FROM OTHER JOURNALS
Jack Bauer, the man who made torture popular
During the United States presidential debate, one of the questions that candidates were asked was: “Is torture justified?” The response that received the greatest support was: “I’d be looking for Jack Bauer at that time, let me tell you.”
Jack Bauer is an immensely popular television character who regularly relies on his own version of “enhanced interrogation”, which is essentially a more palatable label for torture. Thanks to his prime-time presence on national television, roughing up prisoners in a weekly struggle to protect the country, polls shows that American acceptance of torture increased from 36% in 2006 to 44% in 2008.
Somewhere in the midst of war, terror and politics, the idea of torture has become acceptable. Apologists for torture argue that it increases the amount of information extracted from socalled high-value detainees. The reality however, is that torture simply does not work. Analyses of interrogations have shown torture to be ineffective. On the contrary, a former interrogator states that torture “played right into the hands of those who were determined not to give away anything of military importance”. The use of force yields unreliable results and can force the person being tortured to say whatever he thinks the interrogator wants to hear. It is commonly assumed that inflicting pain can “facilitate compliance” with the interrogator’s demands, but there is no scientific research to suggest that coercion can provide accurate and useful information. In a state of extreme urgency or importance, a nation would be ill-served to turn to the least reliable method of interrogation.
Venters HD. Who is Jack Bauer? Lancet 2008;372:1924-5.
Transitioning to universal healthcare coverage in Thailand
In 2001, Thailand’s healthcare system moved towards implementing the Universal Coverage (UC) policy. This study measured household out-of-pocket healthcare payments using socioeconomic surveys, pre- (2000) and post-UC (2002, 2004).The proportion of out-of-pocket healthcare payments as a share of household living expenses among households, including catastrophic healthcare payments, declined once universal coverage was implemented. The figures on catastrophic payments indicated that the poorest incurred lower catastrophic payments compared to the better off. The UC policy also seems to work in preventing impoverishment due to out-of-pocket healthcare payments. The authors conclude that the UC policy is a valuable social protection and safety net strategy that contributes to prevention of financial catastrophe and impoverishment due to out-of-pocket healthcare payments, enabling Thailand to achieve equitable healthcare financing.
Somkotraa T, L agradac L P. Payments for health care and its effect on catastrophe and impoverishment: Experience from the transition to U niversal Coverage in Thailand. Soc Sci Med 2008; 67(12): 2027-35
The future of primary care in the US
An analysis of primary care in the US argues that it will decline over the next decade. The main reason is that medicine is losing state sponsorship and is simultaneously become more attractive for private interests. Additional reasons include: (1) the epidemiologic transition resulting in the dominance of chronic diseases, reducing doctors to providing palliative care and monitoring incurable conditions; (2) the growth of nonphysician clinicians; (3) clinical guidelines that have reduced doctoring to formulaic tasks easily performed by non-physician clinicians;(4) the shift in focus from physical examinations to impersonal diagnostic tests; (5) the field of primary care medicine becoming unattractive, evident in the decline of applications by US graduates to such programmes, and (6) the growth of internet access and direct to consumer advertising that could result in everyday illnesses being self-managed or managed by non-physician clinicians working out of retail clinics.Physicians will no longer need to be the middlemen between patients and specialists.
A commentator on this analysis presents a case for the resilience of professional medicine. He underscores the importance of primary care, and emphasises that future generations of Americans need not worry about the lack of access to primary care, including to qualified physicians. Due to vigilant advocacy by medical professional organisations and cost-conscious health payers, and due to government policies, there is and will continue to be a supply of primary care physicians and primary care residency programmes. Even if the demand for primary care outstrips the supply of primary care physicians, other specialists and non-physician healthcare providers are likely to fill the gaps.
McKinlay J, Marceau L . When there is no doctor: Reasons for the disappearance of primary care physicians in the US during the early 21st century. Soc Sci Med 2008; 67(10): 1481-91. Timmermans S. Oh look, there is a doctor after all. About the resilience of professional medicine: A Commentary on McKinlay and Marceau’s ‘When there is no doctor’. Soc Sci Med 2008; 67(10):1492-6.
Do physicians care about patient choice?
The policy of patient choice was introduced in Sweden in the 1990s to give patients the right to choose their healthcare providers. Evaluations have shown that few patients exercise this right. Questionnaire responses of physicians indicate that though physicians approve of the policy, only a minority regularly helped patients choose healthcare providers by giving them required information and allowing them to choose where to go. Instead, referrals were mostly based on medical grounds; the patient’s right to choose a specific provider was considered less important. Thus, more than a decade after the policy was introduced only a minority of physicians acts according to political intention, explaining why many patients do not exercise their right to choose a hospital.
