FROM OTHER JOURNALS


We scan the Annals of Internal Medicine (www.annals.org), New England Journal of Medicine (www.nejm.org), Journal of the American Medical Association (www.jama.ama-assn.org), Lancet (www.thelancet.com), British Medical Journal (www.bmj.com), Journal of Medical Ethics (http://jme.bmjjournals.com), Canadian Medical Association Journal (www.cma.ca/cmaj.com), and Eubios Journal of Asian and International Bioethics (www.biol/tsukuba.ac) for articles of interest to the medical ethics community. For this issue of the IJME we reviewed the February 2005 – April 2005 issues of these journals. Articles of interest from the National Medical Journal of India, Monash Bioethics Review, Developing World Bioethics and some other journals are abstracted as and when they become available.

End-of-life issues

The author discusses how attitudes to death have changed over the ages, particularly as the result of advances in medicine and technology, and argues persuasively for returning to each person the control over their life’s end.

Hise DM. Death’s doorstep. Eubios Journal of Asian and International Bioethics 2005: 15(2); 38-40.

The authors discuss the several reasons why physicians avoid this encounter and suggest ways to approach such an interaction so that it becomes valuable to both the patient and the doctor.

Back AL et al. On saying goodbye: acknowledging the end of the patient-physician relationship with patients who are near death. Ann Int Med 2005; 142: 682-685.

The authors discuss the circumstances of a case, similar to Terry Schiavo, where the absence of a living will necessitated a court hearing to decide on discontinuance of life support. The essential difference between the two cases was that the Canadian patient’s family found a way to reach a consensus.

Godlovitch G et al. Discontinuing life support in comatose patients: an example from Canadian case law. CMAJ 2005; 172: 1172-1173.

The authors define the term ‘passive euthanasia’ rigorously and discuss why it is acceptable in clinical palliative practice despite the objections of the ethics task force established by the European Association of Palliative Care.

Garrard E et al. Passive euthanasia. J Med Ethics 2005; 31: 64-68

This editorial in response to the Terry Schiavo case in the USA discusses the difference between individuals’ assertion of their own right to die, as expressed through the living will, and when other persons make the request on the patient’s behalf, describing the complicating circumstances in each situation.

Grayling AC. “Right to die” BMJ 2005; 330: 799

This author argues that the disagreement within family members poses a moral question. Families share a bond in which each member has a duty to care for the others. Legal solutions to cases of familial dispute are inherently divisive because they rest on the procedural solution of privileging one family member as “the decision-maker.”

Weijer C. A death in the family: reflections on the Terri Schiavo case. CMAJ 2005; 172:1197-1198.

The editorial grants that governments have the right to intervene in matters of life and death but regrets that “ideology and religion have begun to seriously distort consensus-building.” It calls on physicians to “set aside their own beliefs in deference to the moral autonomy of each patient” and “remain alert to political and legislative tendencies that impose imprecise moral generalisations on the majority, at the expense of reason, scientific understanding and, not infrequently, compassion.”

The sacred and the secular: the life and death of Terri Schiavo (editorial). CMAJ 2005; 172: 1149.

Research ethics

The authors in this collection of articles discuss the relation between research and audit. The first author notes that while research investigate what should be done, audit investigates whether it is being done. Because studies based on audit attract less scrutiny there is temptation for researchers to submit their project as based on simple audit of ongoing practice rather than a research study. By using ingenious examples the author shows how every study, audit or research, poses ethical questions and proposes that ” the need for ethical review should be based on the morality of all actions rather than arbitrary distinctions between audit and research.”

The author of the second article, chair of a multi-centre research ethics committee, agrees except that “the decision of an ethics committee should not be accepted without question because the decisions of committees may vary”. He compares alternatives and points out why this is still the most reliable way to arrive at a decision.

The authors of the third article also agree but warn against a bureaucratic approach to ethics.

Wade DT. Ethics, audit, and research: all shades of grey. BMJ2005; 330: 468-471. Alexander J. Research ethics committees deserve support. BMJ 2005; 330: 472-473. McMillan J. et al. Ethical review and ethical behaviour. BMJ 2005; 330: 473.

