a driving task lacking face validityref.24 One approach to measuring the magnitude of performance deficits associated with sleep loss is to compare performance following sleep loss and alcohol consumption. Dawson and Reidref found that impairment on a tracking task after 17 hours of wakefulness was equivalent to a blood alcohol concentration (BAC) of 0.05 g% (per 100 mL of blood) in a sample of nonresidents. These findings have been replicated with other tasks, including simulated driving, in samples of nonresident university students and truck driversref1, ref2, ref3. Alcohol serves as a useful index for comparison because it impairs performance, even at lower BACsref1, ref2, ref3, ref4, ref5, and legal limits of intoxication have been established. At 0.05 g% BAC (3-4 standard drinks), alcohol increases self-confidence; decreases inhibitions; diminishes attention, judgment, and controlref; and leads to hazardous drivingref. Our primary goal was to compare post-call performance during a heavy call rotation to non–post-call performance during a light call rotation with a BAC of 0.04 to 0.05 g%, using tests of sustained attention, vigilance, and simulated driving. To maximize rested and sleepy states, residents were tested during the final week of light and heavy call rotations. A prospective within-subject 2-session design was used to enhance feasibility and generalizability, reduce attrition, and experimentally control for time of testing, alcohol expectancy, beverage consumption, and test fatigue for our comparison of primary interest. A second goal was to evaluate the association between self-assessed and actual performance call-related sleep loss and alcohol ingestion. Post-call performance impairment during a heavy call rotation is comparable with impairment associated with a 0.04 to 0.05 g% blood alcohol concentration during a light call rotation, as measured by sustained attention, vigilance, and simulated driving tasks. Residents’ ability to judge this impairment may be limited and task-specificref

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    In 1994, a large survey was undertaken to assess the mental health of UK hospital consultantsref. A 27% prevalence of psychiatric morbidity was reported among 882 respondents from 5 specialties: gastroenterology, radiology, surgical oncology, clinical oncology, and medical oncology. This prevalence was in line with findings for consultants reported by others around the same timeref and was markedly higher than the 18% reported in the employed general population. The situation was re-assessed in 2002 for 2 main reasons. First, much has changed in the National Health Service (NHS). Additional funding for health care has been committed and the workforce has expanded. However, patients' expectations regarding their care have risen and clinicians face new pressures, which include: implementation of new policies to drive service improvement, including the NHS Plan and associated national service frameworks; introduction of targets; formal procedures for consultant appraisal; and changes to employment contracts and clinical governance. Second, poor mental health is not only destructive to consultants and their families, but could also compromise the quality of the care provided to patientsref1, ref2. The mental health of consultants was re-assessed after an 8-year period in those not retired from the initial study cohort and in a new cohort, from the same 5 specialties, of consultants who were new to the grade since 1994. This approach enabled to assess changes in the mental health of comparable cohorts of consultants across time and included a group of consultants who responded at both time points. High job stress is associated with poor mental health in hospital consultants, whereas high levels of job satisfaction protect consultants' mental health against the harmful effects of job stressref. At both time points, psychiatric morbidity was estimated with the 12-item General Health Questionnaire (GHQ-12); emotional exhaustion, the principal component of burnout, was assessed with the Maslach Burnout Inventory, and job stress and satisfaction were measured with a study-specific questionnaireref consisting of 25 individual sources of job stress and 17 of job satisfaction rated on a scale of 0 to 3. The characteristics of the respondents were similar at the 2 times, except for increases in the proportion of women (from 12% to 19%) and full-time workers (from 85% to 89%) and a decrease in the proportion undertaking private work (from 68% to 60%). Since 1994, the estimated prevalence of psychiatric morbidity and the level of emotional exhaustion had risen. Consultants reported an increase in their levels of job stress, and a smaller increase in job satisfaction. Similar patterns of change over time in mental health, job stress, and job satisfaction were noted in the longitudinal cohort. Significant increases in psychiatric morbidity and emotional exhaustion were noted for both clinical and surgical oncologists, but not for the 3 other specialties. However, the variation in change in psychiatric morbidity between specialties was not significant. Change over time in the job and demographic profile of the consultant sample accounted for little of the increase in psychiatric morbidity or emotional exhaustion, according to multivariate analyses. For emotional exhaustion, changes over time differed across the specialist groups; the greatest increase was for clinical oncologists. Analyses that included job stress and job satisfaction indicated that these variables accounted for the increase over time in both psychiatric morbidity and emotional exhaustion, and