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), Canadian Medical Association Journal (www.cma.ca/cmaj), Journal of Medical Ethics (www.jmedethics.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 have reviewed the February–April issues of these journals. Articles of interest from the National Medical Journal of India, Monash Bioethics Review, and Developing World Bioethics are abstracted as and when they become available.
If you come across an article that you feel should be included, please forward it to [email protected]
Research
There is a conflict between the obligations of a physician-investigator to deliver optimal care to his patients now and to advance scientific knowledge so that optimal care can be delivered in the future. The author discusses how these conflicts can be resolved.
Grunberg SM et al. The integral role of clinical research in clinical care. N Engl J Med 2003;348:1386-1388
What should a physician do when a patient asks if she/he should participate in a clinical trial? In advising patients about clinical research, physicians enhance the physician-patient relationship and contribute to the overall goals of evidence-based medicine.
Chen DT et al. Clinical research and the physician-patient relationship. Ann Intern Med 2003;138:669-672
Research ethics committee members need convenient, up-to-date guidance. ERIC, an information source now available online (http://www.ericonline.co.uk), meets these needs and also allows readers to submit material for inclusion.
Davies HT et al. Introducing “ERIC”, a living research ethics database. J Med Ethics 2003;29:117
Did bioethics begin in the USA and then spread around the world, or did bioethics exist throughout the ages in every region? The author says this varies with the definition of bioethics and proposes to conduct a comparative study of the history of bioethics among countries or regions. He requests information from readers at Masahiro Morioka ([email protected])
Morioka M. When did “bioethics” begin in each country? A proposal of a comparative study. Eubios Journal of Asian and International Bioethics 2003;13:51-52
Ethics committees are presumably staffed by competent people and decisions are taken after proper discussion. But how accountable are they to the public? Should ethics committee members be free to reveal meeting discussions to the public? The writer suggests that by making the discussions public, the committee is accountable to the public and it lead to transparency and accountability.
Gillam Lynn. Secret ethics business? Monash Bioethics Review. Ethics Committee Supplement. 2003;22:52-62
The authors lament the closure of research trials solely for commercial reasons. They argue that medical research, even by the pharmaceutical industry, should not be considered like any other commercial enterprise to maximise personal or corporate profits.
Psaty BM et al. Stopping medical research to save money: a broken pact with researchers and patients. JAMA 2003;289:2128-2131
The author argues that bioethics should update its conception of the gene by challenging the simplistic notions of genetic causation that has been popularised in the mass media and bio-ethicists should understand, challenge, or defend new gene-related developments.
Ashcroft RE. The double helix 50 years on: models, metaphors, and reductionism. J Med Ethics 2003;29:63-64
Clinical
The authors favour medical organisations’ taking a neutral position on legalisation of physician-assisted suicide because there are significant limitations to palliative care.
Quill TE et al. Professional organizations’ position statements on physician-assisted suicide: a case for studied neutrality. Ann Intern Med 2003;138:208-211
The authors call for rigorous studies to document the impact of greater patient involvement in healthcare processes and outcomes.
Wensing M et al. Improving the quality of health care: methods for incorporating patients’ views in health care. BMJ 2003;326:877-879
Doctors are gradually becoming used to discussing physician stress. Unhappy, tense, tired, or anxious doctors do not provide quality care. Handling errors sensibly, making simple changes to the way work is organised, and counselling are critical for stress reduction.
Firth-Cozens J. Doctors, their well being, and their stress: it’s time to be proactive about stress and prevent it. BMJ 2003;326:670-671
The author says that patient organisations should establish public databanks on medical complications to counter the confidential hospital databanks, thus providing a balance to the power of the medical profession.
Gebhardt DOE et al. Patient organisations should also establish databanks on medical complications. J Med Ethics 2003;29:115
By administering a questionnaire, the authors found that patients value respect, dignity and courtesy more than involvement in decision-making.
Joffe S et al. What do patients value in their hospital care? An empirical perspective on autonomy centered bioethics. J Med Ethics 2003;29:103-108
The authors describe a pilot project where, under an outcomes guarantee, drug manufacturers agreed to refund the health service if a drug failed to meet agreed performance targets. Wider use of such guarantees could improve clinical behaviour and reduce irresponsible drug advertising.
Chapman S et al. Setting up an outcomes guarantee for pharmaceuticals: new approach to risk sharing in primary care. BMJ 2003;326:707-709
The author uses several examples to illustrate how low incomes of doctors in East European countries makes them easy prey for pharmaceutical companies and leads to general corruption and breaking of the code of ethics.
Madalinski MH. What is saving of human life worth in Poland? J Med Ethics 2003; 29:116
Recently, a white British couple underwent in vitro fertilisation (IVF) giving birth to twins described as ‘black’, probably from substitution of another man’s sperm. The legal ramifications of assisted reproductive technologies are discussed.
Murray TH et al. Genetic ties and genetic mixups. J Med Ethics 2003;29:68-69
In response to the above article, the author discusses how new technologies, adoptions, foster-care, etc. are changing ideas of genetic, gestational and social parenthood.
Fuscaldo G. What makes a parent? It’s not black or white. J Med Ethics 2003;29:66-67
The author discusses the views of Islamic scholars whose opinions are based on the Quran and the Hadith on novel situations resulting from assisted reproduction.
