Tirage with terrorists

The Israeli Medical Association (IMA) apparently changed their position on triage, and it did not go down well. According to media reports, the new rules would require emergency medical personnel to treat all those harmed in a terrorist attack according to severity of injury, including those who caused the harm. I would quote the exact words of the IMA position paper, but it seems to have been taken down from their website, amid the ensuing controversy. I would also quote directly from the comments section of some Israeli newspapers, but bloodlust is not everyone's thing.  

The prior guidance on triage in such situations seemed to be influenced by rabbinic principles to the tune of 'charity begins at home'. In that case, you treat your own injured people first, and only those who are 'other than your own' or ‘opposed to your own’ afterwards. The new guidance removed that reference, rendering it more cosmopolitan, where ethnic/national/perpetrator/victim distinctions are irrelevant, and suffering humans in such situations are to be treated by physicians purely according to medical criteria. Opponents of the change find it outrageous that a terrorist could potentially be treated ahead of one of his/her less severely injured victims.  

Of course, the larger background is the longstanding Israeli-Palestianian conflict, including who gets called a terrorist when civilians are put in harm's way or killed to further political aims, and who does not. But even leaving that to one side, the old position on triage was already controversial. The 'charity begins at home' approach turns the physician into an instrument of (certain currents within) the Israeli state, where doctors are instructed to perform political triage with medical resources. This approach may not even be wise politically, given that dead people are harder to gain information from, and that it implies that IDF members should receive likewise (non-)treatment from Palestinian physicians in casualty situations. It would also seem to imply that Israeli physicians should treat even the most minor physical injury of 'one's own' above the injuries of the one(s) who caused the harm, no matter how severe. That implication would undoubtedly appeal to angry posters in comments sections, some of whom say that injured terrorists should simply die, and doctors on the scene should not prevent, or perhaps should even hasten, their death. One can understand the rage evoked by the killing of innocent civilians, but what kind of doctor does that? 

 In any case, the IMA is responsible for clarifying its current position and its ethical rationale. It will also need to state how medical professionals will be protected on the scene if they are to follow any new cosmopolitan guidelines, considering how violently some are opposed to it. 

Ethics of medical photography with children in developing countries

Almost back from the summer hiatus, and now staying somewhere (Montpellier) where there is internet to be had. Note: when in France, and you ask for an internet cafe, you will invariably sent to some dreary dungeon that does photocopies, faxes and laminates family photos, and where there is dusty workstation in the back from the year je-ne-sais-quand. You have to ask for an actual coffee-dispensing cafe which -- reluctantly giving in to this century -- is equipped wifi (pronounced WEE-FEE). To this end, I found a sweet little cafe near the Place de la Comedie, equipped with (gasp) air-con. Normally this convenience is a luxury, but after ten days straight of temperatures of 34C, it may be the only thing stopping me from becoming a poulet roti.

Fumbling through my inbox I noticed that BMC Medical Ethics published an article (open access) on the ethics of taking medicine-related photographs of children. Often you see photos of children in presentations at universities, particularly among faculty and students who have gone global, where for 'global' read: low-income countries with high disease burdens. Sometimes the photos are there for obviously medical purposes, e.g. to visually illustrate a morbidity, a symptom. But sometimes you wonder: some photos are just scene setting (and look a lot like tourist snapshots) and others look like decorative features of powerpoint slides, aiming to give a literally human face to some far flung region. And do those photographed know what happens to their images? Do they know that, in our new media landscape, it might be impossible to precisely track where their images may go and what may be done to them? When parents in low-income countries freely allow researchers to take pictures of their children, should that consent be taken au serieux?

The article is partly based on qualitative research, though only samples the views of a small number of researchers and medical practitioners in England who work in the developed world. It would be interesting to get opinions about the ethics of medical photography and push forward a robust debate on  best ethical practices worldwide.