the differences between specialties in change to emotional exhaustion scores. Changes in levels of job stress and satisfaction over time varied according to a consultant's specialty. Clinical and surgical oncologists were the only specialists that reported increased job stress without a similar increase in job satisfaction. The change in levels of different sources of job stress and satisfaction indicated more specifically the areas of work that were perceived as problematic. Clinical and surgical oncologists reported increased job stress arising from feeling poorly managed and resourced, and from dealing with distressed, angry, and blaming relatives. Clinical oncologists also reported increased job stress from work overload and its effect on their home life and from having managerial responsibilities. These problems were coupled with increased job satisfaction from only one area of their work—their relationships with patients, relatives, and staff. Surgical oncologists reported a decrease in job stress arising from keeping their skills and knowledge up-to-date, but this change was coupled with reduced satisfaction from intellectual stimulation such as teaching and research. The deterioration in the mental health of UK consultants we report is cause for concern to the consultants themselves, to their families, and to the patients for whom they provide care. Of particular concern to the NHS is that this deterioration seems to be the consequence of increased stress at work, which is unmatched by a comparable increase in job satisfaction. The changes that have occurred in the NHS over the 8-year period aim to benefit patients, but appear to have a negative effect on the working lives of consultants. The decline in mental health was not uniform across the five specialties, and most of the change seemed to arise from problems for clinical and surgical oncologists. Interpretation of the findings for medical oncologists is more difficult, as they are a much smaller group, which might explain why similar patterns of change were not significant. The increases in job stress might be accounted for in part by the profile of the consultant work force expansion over the 8 years. In England, the numbers of medical oncologists and gastroenterologists more than doubled between 1994 and 2002, increasing by 147% and 119% respectively, compared with only a 45% increase in number of surgeons and a 33% increase in the number of radiologists and clinical oncologists. Additionally, the reconfiguration of cancer services driven by the Calman Hine Report (1995) and NHS Cancer Plan (2000), while benefiting patients, might contribute to increased job stress without similar, and thereby protective, increased job satisfaction for clinical oncologists and surgical oncologists. Approaches designed to reduce consultants' workload and enhance their job satisfaction should be prioritised to protect this valuable and expensive component of the NHSref.

    The protection and use of confidential information about patients has had welcome priority in the government's thinking in recent yearsref1, ref2, ref3 and becomes more important with the planned introduction of the new NHS care records serviceref. The legal framework for the processing and use of personal information is set out in the Data Protection Act 1998, which makes provision for the protection of privacy and confidentiality of people's personal informationref. At the other end of the privacy spectrum, openness and accountability in the NHS have been given a boost with the implementation in January 2005 of the Freedom of Information Act 2000ref. Many members of the public and healthcare professionals are unclear about the details—perhaps even the existence—of both laws and what they mean in practice. The Freedom of Information Acts (Scotland's was passed in 2002) give people a general right of access to information held by or on behalf of public bodies, which include NHS trusts, primary care trusts, strategic and special health authorities, and others—general practitioners, dentists, opticians, and pharmacists—providing services under parts II or 28C of the NHS Act 1977. The act creates an obligation on these bodies to have a publication scheme showing what information they publish and how it can be obtained. They have to reply to a request under the act for specific information, saying whether that information is held and making it available—subject to some exemptions. Individuals seeking information about different aspects of their healthcare will draw on the provisions of both acts depending on the nature of the request. For example, a patient's request to see his or her own health record is not covered by the Freedom of Information Act. Section 40 specifically exempts personal information of the person making the request within the meaning of the Data Protection Act 1998. Even if the request is received as a request under the Freedom of Information Act, public bodies are obliged to treat it as one made under the provisions of the Data Protection Act, which gives people the right of access to their own electronic and paper based health records, subject in most instances to a prescribed fee. Patients do not have an automatic right to see everything—data controllers (the holders of the record) should not reveal confidential information about a third party without that person's consent; and they do not have to reveal information that they judge would be harmful to the patient. But in addition to personal information, patients and members of the public have a legitimate right to know more about the activities of arranging and providing NHS services. They can now make a