We scan the Annals of Internal Medicine (www.annals.org), New England Journal of Medicine (www.nejm.org), The 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.unescobkk.org/index.php?id=2434) for articles of interest to the medical ethics community. For this issue of the IJME we reviewed the Aug 2007 – Oct 2007 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.

The eighth Asian Bioethics Conference

The entire issue is devoted to the abstracts of the papers and posters presented at the eighth Asian Bioethics Conference, held in Bangkok, Thailand, on March 19-23, 2007. The next conference is scheduled for November 2008 in Jakarta, Indonesia.

Eubios J Asian Int Bioeth 2007; 17: 65-96.

HPV vaccines in the developing world

Cervical cancer is the second leading cause of death among young women in the world. This cancer is prevented by vaccine against the human papilloma virus (HPV) if given before HPV infection is acquired during sexual intercourse. Therefore, to be effective, the vaccine has to be given to adolescent girls before they become sexually active. The cost to developing countries will most probably be subsidised by a conglomerate of world organisations. Even then, a lot of effort will be needed, such as creating the infrastructure and ameliorating the suspicions of the community who may attribute a hidden fertility control agenda to the effort, before this effective cancer prevention intervention can help women in the developing world.

Agosti JM et al. Introducing HPV vaccine in developing countries: key challenges and issues. N Eng J Med 2007; 356: 1908-10.

The elderly’s right to care

In 1998 the UK enacted the Human Rights Act, which affirms right to humane and equitable care, dignity and respect for private life. Yet the elderly in nursing homes are often neglected and given shoddy care. The editorial laments that few people understand what the Act means in practice, and exhorts all persons engaged in the care of the elderly to adhere to these principles.

Humane and compassionate elder care as a human right [Editorial]. Lancet 2007; 370: 629.

Community insurance schemes

Community-based health insurance can protect the poor from sliding into poverty. However, there is little data on how well such insurance schemes actually help the poor. This article describes the experience of SEWA insurance in rural Gujarat.

Ranson MK et al. Equitable utilisation of Indian community based health insurance scheme among its rural membership: cluster randomised controlled trial. BMJ 2007; 334: 1309.

History of health as a human right

This is the first in a series of four on the changing view of health as a human right. Human rights became a major issue after the Nuremberg trials and formation of the United Nations. The concept of health as a human right began about the same time, but was slower to be accepted as such until the AIDS epidemic. This article traces the history of this change and how it has affected health policy.

Gruskin S et al. History, principles, and practice of health and human rights. Lancet 2007; 370: 449-55.

Clinical ethics committees

Society expects that medical care should be based on ethical principles. Clinical ethics committees (CEC) have come into being to help health care professionals resolve the complex issues that arise in the practice of medicine. This article describes the role of ethics committees in resolving such issues. “If CECs are to be effective they must provide, and be seen to provide, support to health professionals dealing with difficult ethical issues, as well as others affected by such cases. In practice this will usually mean making it clear at the outset that their role is to provide a multidisciplinary forum for the discussion of issues, and thereby to support the decision-making of health professionals…. Ethics committees should remain advisory. They have no warrant for preempting the decisional authority of patients or their surrogates. Ethics committees also should not substitute for courts. Committees have neither the personnel nor expertise to adjudicate legal claims. Indeed, committees vary enormously in quality, are bound by no commonly accepted rules of reasoning or system of precedent, and in any case lack the necessary independence of a court.”

McLean SAM. What and who are clinical ethics committees for? J Med Ethics 2007; 33: 497-500.

Payment for compliance backfires

At first glance paying patients to be compliant with their medical regimen seems an easy way to avoid the high of non-compliance cost to patient and society. Yet paying for adherence introduces negative incentives and may actually involve more policing of patients. It also makes people feel that they must be rewarded for doing what is good for them and encourages them to expect not only free drugs, but cash incentives in addition as well.

Shaw J. Is it acceptable for people to be paid to adhere to medication? No. BMJ 2007; 335: 233.

Incentives can work

The author argues that a carrot-and-stick approach already exists for patients with mental health problems, such as compulsory admission to a psychiatric hospital or early release from hospital if the patient adheres to treatment regimen. A small amount of monetary payment is a reward for taking the required medicines and is not exploitative or coercive.

Burns T. Is it acceptable for people to be paid to adhere to medication? Yes. BMJ 2007; 335: 232.

Need advocates for treating the diseases of the poor

The authors describe how neglected diseases such as vector-borne ones are difficult to treat not only because few researchers want to invest time and money in finding a cure for them. There are additional problems such as prevalence of these diseases in areas of conflict, poor governance, and oppression of the affected population. These also contribute to the intractability of the problem. The article describes how researchers can be advocates for these populations.

Beyrer C et al. Neglected diseases, civil conflicts, and the right to health. Lancet 2007; 370: 619-27.

Registering clinical trials

In September 2007 the US FDA Revitalization Act was passed, which improves the ability of the FDA to monitor the safety of drugs and medical devices. It makes it mandatory for all clinical trials to be registered at inception, and thus their results are available for inspection by all. This assures that safety concerns about new drugs will be known to all.

Drazen JM. Open clinical trials. N Engl J Med 2007; 357: 1756-57.