Winblad U . Do physicians care about patient choice? Soc Sci Med 2008; 67(10): 1502-11. Ethics of mandatory HIV testing
Ethics of mandatory HIV testing
The global AIDS epidemic has recently lead to significant changes in HIV testing policies. Provider-initiated HIV testing has been embraced by the Centers for Disease Control and Prevention and the World Health Organization; persons are to be routinely informed that they will be tested for HIV unless they explicitly refuse. While this practice increases the uptake of testing, a number of ethical concerns have raised and debated upon.
Another form of “provider-initiated” testing being practised and promoted in various parts of the world has advocates within international health agencies: this is mandatory premarital HIV testing. However, this form of mandatory testing has received little attention in the bioethical literature. The authors of this essay analyse some of the key ethical issues related to mandatory premarital HIV testing in resource-poor settings with generalised HIV epidemics. They briefly discuss mandatory premarital testing proposals, policies and practices worldwide and offer conceptual and factual distinctions between the different types of policies, using Goma (Democratic Republic of Congo) as a point of departure.
Rennie S, Mupenda B. Ethics of mandatory premarital HIV testing in Africa: The case of Goma, Democratic Republic of Congo. Dev World Bioeth 2008; 8(2): 126 – 137.
Making a case for counselling stressed physicians
The practice of medicine is highly stressful, and this is clear from the reports of high prevalence of depression and suicide among physicians compared to other professional groups. However, doctors are reluctant to seek help. This article reports on a study to investigating interventions for burn-out and emotional exhaustion for doctors in Norway. The intervention set out to motivate reflection on and acknowledgement of the doctors’ situation and personal needs. One year after the intervention, doctors reported a reduction in emotional exhaustion and job stress. They had reduced their working hours by 1.6 hours and this was associated with a reduction in emotional exhaustion as well as a reduction in the proportion of doctors on full time sick leave. This study makes a case for early intervention and psychological help for stressed doctors, given the nature of their job, to lower the risk of burnout and mental distress.
Isaksson KE, Gude T, Tyssen R, Aasland OG. Counselling for burnout in Norwegian doctors: one year cohort study. BMJ 2008;337:a2004
Patient attributes and clinical decision making
This study of clinical decision making found that physicians used their patients’ demographic characteristics to assess their cognitive ability, motivation, and social support. This was considered predictive of adherence and therefore relevant to treatment decisions. Studies show that patients’ basic demographic characteristics provide inadequate information to guide clinical decision making.
Lutfey KE, Campbell SM, Renfrew MR, et al. Soc Sci Med 2008; 67(9):1391-9.
Iran on contemporary medical ethics
Special attention has been paid towards ethics in Islam. Medical professionals and religious leaders in Iran have emphasised the importance of ethics. In the last decade, great strides have been made in biomedical ethics, education, research and legislation. The authors note the establishment of the National and Regional Committees for Medical Research Ethics, the production of national codes of ethics in biomedical research in the 1990s and the introduction of a comprehensive strategic plan for medical ethics at the national level in 2002. Additionally, specific national ethical guidelines for biomedical research were established in 2005.
Larijani B, Zahedi F. Contemporary medical ethics: An overview from Iran. Dev World Bioeth 2008; 8(3): 192-6.
Ethics beyond borders
Health professionals involved in international humanitarian assistance and development work are frequently exposed to complex ethical issues. The authors of this article examine how health workers experience ethics in the course of humanitarian assistance and development work. Five core themes emerged from the data: the tension between respecting local customs and imposing values; the obstacles to providing adequate care; differing understandings of health and illness; questions of identity for health workers; and issues of trust and distrust. The authors make recommendations for organisational strategies that could help aid agencies support and equip their staff as they respond to ethical issues.
Hunt MR. Ethics beyond borders: How health professionals experience health in humanitarian assistance and development work. Dev World Bioeth 2009; 8(2): 59-69.
Informed consent in the genomics era
Genetic cohort studies storing biological materials hold great promise for medical research. They also present new ethical problems that are profoundly different from those associated with the classical clinical trial. One example is in the concept of informed consent. The classical risk/benefit analysis of physical harm does not take into account new threats to the individual such as the inability to obtain insurance, unemployment, genetic discrimination, or disruption of family relationships. Traditional informed consent may therefore no longer be appropriate when dealing with long-term studies usingbiological materials. Informed consent should be seen as an ongoing process between researcher and participant, and not just as a once-and-for-all decision. Research following the initial storage of samples needs to be likewise explained and may be announced using new communication methods.
