Bioethics and guns, home and abroad

Bioethics workers, particularly in the United States, rarely talk about guns and gun-related violence. The issue is perhaps too baldly political: in the US, discussions generally center on the 2nd Amendment right to keep and bear arms, and to what extent can government create policies infringing or limiting that right. Somehow the public and personal health risks of gun possession get lost in the shuffle, or at least bioethicists in the main seem less morally worried about guns than they are about the dilemmas generated by life-saving technologies. Nevertheless, when guns are around, poor health outcomes occur that wouldn't happen otherwise: children who accidentally shoot themselves or others when they come across a gun in the home; adults who reach for a deadly weapon in the heat of a dispute, or those who injure and kill in the commission of a crime. Some discussions on the bioethics of guns exist, but they are few and far between.

The most recent American massacres have drawn bioethicists indirectly into the fray. Gunmen responsible for the attacks in Aurora and Newton seem to have been mentally unstable, leading to questions about the adequacy of the procedures required to get guns and gun licenses in the first place. More specifically, physicians are increasingly being requested to help law enforcement in assessing a person/patient's competence to carry or safely use a concealed weapon. The more technical issues are how such competence is to be determined and how physicians are to be trained to reliably make such determinations. A larger issue is whether giving a green light to concealed weapon possession is -- as a matter of professional ethics -- the sort of thing physicians should be involved in. Guns put holes in human bodies where they are not meant to be, after all. Predictably, the legal questions loom large: will a physician be held liable if a person/patient deemed competent decides to unconceal his/her weapon and go on a rampage?

The American debate typically presupposes the intrinsic goodness of guns for ordinary citizens. An attempt last week to occupy the bioethical high ground on guns comes from a source not normally associated with pacifism: Pakistan. The Karachi Bioethics Group (KBG) is calling for the 'deweaponization' of Pakistani society, observing that gun-related deaths in the country have tripled in the last two decades. (An interesting account of the genesis of the KBG can be found here in the book Observing Bioethics by Fox and Swazey.) The KBG states simply that licenses and provision of guns should only be permitted for the armed forces and the police. No talk of hunting, target practice for pleasure, or fantasies of heroic self-defence. Healthy position on deadly weapons or acquiescence to the power of an authoritarian state? In any case, here we have a bioethics group not shy about taking overtly political positions.

Whose ethics code is this anyway?

The Times of India reports that the Medical Council of India (MCI) is contemplating changing its Code of Medical Ethics (2002; updated 2010) to permit physicians to accept travel and hospitality sponsorship from pharmaceutical companies. This proposed amendment is aimed directly at Article 6.1.8., which excludes the acceptance of gifts, travel support, accommodation, and cash or monetary grants (unless the latter is in the context of working in pharma-funded medical research).

It should not be a surprise that pressure to change this part of the code comes from ... pharmaceutical companies. Representatives of the pharmaceutical industry argue that they are merely trying to help: Indian doctors do not earn very much, often not enough to attend domestic and international conferences, and it is crucial that they are kept up to date with the latest medical advances.  The amendment is merely meant to improve medical education. Detractors recast the 'sponsorship' as bribery: pharma's interest in hosting such conferences is not to improve physician's knowledge, but to enhance brand recognition among (and prescribing practices of) doctors.

These struggles between pharmaceutical companies and professional medical associations are familiar in developing countries, but in countries like India the power relationships are somewhat different: the pharmaceutical companies wield significant economic and political power, and underpaid doctors would be understandably tempted by their siren's song. The MCI is supposed to regulate a responsible relationship between these two. Whether it is able or inclined to do so remains to be seen.

The medical neglect of the African mouth

In some ways, dentistry is the black sheep of the medical family. The social status of dentist in most places does not seem to be on a par with that of a (real) medical doctor. It is not entirely clear why this is the case, but there are conjectures. Perhaps because a trip to the dentist is commonly associated with pain, despite advances in dental anesthetics. Maybe it has to do with historical associations: what later was called 'dentistry' emerged from the Medieval practices of barbers, who besides cutting hair were self-proclaimed experts in tooth extraction. Or it could be that oral conditions are just not to be taken seriously, in the sense that they are generally not life-threatening: this is what separates the dentist from the cardiologist or neurosurgeon. In any case, when dentistry is taken less seriously, it is seen as a lesser priority by funders and policy makers, not to mention the faint attention it is generally given by bioethicists.

A recent article reminded me of the sorry state of dental research, practice and policy in Africa. When health care systems are compromised by poverty and civil conflict, dentistry is regarded as a luxury and treated accordingly.  The article is focused on Swaziland: a country of 1.2 million persons served by nine private dentists, along with another 15 public dental practitioners, although the latter do not have the specialized skills to conduct root canal procedures or the fitting of dentures. What's worse is that the diet of Swaziland (like much of Africa) is becoming more 'Westernized', i.e. more processed and sugary foods are hitting the markets, leading to cavities unlikely to be filled. A rise of a neo-Medieval practice of tooth extraction is likely to accompany the change in food habits.

While oral conditions are not typically life-threatening, anyone with a toothache (or other dental conditions) can attest to their negative impact on quality of life. And quality of life, on that level, anything but a luxury. Given the track record on affordable and equitable access to primary health care on the continent, as well as the traditional subservient position of dentistry within the culture of medicine, the road to better dental health and dental practice in Africa looks to be long, hard and bumpy.



 

The ethics of disseminating research results

Article 33 of the Declaration of Helsinki (2008) reads:

At the conclusion of the study, patients entered into the study are entitled to be informed about the outcome of the study and to share any benefits that result from it, for example, access to interventions identified as beneficial in the study or to other appropriate care or benefits.

As usual with ethics guidelines, they do not come with practical guidance. So how, in concrete terms, do you best carry out this ethical requirement? What if fulfilling this requirement actually involves risks to participants? And do you have to only disseminate at the conclusion of the study?

There is an interesting recent article in PLoS Medicine on this topic. In part, researchers were provoked to disseminate results back to participants in a longitudinal observational HIV treatment study, when a participant said: "You have been asking me questions and taking my blood for years, but I do not know anything about what you have found." Acting on this remark while the research is still ongoing seems to have taken the research team -- and the participant community -- on a challenging but very positive journey. Dissemination of research means translating them in two ways: from the dominant scientific language (English) into the local language, and translating technical terms into more accessible ones to those without extensive formal education. Bringing HIV positive persons in a research study together at the same event poses potential issues of stigma and loss of confidentiality, and subsequent involvement of ethics committees. And the format of dissemination has to be culturally appropriate: powerpoint slides and handouts are not going to do it. In the dissemination event described in the article, everything seems to have gone as it should among researchers and participants, resulting in a greater understanding of and respect for one another. This is an embodiment of what the 'ethical conduct of research' means far beyond the usual fixation on the contents of consent forms.