FROM OTHER JOURNALS
Refusal to care for people with HIV
This study, based on a mailed survey to a random group of Canadian dentists, had a response rate of 66 per cent. Thirty-two per cent of respondents had knowingly treated HIV-infected patients in the last year. One in six reported that they would refuse to treat people with HIV. Refusal to treat was associated with a ‘lack of ethical responsibility’, fear of cross-infection or lack of knowledge of HIV. The writers note: “These results have implications for undergraduate, postgraduate, and continuing education.” Wonder where we stand on the subject.
McCarthy GM et al. Factors associated with refusal to treat HIV-infected patients: the results of a national survey of dentists in Canada. Am J Public Health 1999 89: 541-5.
The right not to tell?
The writers describe a prolonged negotiation, over five years, between the parents of an adolescent boy with HIV / HCV co-infection, and the medical professionals treating him. The doctors wanted to inform the boy of his HIV and HCV status. The parents refused to permit this until they were forced to, legally, when the boy turned 18. The discussion illustrates the difficulties in making ethical decisions. Both doctor and parent have good intentions for the child. Some questions for the medical professional are: how does one respect the rights of parents as well as the emerging autonomy of the child? Could a well-intentioned decision do more harm than good?
Roshni Kulkarni, et al. Nondisclosure of Human Immunodeficiency Virus and Hepatitis C Virus coinfection in a patient with hemophilia: medical and ethical considerations. Journal of Pediatric Hematology/Oncology 2001; 23: 153-8.
When parents think otherwise
What are the choices before a paediatrician when an HIV-positive mother rejects medical recommendations on breast-feeding and anti-retroviral prophylaxis? And what guides an appropriate response? This article analyses the legal and ethical issues that arise as a consequence.
This problem has not yet arrived in India where only the rich have access to such drugs, and insisting that women not breast-feed can be simply idiotic. Still, doctors already certainly face ethical dilemmas in choosing between two obligations — to protect the infant and to respect parental decision making.
Wolf LE et al. When parents reject interventions to reduce postnatal human immunodeficiency virus transmission. Arch Pediatr Adolesc Med 2001; 155: 927-33.
Training, morale and material
This study analysed retrospective data from 732 and prospective data from 960 nurses on needle stick exposures and near misses, and collected information on staffing levels and survey data on the working climate and risk factors for needle stick injuries from 40 units in 20 hospitals. Nurses from poorly-staffed and badly organised units were more likely to report risk factors, as well as injuries and near misses. The remedy: improve staffing, administrative support, and morale.
Clarke Sean P, et al. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 2002; 92: 1115-1119.
Unethical practices by tobacco industry
This report based on an investigation of tobacco company documents illustrates unethical practices resulting from financial ties between the tobacco and pharmaceutical industry with three case studies linking tobacco companies with firms marketing tobacco cessation material. In the first, tobacco companies pressured pharmaceutical companies to tone down educational materials accompanying the product. In the second, they restricted the product’s marketing, and in the third, subsidiary tobacco and pharmaceutical companies of a parent company actually collaborated in the production of a nicotine-release gum.
Bhavna Shamasunder and Lisa Bero. Financial ties and conflicts of interest between pharmaceutical and tobacco companies. JAMA 2002; 288:738-744.
Ethicist for a medical journal
This is a report on the Canadian Medical Association Journal’s appointment of surgeon John Dossetor as its ethicist and ombudsman, the first appointments of their type for a Canadian scientific publication”. Dossetor, who coordinated Canada’s first kidney transplant, later supervised Canada’s cadaver transplant programme at a time when there were no ethics committees, and one heard frightening stories about what doctors did in the patient’s best interest. As a researcher, he grew increasingly concerned about ethical dilemmas arising from medical advances, including in his own practice when a patient brought someone willing to sell a kidney. “It made me think that bioethics was becoming an increasingly important field.” But he cautions readers against expecting clear-cut solutions to issues they raise. “Ethics is not about answers. Ethics is about asking more questions.”
