FROM OTHER JOURNALS
Patient’s choice
According to recent research, when patients have a choice, they are likely to choose a doctor of their own race or ethnic background and they are more likely to be satisfied with their care.
Hopkins Tanne J. Patients are more satisfied with care from doctors of their own race. BMJ 2002;325:1057
Ban on drug ads
The Canadian Medical Association (CMA) staunchly opposes the use of direct-to-consumer advertising (DTCA) of prescription drugs as it feels that DTCA makes viewers think of prescription drugs as consumer goods, ignores information about competing products, may drive up cost of care and strain the patient-physician relationship.
Sullivan P. No direct-to-consumer drug ads: CMA. CMAJ 2002;167:1153
The European Parliament has defeated a proposal to relax the European Union’s ban on advertising prescription drugs to the public.
Cassels A. Europe rejects pitch for direct-to-consumer drug ads. CMAJ 2003;168:209
Medical ethics
The authors review empirical research that can guide physicians in deliberations over whether to withdraw life support, maximizing patient and family involvement in the decision-making process, and negotiating conflicts that may arise.
Way J et al. Withdrawing life support and resolution of conflict with families. BMJ 2002;325:1342-1345
When patients will not survive, intensive care unit (ICU) teams discuss organ and tissue donation with families. Recent legislation requiring ICU physicians to provide outside agencies with confidential details of patients nearing death is controversial. ICU physicians must act in the interests of the patient and his family, notwithstanding the interests of the transplant surgeons. These inherent differences between physicians need to be reconciled.
Rocker GM et al. Organ and tissue donation in the intensive care unit. CMAJ 2002;167:1248
While students need to learn clinical examination by practising on patients, ethical dilemmas occur as patients may be vulnerable and obtaining informed consent can be difficult. A survey found that intimate examinations had been done in anaesthetized or sedated patients, possibly without their consent. Two Ob-Gyn teachers say that respecting the patient is the key to obtaining consent, and learning the approach to the examination is even more important than the examination itself.
Coldicott Y et al. The ethics of intimate examinations: teaching tomorrow’s doctors. BMJ 2003;326:97-101
A study from the University of Toronto reported two other types of ethical challenges; responsibility exceeding a student’s capabilities and involvement in care perceived to be substandard. This study led to a policy that emphasizes patients’ rights, confidentiality, responsibility of clinical teaching staff, and provides trainees with an opportunity to discuss an ethical situation with a bio-ethicist without fear of repercussions.
Singer PA. Editorial. Intimate examinations and other ethical challenges in medical education: Medical schools should develop effective guidelines and implement them. BMJ 2003;326:62-63
Patients as a source of information
This article examines the inconveniences encountered by a patient during hospitalization for a successful surgery. Patients usually cannot assess the technical quality of care but are the best source of information about problems in a hospital system’s communication, education, and pain-management processes, which could seriously compromise clinical care. Cleary PD. A hospitalization from hell: a patient’s perspective on quality.
Ann Intern Med 2003;138:33-39
Errors and adverse events
Authors surveyed practising physicians and members of the public about the causes of and solutions to the problem of preventable medical errors. Many physicians and members of the public reported errors in their own or a family member’s care. Both groups supported the use of sanctions against responsible individuals though they disagreed on effective strategies for reducing errors. Blendon RJ. Views of practicing physicians and the public on medical errors.
N Engl J Med 2002; 347:1933-1940
An editorial says that collaboration between patients and physicians may be hard as they disagreed on the critical issue of confidentiality. Physicians believe that confidentiality will promote openness among colleagues; lay persons favour ‘transparency’ and the pressure of public accountability. Lee TH. A broader concept of medical errors.
N Engl J Med 2002;347:1965-1967
There is an unresolved conflict between the public’s desire for accountability and doctors’ and hospitals’ fear of damage to their reputations and of malpractice liability, though no link between reporting and litigation has ever been demonstrated. The primary purpose of reporting is to learn from experience. The highly touted Aviation Safety Reporting System attributes its success to three factors: reporting is safe, simple and worthwhile. Reporting to state programmes may lead to sanctions but if sanctions are limited to serious violations and if hospitals get useful information then the programme may be perceived as justifiable.
Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633-1638
Genetics and ethics
This article discusses the ethical issues involved in the use of haematopoietic stem cells from cord blood to treat patients with malignant or non-malignant disorders.
Burgio GR et al. Ethical reappraisal of 15 years of cord-blood transplantation. Lancet 2003;361:250-252
Authors looked at methods for the ethical management of genetic testing, and investigated the advantages and limitations of the use of ethical guidelines in clinical genetics.