Mascalzoni D, Hicks A, Pramstaller P, Wjst M. Informed consent in the genomics era. PLoS Med 2008; 5(9): e192.
Exploitation vs undue inducement clinical trials
There is an apparent tension between undue inducement and exploitation in clinical trials. On the one hand, it is claimed that increasing the benefits to research subjects enrolled in international clinical trials could result in undue inducement. On the other hand, international trial sponsors are accused of exploitation because they do not provide research subjects with a fair share of the benefits of research. The authors introduce an analysis of the available research findings on research participants’ otivations and the influence of payments on research subjects’ behaviour and risk assessment. Findings suggest that financial rewards do not distort research subjects’ behaviour or blind them to the risks involved with research. The author concludes that research sponsors should prioritise the prevention of exploitation in international research by providing greater benefits to research participants.
Ballantyne A. Benefits to research subjects in international trials: Do they reduce exploitation or increase undue inducement? Dev World Bioeth 2008; 8(3): 178-91.
Obtaining consent in clinical trials
A study in the metropolitan region of Campinas presents findings on informed consent for studies on contraceptive methods. The consensus among women who have participated (or are participating) in clinical trials on women’s health was that the person who invites a woman to participate in a study should be a member of the research team but not the principal investigator. Study-related information should be given both orally and in writing, both individually and in the group setting. Study volunteers should be informed about the risks, possible side effects and discomforts, including long-term effects. The use of audiovisual aids to provide information is suggested.
Bento SF, Hardy E, Duarte-Osis MJ. Process for obtaining informed consent: Women’s opinions. Dev World Bioeth 2008; 8(3): 197-206.
What they write, and what they say they write
Little is known about how frequently news articles report when medication research has received funding from pharmaceutical companies or how frequently they use generic vs brand medication names. This study reviewed reports on new drugs published in US newspapers and online sources. The researchers’ surveyed company funded research published in medical journals and interviewed editors of the most widely circulated newspapers. Among the findings: 42 % of news articles about medication research did not report company funding; 67 % of articles reporting on medications referred to the medications by their brand names rather than the generic names at least half the time. Contrary to these findings, about 88% of newspaper editors reported that their publications always or often indicated when studies had received company funding. They also said that they always or often referred to medications by the generic names.
Hochman M, Hochman S, Bor D, McCormick D. News media coverage of medication research – reporting pharmaceutical company funding and use of generic medication names. JAMA 2008;300(13):1544-50
Off-label promotion,on-target sales
The authors discuss the practice of off-label promotion of drugs. They point out that such practices for untested, unproven benefits maximise industry profits at the expense of public health. Pharmaceutical marketing has distorted the discourse on off-label uses and encouraged the unmonitored, potentially dangerous use of drugs by patients for whom risks and benefits are unknown.
The authors suggest that while off-label use may sometimes be necessary, it should be undertaken with care and caution and the subject should be discussed by unbiased researchers in bona fide medical journals. Promising therapies should be tested in clinical trials. Companies that engage in off-label promotion should be heavily fined and their future marketing practices subject to increased scrutiny by regulatory agencies. At the same time, financial incentives could be provided to reward physicians and others who report off-label promotion. Restrictions on off-label promotion of drugs should be strengthened, not gutted.
Fugh-Berman A, Melnick D. off-label promotion, on-target sales. PLoS Med 2008; 5(10): e210.
Making sense of non-financial competing interests
The writers of this editorial discuss the concept of the nonfinancial competing interest. Like commercial interests, nonfinancial competing interests can influence professional judgment. As with all competing interests, the dispute is how to manage them. It is accepted that political interference in science is dangerous, that governments and funders do not make decisions on the basis of science alone, and that intellectual and professional commitments often lead to strong personal views. It is thus the responsibility of journals and the wider research communities to safeguard the credibility of the scientific and editorial processes. Steps taken must include full disclosure, which allows for others to make informed judgments about whether there are competing interests, and whether they are relevant. Journals can develop clear and explicit policies that outline definitions of non-financial conflicts of interests and expectations for author, reviewer, and editorial behaviour, ensuring transparency.
In conclusion, despite the messy and imprecise nature of private interests, researchers and editors must persist in establishing a better understanding of their extent and impact.