Health care strike in Mozambique

When I was in Maputo last week, the big ethics issue in the country had nothing to do with biomedical research. There was a buzz about a possible doctor's strike. But the doctors I met said it was actually a bluff: the government would open negotiations before the strike deadline, the medical association would craft some sort of compromise, and the whole thing would blow over. On the other hand, Doctors in Mozambique did go on strike back in January for nine days, though there are conflicting reports as to the extent of the strike.

Well, today they are striking again. According to the newspapers, doctors are demanding a base salary of $3000 per month, while the government is offering between $600 and $1200. Much of the problem has to do with equity: the doctors in the public sector in Mozambique are government employees, and there is a strong sense (rooted in Mozambique's Marxist tradition) that there should not be significant inequities in pay between public sector jobs. If the government raises the base salary of doctors, but does not offer something similar to other public sector employees, they may have a more general strike on their hands. However, if they do not satisfy the demands of the doctors, the lives and welfare of citizens may be in danger: even if the Mozambique Medical Association insists that essential services will remain open, I heard much dispute about what should count as 'essential' in such circumstances. In any case, it would not take much of a strike to have a significant impact on patient health, given that the physician/patient ratio is 1 to 22000.

Glass ceiling for developing world bioethicists?

The Journal of Bioethical Inquiry has recently published a Letter to the Editor entitled: Bioethics and Its Gatekeepers: Does Institutional Racism Exist in Leading Bioethics Journals? The authors have done an analysis of 14 leading bioethics journals in regard to the composition of their editorial and advisory boards. Their question was: how many editorial and advisory board members are located in countries ranked very high, high, medium or low in the Human Development Index? The answer is chilling: approximately 95 percent of editorial board members are based in (very) high-Human Development Index (HDI) countries, less than 4 percent are from medium-HDI countries, and fewer than 1.5 percent are from low-HDI countries. Eight out of 14 leading bioethics journal have no medium- or low-HDI country editorial board membership. Eleven bioethics journals in their sample of 14 have no board members from any low-HDI country.


How is this to be understood? The authors claim that the underrepresentation of developing countries on bioethics editorial and advisory boards suggests 'institutional racism' on the part of bioethics journals. This broadside misses the mark, for reasons other than the obvious, i.e. that membership in a developing country does not constitute membership in a 'race.' The barriers to professional advancement in bioethics are not (just) racial, and run deeper. The dominant educational centers for bioethics (as well as the journals) are in North America, Western Europe and Australia; many educational institutions in developing countries do not include (or barely cover) medical ethics, research ethics or public health ethics in their curriculum. The dominant language of bioethics is English, which poses linguistic problems for many.  In the current situation, those in the developing world who devote a substantive amount of their professional life in bioethics do so at their economic peril, unless they manage to combine it with a lucrative occupation. So the near absence of the developing world at the tables of bioethics editorial and advisory boards is not simply institutional racism on the part of those journals, but that for the most part (despite a number of educational initiatives) bioethics as a professional interest remains largely a mainstay of rich and powerful countries, despite their being no shortage of pressing and fascinating bioethical problems in low-resource settings.  

Judicial amputations in Sudan

According to news and NGO reports, a judicial cross amputation recently took place in Sudan. The cross amputation, in this case, was the amputation of a man's right hand and left foot. The man was charged with armed robbery, and this was part of his punishment. But amputation is usually a medical procedure, so it is suspected that health professionals and institutions were involved, more specifically doctors at Khartoum's Al-Ribat University Hospital.

Human rights groups and representative of medical associations are protesting this form of punishment as barbaric, and the involvement of medical practitioners in judicial amputation as reprehensible. Amnesty International calls the practice a clear violation of prohibitions against cruel and inhumane punishment. A spokesman for the World Medical Association said judicial amputation is contrary to their guidelines regarding physician participation in torture and ill-treatment of persons. Similarly, the British Medical Association issued a statement about the impermissibility of using clinical skills for non-clinical, judicial purposes.