request under the Freedom of Information Act about how decisions were made, for instance on service allocation, overall prescribing patterns, or major capital expenditure. The act is fully retrospective, so people can request information about events at any time in the past. Not all such information will be open to scrutiny. We do not know as yet whether the many exemptions in the Freedom of Information Act will serve as reasonable grounds for restricting access to information or be used as excuses for avoiding the openness the act is intended to achieve. In addition to personal data of the individual making the request, specific exemptions (subject to a judgment about public interest) include among others the likelihood of creating an actionable breach of confidence around information provided by a third party (section 41) and revealing of trade secrets, or prejudicing commercial interests of any person or body (section 43). A request under the Freedom of Information Act can also be refused if the cost of meeting it would exceed the sums laid down in regulations or would cause unjustifiable workloadref. The acts are symbolic of the need in modern societies to protect the privacy and confidentiality of individuals and at the same time ensure appropriate accountability of publicly funded services. At their best the acts should promote improved communication and management of records. The more that is published and the more easily and frequently patients have routine access to information about their health care, the less likely they are to need recourse to the law to get the information they seek. Examples exist across the NHS of hospitals and practices routinely making information available to patients. These include general practices that invite patients to look at their own records or clinicians who routinely copy letters to patients, according to the policy of the Department of Healthref. Where healthcare professionals have developed such schemes, they and their patients have been rewarded with improved consultations, better understanding of treatment options, and the chance to correct mistakes in recordsref. In time the national programme for information technology will open "Healthspace," in which patients will be able to look at their records at their own convenience. This will be a major advance for patients and will go some way to creating more meaningful partnerships between patients and clinicians. Many clinicians and health managers are unused to providing information about their performance, which is now open to scrutiny. Some may grudgingly seek to comply only with the letter of the law, and in doing so they may miss the wider potential of the acts to contribute to a patient centred NHS. Legislation on its own cannot bring about a major change in culture. But it can act as a catalyst for improved performance in many ways. At its best, freedom of information should be a marker for openness and accountability in public services. It complements provisions for data protection for improving people's access to information about themselves, alongside the protection of their confidentiality and privacy. Both acts should help maintain progress to an NHS built on a "3-way partnership of respect, honesty and openness—between the NHS and the public, professionals and patients, and professionals and professionalsref."ref
    Doctors for Research Integrity

    Social determinants of health inequalities
    The gross inequalities in health that we see within and between countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people. A major thrust of the Commission is turning public-health knowledge into political action. There are gross inequalities in health between countries. Life expectancy at birth, to take one measure, ranges from 34 years in Sierra Leone to 81.9 years in Japan. Within countries, too, there are large inequalities--a 20-year gap in life expectancy between the most and least advantaged populations in the USA, for example. One welcome response to these health inequalities is to put more effort into the control of major diseases that kill and to improve health systemsref. A second belated response is to deal with poverty. This issue is the thrust of the Millennium Development Goalsref1, ref2. These goals challenge the world community to tackle poverty in the world's poorest countries. Included in these goals is reduction of child mortality, the health outcome most sensitive to the effects of absolute material deprivation. To reduce inequalities in health across the world there is need for a third major thrust that is complementary to development of health systems and relief of poverty: to take action on the social determinants of health. Such action will include relief of poverty but it will have the broader aim of improving the circumstances in which people live and work. It will, therefore, address not only the major infectious diseases linked with poverty of material conditions but also non-communicable diseases--both physical and mental--and violent deaths that form the major burden of disease and death in every region of the world outside Africa and add substantially to the burden of communicable disease in sub-Saharan Africa. To understand the social determinants of health, how they operate, and how they can be changed to improve health and reduce health inequalities, WHO is setting up an independent Commission on Social Determinants of Health, with the mission to link knowledge with action (panel 1). Public policy--both national and global--should change to take into account the evidence on social determinants of health and interventions and policies that will address them.