Public health ethics

The authors use the legal ruling in 1905, which upheld the right of the government to mandate vaccination against smallpox against the individual right to refuse it, to debate the relationship between liberty and public health today. They point out that legal power alone cannot protect public health and the medical and public health communities must gain the trust of the diverse public in order for them to accept public health measures.

Parmet WE. et al. Individual rights versus the public’s health. 100 years after Jacobson v. Massachusetts. NEJM 2005; 352:652-654.

Medical students and clinical work

The author surveyed health-care staff at one hospital in a developing country, Solomon Islands, about the type of medical work that medical students on elective rotation should be allowed to do in that hospital and what they thought the students are allowed to do in their home institution. She found that the staff accepted the students doing all the clinical work without any medical supervision. Also, the staff was unaware that this would not be acceptable in the student’s home institution. She discusses the reasons for this dichotomy and suggests steps to address this issue.

Radstone SJ. Practicing on the poor? Healthcare workers’ beliefs about the role of medical students during their elective. J Med Ethics 2005; 31:109-110.

Drug trials in India

According to a new rule promulgated by the government of India in January 2005, pharmaceutical companies will be allowed to conduct trials of new drugs in India in tandem with trials in other countries. The authors are against this for a number of reasons, the chief one being that the government does not have the staff or expertise to evaluate and monitor the protocols. The new rule exposes the population to unethical and exploitative practices. They outline the changes that must take place in the regulatory structures before such trials are allowed.

Nundy S and Gulhati CM. A new colonialism? Conducting clinical trials in India. NEJM 2005; 352: 1633-1636.

Doctors doing harm: female circumcision

The author describes various forms of female circumcision prevalent in African countries, and their cultural significance. They VARY from mere washing of the clitoris to various degrees of excision of genitals. Doctors have performed circumcision to prevent greater harm caused by traditional circumcisers. The author insists that the law must absolutely forbid the excision in any form by doctors as well as others. He encourages the substitution of excision with the safe practice of clitoris washing alone so as to maintain traditional cultural identities.

Omonzejele PF. Obligation of non-maleficence and female circumcision in Africa: a moral discourse. Eubios Journal of Asian and International Bioethics 2005; 15: 49-52.

Pakistani physicians’ views

The authors interviewed individual and groups of physicians in a university hospital to assess the physicians’ perspective. This qualitative study identified several areas of concern including autonomy of the patient, role of family, time available for in-depth discussion, constraints of working through interpreters, etc. One lacuna identified was the lack of information on patients’ perspective on these factors. Another area that remained untouched in the discussions undertaken for this study was the teachings of Islam regarding individual rights and caregivers’ responsibilities.

Jafarey AM et al. Informed consent in the Pakistani milieu: the physician’s perspective. J Med Ethics 2005; 31: 93-96.

Universal norms in bioethics

This reproduces the Preliminary Draft Declaration on Universal Norms on Bioethics, which was finalised by the UNSECO International Bioethics Committee (IBC) at its Extraordinary Session on January 28, 2005 after numerous consultations at international, regional and national levels.

UNESCO Division of Ethics of Science & Technology. Preliminary Draft Declaration on Universal Norms on Bioethics. Eubios Journal of Asian and International Bioethics 2005; 15: 57-62.

Family planning in China

The authors who are Israeli explored this issue because it contrasts with the policy of the Israeli government and the Judaic religion. They sent an email to 75 bioethicists in China about the Chinese only-one-child-per-couple policy. Only 1 bioethicist responded. He said that while he had only one child, he sees future problems, as China would have fewer young people compared to the aged. The two authors differed in their views on the subject. The first author, while agreeing with the Chinese government’s policy to reduce population, disagreed with the means to achieve it, saying education rather than coercion was preferable. The second author accepted that China needed to limit population growth immediately in order to be able to provide resources for its population and agreed that while education was preferable, the method was too slow to meet the country’s goals. The authors agreed that Chinese society with its emphasis on community rather than the individual, in both Confucian and Communist philosophy was able to accept the need for the law and therefore obey it.

Cohen M, Efraty S. China: Ethical issues in the family planning program. Eubios Journal of Asian and International Bioethics 2005; 15: 55-57.