Global health

The Lancet has launched a forum to encourage students to learn more about and become involved in global health. Students at this forum want more teaching about global health issues in their curriculum and have asked for inputs from others besides medical professionals, such as economists, social scientists and anthropologists, to give a wider perspective.

Medical students as champions for social justice [Editorial]. Lancet 2007; 370: 457.

Doctors and human rights

Through three examples, Rwanda, Nepal and the US, physicians describe their experiences of bearing witness to gross violations of human rights. Their efforts to give help, document and make public what they saw has strengthened health as a human right.

Orbinski J et al. Violations of human rights: health practitioners as witnesses. Lancet 2007; 370: 698-704.

Terminally ill patients should not get experimental drugs

The author, a medical oncologist, feels that terminally ill patients are desperate for a cure, and are unable to judge the risks and benefits of an experimental medicine. Until the drug has completed clinical trials, its potential to cause harm is unknown and in chasing a dream of cure, terminally ill patients forego more appropriate treatments that can alleviate their suffering and improve the quality of their lives. Giving drugs outside trials could also damage clinical trials.

Gesme D. Should terminally ill patients have the right to take drugs that pass phase I testing? No. BMJ 2007; 335: 479.

Experimental drugs may be all that terminally ill patients have

Patients are often unable to participate in clinical trials because they may not meet the strict enrollment criteria or are unable to meet financial/social requirements. They often find out about a promising drug through the media and want to take it in the hope that it might benefit them. They are willing to take the risk of toxicity as in their situation any benefit is worth the risk. The author feels that clinical trials will actually be strengthened and not hurt as doctors will collect data on such patients and add it to the data collected through the trials.

Freireich EJ. Should terminally ill patients have the right to take drugs that pass phase I testing? Yes. BMJ 2007; 335: 478.

Reserving postgraduate training places

Currently 36 per cent of doctors practising in the National Health Service have been trained abroad. The UK has acquiesced in this as it is cheaper to recruit fully trained doctors depending on the yearly need in the UK than to anticipate the actual number of doctors needed per year and train them from scratch. While the UK does not actively recruit doctors from countries where they are needed, it also does not wish to limit migration as it is the right of an individual to choose where to live. These doctors who do migrate to the UK must have equal access to jobs and other opportunities for career advancement including postgraduate training places.

Borman E. Should postgraduate training places be reserved for UK graduates? No. BMJ 2007; 335: 591.

Reserving postgraduate training places

The UK has been importing its medical workforce for decades, but recently it has expanded the number of medical seats anticipating an increased need for physicians as a result of the country’s aging population. Completing medical education is not enough for a doctor, and further training is required to enter medical practice. It would be a waste of society’s resources if the graduating medical students in the UK are unable to find postgraduate training slots because they have been allotted to foreign graduates.

Byrne E. Should postgraduate training places be reserved for UK graduates? Yes. BMJ 2007; 335: 590.

Isolation, quarantine and the law

Isolation refers to keeping an individual already ill from a contagious disease in seclusion, while quarantine refers to putting large numbers of people who are not yet ill in seclusion because of their exposure to a contagious disease. In the USA both state and federal governments have the legal authority to enforce isolation or quarantine. This article describes the current laws that are involved and the loopholes in that law.

Parmet, WE. Legal power and legal rights: isolation and quarantine in the case of drug-resistant tuberculosis. N Engl J Med 2007; 357: 433-5.

The nutritional supplement industry

This editorial discusses commercial interests in nutrition. Supplements are marketed as essential components of a balanced diet, without which the health of people will suffer. These supplements are very profitable as they are free from price control. Manufacturers bypass regulatory requirements that they may not be advertised for the treatment of any diseases, or sold in drug stores. They can also be harmful. Physicians must protect the public from the harm that such supplements can cause. They should inform the public about their irrational nature, even dangers, and refuse to prescribe them. An article in the same issue of the journal discusses a “natural food supplement” named “NONI” that is advertised as containing 150 isolated “nutrachemicals” and is marketed extensively in rural India for conditions ranging from diabetes to allergies.

Business interest in human nutrition. [Editorial] BODHI 2007; 14 (2): 25-6. Anonymous. The story of Indian NONI: the manufacturer threatens legal action. BODHI 2007; 14 (2): 27-8.

Data safety monitoring boards

This editorial describes the roles, components and models of functioning for data safety and monitoring boards (DSMB). DSMBs are particularly important with India’s increasing participation in global clinical trials. The DSMB is “an independent advisory committee established by the sponsor of a study to assess the progress of a clinical trial, the safety data and critical efficacy and endpoints at pre-determined intervals, and to recommend to the sponsor whether to continue, modify or stop a trial.” The DSMB is distinct from an ethics review committee. It is not necessary for all trials.

Thatte U, Kulkarni-Munshi R. Data safety monitoring boards. Natl Med J India 2007; 20: 165-8.

Commissions or kickbacks

This commentary discusses the reasons behind, and the consequence of, giving commissions in private healthcare. It states that the root of the problem is the unplanned promotion of healthcare as a commodity from which one can profit. The fault does not lie with doctors or medical councils but with the absence of public information. Consumers must be educated to choose wisely rather than be controlled by the healthcare profession, and advertising should be regulated.

Bajaj R. It is time to wash the linen. Natl Med J India 2007; 20: 147-9.