    The Commission on Social Determinants of Health
    The Commission will not only review existing knowledge but also raise societal debate and promote uptake of policies that will reduce inequalities in health within and between countries.  The Commission's aim is, within 3 years, to set solid foundations for its vision: the societal relations and factors that influence health and health systems will be visible, understood, and recognised as important. On this basis, the opportunities for policy and action and the costs of not acting on these social dimensions will be widely known and debated. Success will be achieved if institutions working in health at local, national, and global level will be using this knowledge to set and implement relevant public policy affecting health. The Commission will contribute to a long-term process of incorporating social determinants of health into planning, policy and technical work at WHO.
    This introduction to the Commission's task lays out the problems of inequalities in health that the Commission will address and the approach that it will take. This report will argue that health status should be of concern to all policy makers, not merely those within the health sector. If health of a population suffers it is an indicator that the set of social arrangements needs to change. Simply, the Commission will seek to have public policy based on a vision of the world where people matter and social justice is paramount.
    Inequalities in health between and within countries: poverty and inequality
    A catastrophe on the scale of the Indian Ocean tsunami rightly focuses attention on the susceptibility of poor and vulnerable populations to natural disasters. It is no less important to keep on the agenda the more enduring problem of inequalities in health among countries.

    A particularly telling example of health inequalities within countries is the 20-year gap in life expectancy between Australian Aboriginal and Torres Strait Islander peoples--life expectancy is 56.3 years for men and 62·8 years for women--and the Australian averageref. The men in this population would look unhealthy in India (male life expectancy 60.1 years) whereas Australian life expectancy is among the highest in the world, marginally behind Iceland, Sweden, and Japan. The poor health of Aboriginal and Torres Strait Islander peoples is not the result of a high rate of child deaths. Infant mortality is 12.7 per 1000 livebirths. This figure is high by Australian standards, but on a scale from Iceland to Sierra Leone, it is much closer to Iceland than to Sierra Leone. The shortened life expectancy of Aboriginal and Torres Strait Islander peoples results from mortality in adults from non-communicable disease and injury. In this sense, the population is typical of the world health picture. Of the 45 million deaths among adults age 15 years and older in 2002, 32 million were due to non-communicable disease and a further 4.5 million to violent causes. Aboriginal and Torres Strait Islander peoples are a socially excluded minority within their country. But poor health is not confined to poor populations or those who are socially excluded. As with child mortality, there is a socioeconomic gradient in adult mortality rates within countries. Figure 3 shows that in Bangladesh, adult mortality rates vary inversely with level of educationref. This gradient in mortality is quite remarkable. Within rich countries, with strikingly different material conditions from Bangladesh, there is a social gradient in mortality prompting consideration of the causal links between status and health. Whether the social gradient in poor countries can be attributed to the same causal pathways is an urgent task for review. It is especially important because, in many countries, inequalities in health have been increasingref1, ref2, ref3. In Russia for example, where life expectancy is low, social inequalities have grown (figure 4)ref. Mortality statistics are readily available. They should not, however, lead to ignorance of the burden of non-fatal disease. In particular, mental illness causes much suffering but its effect is not clear by inspection of mortality data. Worldwide, the second highest cause of disease burden among adults age 15-59 years is unipolar depressive disorder.
    The ageing of the world's population
    It is convenient, but quite wrong, to think that the greying of the world's population is an issue only for the rich countries. The fastest rates of projected increase between 2000 and 2030 in the population older than 65 years are in countries at an intermediate level of human development, starting from a low base. The social determinants of the health of older people claim attention alongside those of health at younger ages.