Sibbald Barbara. CMAJ appoints first ethicist/ombudsman. Canadian Medical Association Journal 2002 May 14; 166 (10): http://www.cmaj.ca/cgi/content/full/166/10/1327-a
Ethics and public health research
The American Journal of Public Health’s Health Policy and Ethics Forum is a regular column for “discussion on ethics in public health research and practice”. The Forum articles in the July issue look at research ethics. The editorial notes that public health ethics is all about “the need to exercise power to ensure the health of populations and at the same time to avoid potential abuses”. One of the papers in this section concerns the role played by institutional review boards in the monitoring of research. The section also contains three papers on non-therapeutic research on non-consenting subjects. Do parents have the right to consent on behalf of their children? Two other articles on international collaborative research look at the promises and pitfalls of the genomic revolution, and on the need to recognise the rights and ‘agency’ of vulnerable populations in the ethical review process.
The issue also contains a code: Principles of Ethical Public Health Practice, which has been formally accepted by the American Public Health Association, and which is available on www.apha.org/codeofethics.
Health policy and ethics forum. Am J Public Health 2002; 92: 1056-59, 1067-84. http://www.ajph.org/content/vol92/issue7/index.shtml#HEALTH_POLICY_AND_ETHICS_FORUM
Informed choice in screening programmes
In the UK, there is a shift towards ‘informed choice’ as an ethical imperative in screening programmes. The authors look at whether such how this change will affect screening for risk of coronary heart disease in primary care.
Screening programmes are public health efforts calling large populations to participate and benefit from the information that might be obtained in such tests. In India, the health check-ups advertised by corporate hospitals are essentially screening programmes, though their value – as they are run today – may be questioned. One important component of screening programmes is the positive message they send, that early detection will be of benefit to the individual undergoing the tests. There is no mention of the possibility of psychological and physical harm that can be caused by a false positive test for cancer, for example, or the consequences of prenatal screening results.
Marteau Theresa M, Kinmonth Ann Louise. Screening for cardiovascular risk: public health imperative or matter for individual informed choice? BMJ 2002;325:78-80.
An ‘ethical market in live organs’
This editorial follows up on the American Medical Association’s decision to encourage studies to see if financial incentives would increase cadaver organ donations. The authors describe ‘an ethical market in live organs’. Channelising the organ trade through a single buyer, such as the government health service, would prevent exploitation of the poor, ensure equitable distribution of organs, and address safety concerns, they argue,
“Nothing we have said rules out altruistic donation as a mode of organ procurement alongside a commercial scheme; we would not wish to discourage donation.”
Harris John, Erin Charles. An ethically defensible market in organs. A single buyer like the NHS is an answer. BMJ 2002; 325: 114-115.
Unethical drug promotion
This editorial comments on the ethical problems inherent in pharmaceutical advertising, and discusses various efforts to address the problem. Aggressive medical reps, medical sponsorship, direct to consumer advertising… the list of dirty tricks is endless.
The WHO’s ‘Ethical criteria for medicinal drug promotion” are flouted with impunity; the International Federation of Pharmaceutical Manufacturers’ Associations’ code of pharmaceutical marketing practices is ignored in developing countries, and efforts to monitor advertising material in journals rarely work. In India, legislation on drug advertising has not been enforceable.
However, the writer notes, students at a few medical colleges are being prepared for such tricks. They are being taught to ‘take control’ of the interview with the medical representative to be informed according to their needs, not those of the industry.
Such efforts may be tiny but incremental, and perhaps doctors will start demanding ethical behaviour of drug companies. “Unless this demand comes from the medical establishment who refuse to take lavish gifts, eat lunches and dinners sponsored by drug companies, and attend CME programmes paid for by the companies we can never expect drug companies to self regulate.”
Thawani Vijay. Drug promotion: can self-regulation work? Indian Journal Of Pharmacology 2002; 34: 227-228.
Breaking bad news
How much should a physician tell his patient the whole truth about a potentially terminal illness like cancer? Should s/he speak to the patient or relatives? In a country like India, there are many opinions on this subject. Japanese courts have held that cancer disclosure is at the physician’s discretion. This perspective is changing on the basis of legal decisions on medical malpractice cases. The author reviews these legal decisions, and notes the need for mental and physical support to the patient when making such disclosures.
Takanami S. Cancer disclosure from recent medical malpractice cases in Japan. Eubios Journal of Asian and International Bioethics 2002; 12: 19-21.
The culture of poverty?
The writer discusses some ethical aspects of research in poor communities, which comes with extra obligations, since people’s autonomy will be compromised by their circumstances. At the same time, “Poverty has its own cultural values, its own perception of beneficence, non-malfeasance and justice, which may differ from those of the medical doctors and researchers.”