The involvement of medical professionals in anti-Hippocratic activities -- in order to promote the morally questionable purposes of a state -- is fairly widespread. Judicial amputation is just a particularly vivid form. Less vivid, but no less questionable, is the involvement of physicians in capital punishment or 'harsh interrogations.' Anti-Hippocratic activities elsewhere may be regarded as a form of justice or justified by national interests closer to home.

Visual recording for biomedical purposes: Islamic perspectives

The Journal of Medical Ethics just came out with a short article on the Islamic perspective regarding  taking photographs or making video recordings of people's bodies for medical purposes. Not surprisingly, there are many similarities with 'conventional', non-Islamic ethical standards: informed consent is important, as well as respect for dignity, confidentiality and privacy. It matters how the images are to be used and how they are stored; the recording should also have a legitimate scientific purpose, which could not be realized by alternative, less infringing or less identifying means.

But there are some interesting differences: for medical recording to be ethical, the process of gaining and using the images has to adhere to (or at least not contradict) Shari'ah law. One important consideration is what part of the body is being photographed or video recorded. The concept of awrah refers to a body part that is forbidden to be shown to specific individuals, either in person or in photographs. While it is forbidden to record body parts considered awrah, there are rare exceptions: when a trustworthy Muslim specialist certifies that there is a necessity to store, use or view images involving awrah (such as reporting of sexual abuse), then this is justified and does not contravene Shari'ah law. Interestingly, there are strong gender differences in what is considered awrah. For men, awrah is the area between the navel and the knee. For women, awrah is the whole body except the hands and face, and in some circumstances the feet also fall into the category of the 'unrecordable.'

For an outsider, it seems strange that photographing a woman's elbow for medical purposes is considered as prima facie unethical as photographing her vagina for medical purposes. The discrepancy also seems to foster to gender inequity in health, given that recordings are commonly used in clinical care, biomedical research and medical education: I imagine that, given the strictures, most of these images are of male bodies. Whether or not you agree with them, these are considerations important to know when delivering care or conducting research with devout members of this faith.

Failing to treat TB, until TB treatment fails

There are reports coming out of India of patients who have tuberculosis that responds to none of the existing drug regimes. When you have MDR (multidrug resistant) TB, the first-line drugs will not work on it, and your physician has to resort to second-line drugs that tend to be more expensive, less effective, have more side effects, and take longer to cure you from TB. When you have XDR (extensively drug resistant) TB, there is no point in you taking the first-line drugs as well as several of those in the second-line. Your clinical options and prognosis dwindle. Now there is the concept of TDR (totally drug resistant) TB, where patients are cast back into medical history, back to the time of the sanitorium and folk remedies.

TB is curable and, as is well recognized, failure to cure has to do with non-adherence to lengthy TB treatment, poor diagnostics, weak health care systems, and lack of political will. TB, in principle, could have been as prevalent today worldwide as polio. Instead, primary TB continues to kill millions every year, and if that is not bad enough, we now apparently have pockets of TDR in the world to control and contain. It is striking that a recent letter to Clinical Infectious Diseases states that systematically poor clinical management -- lack of medical ethics at the most basic level -- is helping to fuel TB drug resistance:

The vast majority of these unfortunate patients seek care from private physicians in a desperate attempt to find a cure for their tuberculosis. This sector of private-sector physicians in India is among the largest in the world and these physicians are unregulated both in terms of prescribing practice and qualifications. A study that we conducted in Mumbai showed that only 5 of 106 private practitioners practicing in a crowded area called Dharavi could prescribe a correct prescription for a hypothetical patient with MDR tuberculosis. The majority of prescriptions were inappropriate and would only have served to further amplify resistance, converting MDR tuberculosis to XDR tuberculosis and TDR tuberculosis.