    Social determinants: poverty, inequality, and the causes of the causes
    In consulting widely in developing the plan for the Commission on Social Determinants of Health, a common question was: "What's new? We know that poverty is bad for health. Does that need a Commission?" It is not difficult to understand how poverty in the form of material deprivation--dirty water, poor nutrition--allied to lack of quality medical care can account for the tragically foreshortened lives of people in Sierra Leone. Such understanding is insufficient in two important ways. First, it fails properly to take into account that relief of such material deprivation is not simply a technical matter of providing clean water or better medical care. Who gets these resources is socially determined. Second, and related, international policies have not been pursued as if they had people's basic needs in mind. The critics of the policies pursued by the International Monetary Fund in the global South have argued eloquently that the economic policies pursued under structural adjustment have not benefited disadvantaged people in poor countries.19 Recognising the health effects of poverty is one thing. Taking action to relieve its effects entails a richer understanding of the health effects of social and economic policies. Dirty water, lack of calories, and poor antenatal care cannot account for the 20-year deficit in life expectancy of Australian Aboriginal and Torres Strait Islander peoples. On a world scale, their infant mortality rate, at 12.7 per 1000 livebirths, is low. Their high rate of adult mortality is from cardiovascular diseases, cancers, endocrine nutritional and metabolic diseases (including diabetes), external causes (violence), respiratory disorders, and digestive diseases.10 This fact is not to deny that poverty is important. But the form that poverty takes and its health consequences are quite different when considering chronic disease and violent deaths in adults, compared to deaths from infectious disease in children. It entails a richer understanding of the social determinants of health. The health experience of Aboriginal and Torres Strait Islander peoples has relevance for the health of disadvantaged people worldwide. While in Africa the major contributor to premature mortality is communicable disease, in every other region of the world it is non-communicable disease. Careful analysis of the global burden of disease has pointed to the importance of risk factors, such as being overweight, smoking, alcohol, and poor diet.20 These are indeed potent causes. But would it be helpful to go into a deprived Australian Aboriginal population and point out that they should really take better care of themselves--that their smoking and obesity were killing them; and if they must drink, please do so in moderation? Unlikely. To borrow Geoffrey Rose's term, we need to examine the causes of the causes: the social conditions that give rise to high risk of non-communicable disease whether acting through unhealthy behaviours or through the effects of impossibly stressful lives (panel 2).
    Panel 2: The Solid Facts
    Because the causes of the causes are not obvious, the WHO Regional Office for Europe asked a group at University College London to summarise the evidence on the social determinants of health, published as The Solid Facts. It had 10 messages on the social determinants of health based on: As an indication that there was a ready audience for these messages, in the first 12 months after publication of the second edition it was downloaded from the internet 218 000 times. The Solid Facts reviewed evidence from Europe, aimed mainly at reducing inequalities in health within countries. The task of the Commission will be to review evidence on the social determinants of health that are relevant to global health: inequalities among countries and within. A further answer to the what's new question: although it might be obvious that poverty is at the root of much of the problem of infectious disease, and needs to be solved, it is less obvious how to break the link between poverty and disease. Income poverty provides, at best, an incomplete explanation of differences in mortality among countries or among subgroups within countries. It is well known that among rich countries, there is little correlation between gross national product (GNP) per person and life expectancy. Greece for example, with a GNP at purchasing power parities of just more than US$17 000, has a life expectancy of 78.1 years; the USA, with a GNP of more than $34 000, has a life expectancy of 76.9 years. Costa Rica and Cuba stand out as countries with GNPs less than $10 000 and yet life expectancies of 77.9 years and 76.5 years. There are many examples of relatively poor populations with similar incomes but strikingly different health records.8 Kerala and China, famously, have good health, despite low incomes.24 The social processes that lead to this beneficial state of health need not wait for the world order to be changed to relieve poverty in the worst-off countries. A social determinants perspective is crucial. It is also important to enquire whether the action that is taking place to relieve poverty is having the desired effect not only on average incomes but also