Azevedo ES. Decisions in circumstances of poverty. Eubios Journal of Asian and International Bioethics 2002; 12: 105-7.
Mental health
Some articles in the July 2002 issue of aaina, a mental health advocacy newsletter: The editorial looks at the new Code of Medical Ethics and its relevance to mental health professionals. A number of legal judgements in the area of mental health are discussed. For more details on the publication, write to the Center for Advocacy in Mental Health, 36 B Ground Floor, Jaladhara Housing Society, 583 Narayan Peth, Pune 411 030. Email [email protected] or visit www.wamhic.com. aaina, a mental health advocacy newsletter 2002; 2 (2).
Equity implications of managed care, and other ethical questions
This editorial on the equity implications of managed care comments on the discrepancy of a national health policy which claims concern for equity while calling for a greater involvement of the private sector. For the former, “govenments must be prepared to play a stronger role in the health sector…”
This issue of the National Medical Journal of India contains many inputs of the non-medical type. Another editorial notes that current research in injectable contraceptives is a direct product of coercive population policies; neither will provide women with the choice of safe, effective and user-friendly contraceptives. An Eye on the Web provides a review of internet resources on medical ethics. And the letters from Johannesburg, Chennai and Mumbai provide valuble pictures of the political, social and economic influences on health and medical practice.
Thind A. Managed care and developing countries: what are the equity implications? Natl Med J India 2002; 15: 121-3. Rao M. Injectables, incentives and disincentives: short-sighted population policies. 123-7. Roy N. An eye on the web. 164-8. Letter from… 169-72.
Drug marketing
A former employee of the Warner-Lambert Pharmaceutical Company in the US has filed a lawsuit against the company, alleging that its sales representatives encouraged doctors to prescribe gabapentin, an anti-epileptic, for other unapproved uses like pain, bipolar disorder, and attention deficit disorder in children.
Unsealed court documents show that some doctors were paid to let sales representatives into their examining rooms to meet patients, review medical charts, and recommend what drugs to prescribe, a totally “inexcusable” act. The company tracked doctors’ prescribing practices, rewarded ‘high volume prescribers’ with speaking assignments and consultancies, paid them to enter patients in clinical trials, and influenced doctors who wrote articles about gabapentin for medical journals by paying them, sometimes secretly, and even hiring a marketing company to write first drafts.
Fred Charatan. Doctor sues company over unethical marketing. BMJ May 2002;324:1234.
Drug regulation
In the May-June 2002 issue of the Bulletin on Drug and Health Information, Andrew Herxheimer describes the way in which drug companies influence prescribing practices and the reasons for this, and proposes a system to prevent conflicts of interest guiding medical decisions. The same issue reviews the deaths following contaminated glycerin in JJ Hospital, Mumbai, in 1986, when an investigation revealed a nexus between the drug industry and regulatory authorities. But no lessons were learned, the writer points out, as similar contamination killed patients 12 years later. In the absence of proper quality control, and given the ‘unholy alliance of drug manufacturers, bureaucrats and their political masters,’ we can expect more such tragedies in the future. To subscribe to BODHI write to Foundation for Health Action, 254 Lake Town, Block B, Calcutta 700 089. Email: [email protected]
Herxheimer A. Doctors and drug industry: dancing to different tunes. BODHI 2002; 46: 33-36. Kundu S. Unholy nexus hits doctor and patient alike. (Adapted from the Bulletin of the WHO 2001; 79: 88-95.) BODHI 2002; 46: 37-40.
Unethical research in China by Harvard
Medical research in rural China by a professor at the Harvard School of Public Health, USA, was not properly monitored to ensure participants’ safety, according to an investigation by the US Office for Human Research Protection (OHRP). The study conducted by Professor Xiping Xu covered topics ranging from the genetics of lung function to the effect of lead on reproduction.
The OHRP investigation found that the hospital ethics board lacked the expertise to review research and failed to consider the cultural conditions, the social, economic and political status of the subject population. The rural Chinese population do not benefit from the study findings as they do not use western drugs. Consent forms in one study failed to indicate that participation was voluntary, did not list the risks and discomfort associated with tests and some had complex language. Numerous changes reportedly were made to consent forms and the amount of blood harvested from participants increased from two to six teaspoons. The hospital’s ethics board reviewed none of these digressions. Harvard has suspended all Chinese studies while it reviews the research.