Wrong and right in Haiti

It is an old saying that disasters bring out the best and the worst in people. The idea makes sense: extreme events provoke extreme reactions. As far as 'the worst' goes, a disaster makes a country vulnerable, and creates opportunities for exploitation of the vulnerable. Take the news coverage of the earthquake's aftermath. A number of news agencies (notably, CNN) have sent in doctors who give emergency medical care and act as reporters while doing so. Bioethics experts throughout the US have been appalled by what they see as the lack of medical ethics on the part of these doctor/celebrities. The complaint is not about the classic themes, i.e. lack of informed consent or breaches of patient confidentiality. It is about exploitation of those that are poor, injured and dying. Since when is it acceptable for doctors, of all people, to help serve up the Haitian people as entertainment for those safely lounging on their sofas? That sort of behavior -- facilitating the consumation of the poor by the rich -- is what one expects of ... journalists. And it follows that the doctors involved invoke the usual journalistic justification: no, it is not at all about raising TV ratings, it is all about raising global awareness of the needs of the Haitian people.

On the bright side is the outpouring of donations to humanitarian organizations. There are organizations who are willing and able to help those in Haiti, even when a camera is not pointed in their direction. I would like to give a shout-out to one of them, International Medical Corps, a global non-profit organization of volunteer doctors and nurse who have boots on the ground in Haiti now.

Send something their way. Donating $10 is as easy as texting the word 'Haiti' to 85944. Click on this link to find out more.

Dilemmas of testing and treatment

An editorial in a Pakistani newspaper offers this seemingly commonsensical ethical directive: do not give patients treatment until they have been correctly diagnosed (via testing procedures) to have the condition the treatment is meant for. Following this train of thought, a contrast is worked up between what the author calls 'speculation-based' and 'evidence-based' medicine. The former -- typically represented by 'quacks' -- can lead to all sorts of bad consequences, such as the potential harm caused when patients are given treatment for conditions they do not actually have.

In contexts of poverty, however, the connection between testing and treatment often gets complicated. Sometimes the access to treatment is better than the access to testing; sometimes it is the reverse. When diagnostics are scarce, sometimes all you have to go on are clinical symptoms and educated guesses. You don't have to be a 'quack' to find yourself in this position: just being a doctor in an under-resourced area of one of the world's poorer countries is enough. While this sort of guesswork can put patients at risk, doing nothing while waiting for reliable diagnostic tools to arrive is not risk-free either. Are doctors who make medical decisions about patients without testing them first to confirm their condition acting ethically? The World Health Organization has taken a pragmatic position on this issue, and for years it has recommended administering antiretroviral treatment for HIV/AIDS based on clinical criteria when no reliable diagnostic tools are available. As for testing without treatment, this -- a situation faced by many thousands in the developing world -- might be worse in some ways than treatment without testing: the latter at least involves the chance of receiving appropriate treatment.

The conscientious objector argument in Thailand

A couple of months ago, the 'conscientious objector' argument in medicine made headlines when the US Department of Health and Human Services proposed regulations that aim to protect health professionals who, for reasons of moral or religious conscience, are unwilling to provide certain medical services to patients. As everybody knows, 'certain medical services' is code for abortion, and no topic divides Americans ideologically more effectively than abortion does. 'Pro-choice' advocates argue that the head of Health and Human Services, Mike Leavitt, not so much concerned about 'discrimination' towards health professionals or freedom of conscience. The real concern is on the embryos and fetuses. But between talk about the conscience of the physician and talk about the fetus, something gets left out: namely the woman who is seeking abortion as a (legal) medical service. Proponents of the proposed regulation point out that it does not prohibit women from seeking abortion services; it merely prohibits women requiring the procedure from physicians who have religious or moral objections to it. Among other things, opponents of the regulation say that once you allow for the conscientious objection argument, you will soon have pharmacists refusing to dispense contraception or nurses refusing to recommend the 'morning after' pill. Women's reproductive rights get increasingly hemmed in by the values of social conservatives.