on income distribution and hence on the poorest people. The social gradient in health is a particular challenge. Where material deprivation is severe, a social gradient in mortality could arise from degrees of absolute deprivation. In rich countries with low levels of material deprivation the gradient changes the focus from absolute to relative deprivation. Relative deprivation relates to a broader approach to social functioning and meeting of human needs12--capabilities in the words of Amartya Sen, spiritual resources to use Robert Fogel's term. It is likely that both material or physical needs and capability, spiritual, or psychosocial needs are important to the gradient in health, which will, therefore, be an important focus. A focus on material conditions and control of infectious disease must not be to the exclusion of social determinants. The circumstances in which people live and work are as important for communicable as they are for non-communicable disease. Social conditions powerfully influence both the onset and response to treatment of the major infectious diseases that kill. The Commission on Social Determinants of Health will need to have in its sights poverty of the sub-Saharan African sort and the social determinants that account for Bolivia having 14 fewer years of life expectancy than Costa Rica or Aboriginal and Torres Strait Islander peoples having 20 years fewer than other Australians. As these examples illustrate, it will examine inequalities in health between countries and inequalities within. A review of policies in European countries identified several that took action on the social determinants of health. Although the reason for the policies was not necessarily to improve health they were nevertheless relevant to health: taxation and tax credits, old-age pensions, sickness or rehabilitation benefits, maternity or child benefits, unemployment benefits, housing policies, labour markets, communities, and care facilities. In Sweden, the new strategy for public health is "to create social conditions that will ensure good health for the entire population"ref. Of 11 policy domains, five relate to social determinants: participation in society, economic and social security, conditions in childhood and adolescence, healthier working life, and environment and products. These are in addition to health promoting medical care and the usual health behaviours. The UK set reduction of health inequalities as a key aim of health policy. It assembled evidence and expert judgments on areas suitable for policy development. These then formed the basis of a plan of action to reduce health inequalities. These are examples from rich countries. There are further encouraging examples. Familias en Accion in Colombia transfers cash to poor families. To qualify, families must ensure their children receive preventive health care, enrol in school, and attend classes. The results are encouraging: favourable growth of children and fewer episodes of diarrhoea. The Oportunidades programme in Mexico had somewhat similar aims with similarly encouraging resultsref. 2 linked themes provide the rationale for the Commission on Social Determinants of Health. First, there is no choice. If the major determinants of health are social, so must be the remedies. Treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health. Disease control, properly planned and directed, has a good history, but so too does social and economic development in combating major disease and improving population health. Wider social policy will be crucial to reduction of inequalities in health. There is a second theme that relates to the question of how one can tell if a population is thriving. One standard answer is to measure economic wellbeing with measures such as GNP, average income, or consumption patterns. A better answer is to measure health status. There is no difficulty in convincing medical and health personnel that health is important--that is what we do. It is more challenging, but necessary, to convince policy makers and others that the health of the population is important precisely because it is a measure of whether, in the end, a population is benefiting as a result of a set of social arrangements. In other words, action on the social determinants of health is necessary not only to improve health but also because such improvement will indicate that society has moved in a direction of meeting human needs. There is a great deal of dogmatic dispute about the rights and wrongs of economic and social policies. People use labels--globalisation, neoliberal economic policies--as badges of allegiance and terms of abuse. The Commission will have one basic dogma: policies that harm human health need to be identified and, where possible, changed. From this perspective, globalisation and markets are good or bad in so far as the way they are operated affects health. Inequalities in health between and within countries are avoidable. There is no necessary biological reason why life expectancy should be 48 years longer in Japan than in Sierra Leone or 20 years shorter in Australian Aboriginal and Torres Strait Islander peoples than in other Australians. Reducing these social inequalities in health, and thus meeting human needs, is an issue of social justice.