Parker M, Lucassen A. Working towards ethical management of genetic testing. Lancet 2002;360:1685-1688
Industry and medicine
Doctors and patients need to be able to rely on the commitment of the regulatory system in their country to put the interests of public health above the commercial interests of the drug industry. However, over the past 20 years, governments succumbing to industry pressure have restructured the system. The new system depends on industry fees for survival and national agencies now compete with each other for industry fees for regulatory work. This may compromise patient safety.
Abraham J et al. Making regulation responsive to commercial interests: Streamlining drug industry watchdogs. BMJ 2002;325:1164-1169
Death penalty
Almost all executions in the USA are now performed by lethal injection which is unique because it simulates the intravenous induction of general anaesthesia. Doctors’ participation is essential for inmates with poor vascular access. Medical professionals’ organisations in the United States forbid participation in executions, but most doctors are unaware of these guidelines.
Groner JI. Lethal injection: a stain on the face of medicine. BMJ 2002;325:1026-1028
Two major aspects of the death penalty in the United States directly involve physicians: how the death penalty is carried out and who is subject to execution. Apart from participating in various aspects of execution, physicians will now be involved in determining who is clinically mentally retarded and thus ineligible for execution. Removing someone from within the reach of the death penalty on the basis of mental retardation is not unethical medical work. However, the medical criteria used to diagnose mental retardation are vague. Therefore, physicians have a special ethical responsibility to participate actively in the ongoing debate over capital punishment.
Annas GJ. Moral progress, mental retardation, and the death penalty. N Engl J Med 2002;347:1814-1818
Conflict of interest
The General Medical Council recently found that Mr Anjan Kumar Banerjee and his research supervisor, Professor Timothy John Peters were guilty of serious professional misconduct committed a decade earlier. This was not just a case of one doctor covering up for another but of corruption at a senior level in academic institutions that helped to conceal the misconduct.
Wilmshurst P. Institutional corruption in medicine. BMJ 2002;325:1232-1235
BMJ asks all authors and reviewers and sponsors of trials to complete competing interests forms. There is nothing wrong in having competing interests, the problem lies in not declaring them.
Smith R. Making progress with competing interests: still some way to go. BMJ 2002;325:1375-1376 (Papers p.1391)
Investigation of published research revealed extensive financial relationships among industry, scientific investigators and academic institutions, as well as restrictions on publication and data sharing when industry was the research sponsor.
Bekelman JE et al. Scope and impact of financial conflicts of interest in biomedical research: a systematic review. JAMA 2003;289:454-465
Advertisements are a major source of income for medical journals. Yet 44% of advertisements would lead to improper prescribing and 92% are not in compliance with the criteria for advertising. Editors advise readers to not take claims in journal advertisements at face value.
Fletcher RH. Adverts in medical journals: caveat lector. Lancet 2003;361:9351
Human rights
Western health professionals and the public have a misguided image of the aftermath of war that comes from the Judaeo-Christian traditions of confessing and forgiving. Labels such as ‘healing’ or ‘recovery’ through ‘processing’ (of traumatic experience), ‘acceptance,’ and ‘coming to terms with the past’ suggest that the pathological effects of war are found inside a person and that the person recovers as if from an illness. Victims want to reassert that the problem is moral and collective rather than medico-psychological and individual.
Summerfield D. Effects of war: moral knowledge, revenge, reconciliation, and medicalised concepts of ‘recovery’. BMJ 2002;325:1105-1107
A global campaign to integrate health and human rights in undergraduate and postgraduate medical training was launched this year by Physicians for Human Rights-UK (PHR-UK) to anchor the doctor-patient relationship firmly to human rights’ principles and to minimize discrimination by the medical profession.
Hall P. Doctors urgently need education in human rights. Lancet 2002;360:9348
Some assume that in a human rights approach, individual rights are protected at all costs, despite adverse effects on the public’s health. This is inaccurate and the apparent conflict between the two can be resolved to create sound public health programmes.
Gruskin S. Do human rights have a role in public health work? Lancet 2002;360:9348
Although the Indian government outlines a very sound AIDS policy, there are several gaps in the translation of this policy into action. This paper analyses these gaps and recommends some strategies to close them.
Sivaram S. AIDS care and human rights in rural India: translating policy into practice. Eubios Journal of Asian and International Bioethics 2002;12:214-216
Research
Research studies commonly randomise patients between standard care and some new form of treatment which the patient might have obtained directly from the doctor. Yet patients are not told about this. This practice increases participation in research studies, but the studies may therefore be of questionable ethical soundness.
Menikoff J. The hidden alternative: getting investigational treatments off-study. Lancet 2003;361:63-67
Women’s health
Large-scale clinical trials of interventions have been started in developing countries for preventing epidemic of HIV. The volunteers do not have access to basic medical services, or to reproductive or human rights, posing ethical dilemmas for the researchers. If possible, researchers and community members should try to develop practical solutions to such dilemmas before studies are started.