In a paper a couple of years ago, Julian Savulescu wrote a paper about conscientious objectors, in which he looked to make a reductio ad absurdum argument. Imagine, he writes, if a doctor said that he refused to treat patients over the age of 70, because on moral grounds, scarce medical resources could be better invested in the younger population. People would find such an 'act of conscience' appalling. The example suggests that once you allow for the conscientious objector argument, health professionals will be empowered to refuse to treat patients for all sorts of reasons. A weakness of Savulescu's argument, of course, is that it makes use of a thought experiment. There probably is no doctor who actually thinks this way. But there are doctors (nurses, pharmacists) in the world who do think this way about the provision of abortion services.

A better, real-world example of the conscientious objector argument gone awry surfaced last week. Thailand is currently embroiled in serious civil conflict, the culmination of three years of strife between forces for or against ousted Prime Minister Thaksin Shinawatra. The People's Alliance of Democracy (PAD) launched a street campaign in May against the government of Samak Sundaravej that they claim to be a puppet of Thaksin. There have been violent clashes between protesters and the government police, and in solidarity with the protesters, doctors in some hospitals have refused (or threatened to refuse) to treat injured police officers. The police have been using excessive force against protesters, and the physicians are basically claiming that treating injured policemen would be acting against their own moral conscience. Human rights groups have rightly condemned the doctors' action, saying that it is a violation of medical ethics and international humanitarian law, reaffirming that the doctor's primary task is to heal, not to judge.

Dirty Ugly Things

Okwe is a Nigerian cab driver who moonlights as a hotel desk clerk. Because he was a doctor in Africa -- but not able to practice in London -- he finds himself giving what medical treatment he can to fellow immigrants. Okwe shares an apartment with Senay, a Turkish Muslim woman, who works as a maid in the same hotel as Okwe. She has a rough time of it: a visit from the immigration service forces her to quit her job in the hotel and work in a clothing sweatshop, where the boss threatens to report her to the authorities unless she perform oral sex on him. Juan, the manager of the hotel, runs an illegal operation at the hotel where immigrants sell their kidneys for something precious: a new passport, a new identity. Senay, in desperate financial need, agrees to exchange a kidney for a passport, but not (of course) before Juan forces her to have sex with him first. When Okwe hears of Senay's plan, he tells Juan that he will perform the operation in order to ensure its safety. Here is the plot twist: Okwe and Senay drug Juan, harvest his kidney, sell it to Juan's contact, and lead new lives with new passports. The victims become victimizers and visa versa. This is the basic plot of Stephen Frear's Dirty Pretty Things.

Dirty Pretty Things is basically about how things go between haves and the have-nots within the global economy, and accompanying violence, coercion (sexual and otherwise), stigma, shame, fear. The film highlights how the disempowered are caught up in a system that strips them of what little control over their lives they still have. That's where the kidney comes in. To the extent that you belong to the so-called 'less fortunate', your body is not your own, because it (or bits of it) may be one of the few things of interest to the 'global market.' Globalization spawns new niches for prostitution.

I was reminded of Dirty Pretty Things when the scandal of kidney thefts in India broke out a couple of days ago. It is not news that there are unscruplous groups persuading mostly illiterate day laborers to sell their kidneys: this has been known to be going on for years. It is not new that some impoverished Indians seek to sell their kidneys: an expression of terrible human suffering, rather than the spirit of enterprise. What is somewhat new are emerging cases of forced trade -- persons lied to, held against their will, drugged, operated on and left to their own devices. A whole network of medical professionals and institutions seem to be entangled in the gruesome business, and it looks like police were paid to look the other way.

What is the significance of this scandal? There are some who might argue that these incidents will happen time and again until trade in organs is legalized. It is simple: there are significant demands for transplant organs, criminalizing organ trade drive it underground, and those who operate (literally) in a criminal underground are unsurprisingly weak in the ethics department. But given global and regional disparities, how could a regulated, legal, 'free' trade in organs be anything other than another way for the rich to cannibilize the poor? Would a legal organ trade in circumstances of poverty really be so morally superior to the outright stealing of body parts?