    The involvement of doctors in torture and the abuse of prisoners' human rights has been well documented over the past few decades. It is therefore disturbing that the cultural and social factors that have seduced individual health professionals and their institutions into participating in abuse have persisted, and have therefore remained unchallenged. More gravely, both governmental and medical bodies have begun adjusting and blurring their ethical guidance, tilting themselves towards endorsement of gross ethical malpractice, thereby ensuring the continuation of doctors' involvement. In the middle of 2004, allegations of mistreatment by military personnel in the prison at Abu Ghraib, and in the detention centre at Guantanamo Bay, received worldwide headlines. Press reports (Slevin P, Stephens J. Detainees' medical files shared. Washington Post June 20 2004; A1; Lewis N. Interrogators cite doctors' aid at Guantanamo. New York Times June 24 2004; A1) about the passive or active involvement of doctors surfaced in June, 2004, followed by more authoritative documentation of the scale and type of abuseref1, ref2. These reports, later partly confirmed by an independent reportref to the US Government under the chairmanship of John Schlesinger, and a leaked report from the International Committee of the Red Cross, made it clear that medical personnel failed to report evidence of torture, failed to intervene to stop it being repeated, and made available to interrogators information from confidential medical files, thereby allowing interrogators to exploit weaknesses. There is speculation, but no evidence, that death certificates of those who died under torture have been falsified. A recent article (Lee BJ. The stain of torture. Washington Post July 1 2005) by the former physician to former President George H W Bush makes clear the repugnance felt by the wider USA medical community. The shock of these revelations is only slightly mitigated by the knowledge that these cases are likely to represent isolated, rather than endemic, patterns of behaviour by US military doctors. However, as history tells us, the lack of a consistent and robust response from bodies responsible for condemning poor ethical practice will ensure the persistence of such practices. If the global medical community is to take effective steps to reverse this corruption of ethics, we need to understand that this corruption is a disease, with a documented aetiology, and one that has so far defied treatment. It might seem insensitive and disproportionate to cite the Nazi doctors in comparison, but it is necessary to do so. The involvement of German doctors in the 1930s and 1940s remains an indelible stain on medical ethics; active “euthanasia” and experiments involving Jews, gypsies, and the mentally ill were done on a massive scale without apparent question or guilt. The work of Lifton (Lifton R. The Nazi doctors: the psychology of medical killing. Papermac 1986 LondonThe Nazi doctors: the psychology of medical killing. Papermac, London (1986)) has helped to explain how this desensitisation and deviation from a normal moral compass occurred. He identified several factors, including acceptance of a state ideology that created scapegoats for the ills of society, and what he called “doubling”, an ability to exist in two separate but functional halves. Others included fear of reprisal if refusing to participate, and a poor understanding of basic medical ethical principles. It is tempting to assume that this behaviour is rare, and it is, but only in scale. It has been repeated, to give but a few examples, in South Africa, Chile, Turkey, and the former USSR (British Medical Association. . In: Medicine betrayed, Zed Books, London  (1992).67). In all these cases, the problem persisted and became more embedded as a result of failure by national medical associations to object. Turning to Guantanamo and Abu Ghraib, we see the same factors at work. In February, 2002, George W Bush (Humane treatment of al Qaeda and Taliban detainees. Memo from the President, Feb 7, 2002. Whitehouse, Washington DC (2002)), declared that Al Qaeda terrorists were no longer covered by the Geneva Convention. In August of the same year, a lengthy memorandum (Standards of conduct for interrogation under Sections 2340-2340A of title 18 of the United States code. Memorandum for Alberto R Gonzales, Counsel to the President, August 1, 2002. US Department of Justice, Washington DC (2002)) prepared by the US Justice Department for Alberto Gonzalez, then Counsel to the President, (and now the USA's Attorney General), redefined torture, stating that “for an act to constitute torture … it must inflict pain that is difficult to endure”. The memorandum continues: “Physical pain amounting to torture must be equivalent in intensity to the pain accompanying serious physical injury, such as organ failure, impairment of bodily function, or even death.” The absence of any substantial objection from US medical bodies brought into play the first of Lifton's conditions—the acceptance of a societal or political imperative. This failure to oppose put prisoners, already incarcerated without trial or access to legal representation, at the mercy of unprincipled doctors. How many doctors have bought into the prevailing ideology is not yet clear. Quite possibly relatively few. But the recurrence, over what is now a 70-year period, of actions that should exist only in history is evidence that the global medical community has failed to respond appropriately. This inertia is bad enough, but there is evidence of a more worrying trend—governments and professional bodies rewriting existing ethical guidance in the service of abuse. The use of psychological techniques to break prisoners' wills in interrogation has a long history (Physicians for Human Rights. Break them down—systematic use of psychological torture by US Forces. Physicians