Ahmad NH. Assisted reproduction-Islamic views on the science of procreation. Eubios Journal of Asian and International Bioethics 2003;13:59-60
The author describes the ethical dilemmas of research involving cognitively impaired adults and provides a framework for addressing them.
Karlawish JHT. Research involving cognitively impaired adults. N Engl J Med 2003; 348:1389-1392
The authors discuss how couples at risk for having a child with a genetic illness perceive in vitro fertilization followed by PGD as more ethical than prenatal diagnosis followed by abortion.
Cameron C et al. Is there an ethical difference between preimplantation genetic diagnosis (PGD) and abortion? J Med Ethics 2003;29:90-92
Health Policy
Confidentiality has always been an essential element in medical consultation. Privacy, however, is not an absolute right and has to be balanced against the rights of others or societal groups. The new NHS code attempts to strike a compromise between these views.
Chalmers J et al. Patient privacy and confidentiality. BMJ 2003;326:725-726
China has a mandatory form of screening (detailed questionnaire, complete physical examination and blood tests) for fitness to wed and reproduce. Its main purpose is to screen for hereditary illness and conditions that may jeopardise parenting abilities, such as psychiatric problems. Its public health benefits include diagnosis and treatment of unrecognised diseases, reduced transmission of disease to partners and offspring, a forum for health education, and a convenient means of collecting information on the health of the population for epidemiological and planning purposes. However, it undermines the fundamental human right to marry and reproduce and has potential for oppression and eugenic misuse.
Hesketh T. Getting married in China: pass the medical first. BMJ 2003;326:277-279
The authors discuss why developed countries investing in health research should consider the social, economical and environmental context in addition to ‘burden of disease’ (specific diseases affecting poor people most) approach in setting research priorities.
Labonte R et al. Setting global health research priorities: burden of disease and inherently global health issues should both be considered. BMJ 2003;326:722-723
The role of race in the cause and treatment of disease has been abused in the past and may lead to abuse in the future. But it is only by recording race that racially-biased health policy and practices may be uncovered. The author discusses these different points of view expressed in two articles in the same issue of the journal.
Phimister EG. Medicine and the racial divide. N Engl J Med 2003;348:1081
The South African government restricted the use of the drug nevirapine that reduces the transmission of HIV from mother to infants. NGOs challenged this in court which ruled recently that everyone has the right to have access to (a) healthcare services, including reproductive healthcare, and (b) the state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realization of each of these rights. The author discusses the right to health ruling and its ramifications.
Annas GJ. The right to health and the nevirapine case in South Africa. N Engl J Med 2003;348:750-754
The article discusses why an unbiased evaluation of new products and an unconstrained post-marketing surveillance of adverse events cannot be performed by government agencies that are increasingly collaborating with and/or are controlled by industry.
Editorial. We need Romanow’s National Drug Agency. CMAJ 2003;168:249
Sex selection in India went high-tech with the use of the latest in vitro fertilisation (IVF) to choose the embryo of the ‘desired’ sex. Some doctors have launched campaigns for the couple’s right to choose, claiming that sex selection will have no unwanted social consequences. This article outlines the ethical arguments against preconceptual sex selection.
GD Ravindran. Physicians must not help parents decide the gender of their unborn child: the case against preconception gender selection. Natl Med J India. 2003:16:93-94
Why are staff in the public sector rude to poor patients, demand bribes and sell free samples? The author argues that such practices are some of the many coping mechanisms-some of which are ‘predatory’-that staff develop when poorly paid, unmotivated and in poor working conditions. The solution does not lie in banning staff from private practice as there is little scope for increase in salary, and improving the working environment is important but not enough. ‘Improvement of working conditions…also means developing career prospects and providing perspectives for training…most importantly, it requires professional behaviour free from the clientelism and arbitrariness prevalent in the public sector .’
W Van Leberge, C Conceicao, W Van Damme and P Ferrinho. When staff is underpaid: dealing with the individual coping strategies of health personnel. Bulletin of the World Health Organization, 2002;80:581-583. Reprinted in the Bulletin on Drug and Health Information 2002;9:98-103
Education
A new interactive case-based series explores what ‘ordinary’ cases can teach about options for management, and how to communicate with patients and their relatives. Readers, including patients, are asked to post their views on the website. Part of the learning value for doctors is likely to come from examining the diversity of the responses.
Richards T et al. Learning from our patients and each other: interactive case reports offer readers the chance to take part in learning. BMJ 2003;326:564
To improve the quality of care, patients must be encouraged to participate in treatment decisions. Towards this goal, BMJ has developed a new website, BestTreatments, that gives the same high-quality, evidence-based information to both doctors and patients on the effectiveness of treatment for common chronic diseases.
Nash, B et al. Connecting doctors, patients, and the evidence: excerpts from BestTreatments give the same evidence to doctors and patients. BMJ 2003;326:674
To assess their ethical development, the authors administered a questionnaire to medical students and found a significant decline in this attribute over time. They wonder if ‘a hidden curriculum’ in medical education inhibits the development of moral reasoning.
Patenaude J et al. Changes in students’ moral development during medical school: a cohort study. CMAJ 2003;168:840
The author ponders on ways to strengthen physicians’ ethical behaviour-administering a test on moral judgement to entering students; providing effective ethics training during medical school and residency training; evaluation of performance in ethics. He concludes that ‘Most fundamentally, what is needed is the habit of mind of adopting and valuing the patient’s perspective on unfolding medical events and creating a shared medical experience with the patient.’