Editorial bias

The author points out that informal exchanges by editors to friends and colleagues tend to give prominence to or sideline a particular point of view. This “old network” is just as culpable as any other conflict of interest and is also less visible and therefore difficult to eradicate.

Laube RE. Dealing with editorial misconduct: What about relationship with reviewers and authors? BMJ 2005; 330: 364.

Interns’ working hours

The authors report the result of the first randomised trial to study the effect of reduced work hours of interns on medical errors. Interns who worked the traditional 79 hours/week had 36 per cent more errors than those who worked the alternative 63 hours/week. The authors hope that this study persuades administrators to lighten the workload of doctors.

Bernstein M et al. Does reducing interns’ work hours reduce the rate of medical errors? CMAJ 2005; 172: 474.

Approaches to HIVprevention

The editorial points out that 10 per cent of new HIV infections are related to illicit injection drug use. Until the focus of governments shifts from law enforcement and criminalisation of behaviours to treatment and rehabilitation, the numbers cannot be reduced. “Including opioid substitutes to the WHO-endorsed pharmacopeia will give timely support to the establishment and wider use of addiction treatment programs, and in so doing will help more injectable drug users to come inside the tent of HIV treatment and prevention.”

HIV, harm reduction and human rights(editorial). CMAJ 2005; 172: 605.

Controlling reproductive tourism

The author argues that American infertile couples who are desperate to conceive a child will travel to any place to achieve that goal even if the medical technology is not approved by the American government. Governments disagree about what constitutes “disease” in this field and what defines health, therefore some states and countries (and insurance companies) will cover the cost and others will not. The author predicts that soon the US government will have to step in to deal with this reproductive tourism with policies that address the issues.

Spar D. Reproductive tourism and the regulatory map. NEJM 2005; 352:531-533.

More than ‘DNR’?

Implantable cardioverter defibrillators are life-saving devices for many patients with cardiac disease but patients suffering from other progressive disease may, near the end of life, decline cardiopulmonary resuscitation. DNR order in such a patient may actually involve electrical cardioversion, something that is proscribed in DNR patients without implanted defibrillator. The author discusses ethical considerations in disabling such a defibrillator.

Berger JT. The ethics of deactivating implanted cardioverter defibrillators Ann Int Med 2005;142: 631-634.

Organ donation in Canada

The author discusses the drawbacks of the current organ donation programmes in Canada and suggests that they be replaced by a single public cadaveric donation programme where the potential donors who sign up for cadaveric donation also get priority for receiving an organ should they ever require it.

Giles S. An antidote to the emerging two-tier organ donation policy in Canada: the public cadaveric organ donation program. J Med Ethics 2005; 31: 188-191.

Do ethics committees hinder research?

Author feels that ethics committees are too stringent thus hindering research. From personal experience she feels that patients and care givers should be involved in deciding whether or not to accept certain “adverse effects” and still participate in a research project. She argues that there is less of an imbalance in power in dementia as doctors are effectively powerless because they can do little to treat it. Caregivers of such patients are often well informed “experts” and are acknowledged by some as being better able than professionals to judge moral issues relating to their relative.

Nurock S. Patients may be less risk averse than committees. BMJ 2005; 330: 471-472.

Guidelines for CMEs

In the USA CME programmes receive major financial support from commercial entities such as for-profit medical education and communication companies. The Accreditation Council for Continuing Medical Education has come up with new guidelines effective from 2006 to improve transparency and reduce commercial bias of such programmes.

Steinbrook R. Commercial support and Continuing Medical Education. NEJM 2005; 352: 534-535.

Post-marketing surveillance in the US

Approval for a new drug gives relatively less information about its adverse effects because it has been tried on a very small number of people. However once it is released into the market, many million more consume it and more adverse effects become apparent. In the past most drugs introduced in the USA had already been in the European market for several years. But recently the FDA has speeded up its review process under pressure from the pharmaceutical industry so 60 per cent of new drugs enter the US market first. Therefore the US needs a better way of monitoring new drugs. This includes extensive and prolonged post-marketing data collection by manufacturers and a Drug Safety Oversight Board as a subsection of the FDA.

Okie S. Safety in numbers? Monitoring risk in approved drugs. NEJM 2005; 352:1173-1176.
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