for Human Rights, Boston (2005)). Clearly, professional advice is needed so that such techniques can be applied effectively. That psychiatrists and psychologists have provided this advice is documentedref and admitted, but these are health professionals whose ethical codes require the highest standards. The problem is that published codes are strong in their application with the one-to-one relationship with patients, but weak when applied to communities, and therefore open to distortion and misrepresentation. For example, Dr David Tornberg, US Deputy Assistant Secretary of Defense for Health Affairs, stated that “physicians assigned to military intelligence have no doctor-patient relationship with detainees and, in the absence of life-threatening emergency, have no obligation to offer medical aid.”ref US Secretary of Defense for Health, William Winkenwerder, has acknowledged that several medical personnel working at Guantanamo are not providing direct care for patients, but are using their skills “to assist the interrogators”, in the role of “behavioural scientists” (Mayer J. The experiment. The New Yorker July 11 and 18 2005; 61-71). These personnel are not answerable to the Department of Defense, but to military intelligence, and work within Behavioural Science Consultation Teams, commonly known as “Biscuits”. In new guidance (Assistant Secretary of Defence (Health Affairs). Medical program principles and procedures for the protection and treatment of detainees in the custody of the Armed Forces of the United States. Assistant Secretary of Defence (Health Affairs), Washington DC (June 2005)) issued to the military, the Pentagon has subtly changed the wording of a 1982 United Nationsref resolution on the ethical duties of health professionals with respect to prisoners. At first glance, this document seems to provide more protection to prisoners, but when one realises that the guidance sets out ethical guidance only in the context of a “provider/patient treatment relationship” (my italics) and outlaws “interrogations not in accordance with applicable law”, confidence evaporates. Bush's memorandum has placed these suspects outside a protective legal framework, and the Pentagon's guidance allows professional expertise to be used in interrogation techniques. Professional bodies have also recently shown a tendency to blur the boundaries. The American Psychiatric Association's Statement on Psychiatric Practicesref at Guantanamo Bay is weak. Far worse is the recent report of the American Psychological Association's “Presidential Task Force” (Report on the American Psychological Association Presidential Task Force on psychological ethics and national security. American Psychological Association, Washington DC (June, 2005).). This report rehearses conventional ethical principles about care of individual patients, but then does an about-face when it comes to sanctioning input from psychologists and advice on techniques to be used in interrogation. In effect, it becomes acceptable for a health professional to dispense with any ethical responsibilities when their training and expertise is used outside a strictly therapeutic context. The use of such knowledge in creating techniques intended to damage the minds of people under interrogation, and to advise how these techniques can be refined, is grossly unethical, and the fact that a professional body can support such activity is a disgrace. In the face of this institutional support for abuse, what can be done? First, the assault, led by the USA and UK Governments on international bodies, such as the United Nations, should be reversed. The profession of medicine has its national and international bodies, and these should work better, not simply to set out ethical practice, but to call its constituent members to account. The upcoming meeting of the World Medical Association in October is a good place to start, with this topic on the agenda. Second, the lack of ethical knowledge identified by Lifton in pre-war Germany persists. This can only be corrected by a renewed effort to map out the ethical boundaries appropriate for doctors acting in areas of dual responsibilityref, at undergraduate and postgraduate level. The involvement of doctors in direct or indirect abuse of prisoners is not just a stain on medical ethics. By abandoning our principles, we add fuel to the fires of distrust and despair, and increase the risk to us all, as the recent outrages in London demonstrateref.

    Conferences that welcome spouses aid research tooref

    Living will, also called will to live, advance health directive, or advance health care directive, is a specific type of power of attorney or health care proxy or advance directive. It is a legal instrument that usually is witnessed or notarized. These documents state :

    As the name suggests, the term "will to live", as opposed to the other terms, tends to emphasize the wish to live as long as possible rather than refusing treatment in the case of serious conditions. In the Netherlands, patients and potential patients can specify the circumstances under which they would want euthanasia for themselves. They do this by providing a written euthanasia directive. This helps establish the previously expressed wish of the patient even if the patient is no longer able to communicate. However, it is only one of the factors that is taken into account. In Switzerland, there are several organizations which take care of registering patient decrees, forms which are signed by the patients declaring that in case of permanent loss of judgement (e.g., inability to communicate or severe brain damage) all means of prolonging life shall be stopped. Family members and these organizations also keep proxies which entitle its holder to enforce such patient decrees. Establishing such decrees is relatively uncomplicated
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