Monday, March 31, 2008

Drug promotion in India: disconnecting medicine from health by means of money

Doctors can be a vulnerable population too. And when they are vulnerable, it might be their patients that ultimately pay the price, literally and figuratively. That seems to be one of the morals to be drawn from a recent article in Business Week about pharmaceutical companies providing offering industrial strength incentives to physicians in India. If a doctor is not that well-off him- or herself, how could he or she not let his or her clinical judgments be influenced by goodies such as jewelry, electronic goods, cars, or free trips (spouse included) to international conferences? As reported by the Indian Journal of Medical Ethics awhile back, probably the most vulgar example of drug promotion is the use of 'rate cards' for Indian doctors in small towns and cities: a doctor can get a cell phone for prescribing 1,000 tablets per month of a particular medication; 5,000 tablets gets the doctor an air-conditioner, while dispensing 10,000 tabs can score the physician a motorcycle.

While cruising around town on the motorcycle, the physician may (or may not) wonder how many of patients actually needed the medications he or she prescribed, and what the public health or environmental effects are of the unfettered dispensation of pharmaceutical drugs. But the blame should really go upward; it is not a simple matter of doctors with character flaws. Governmental bodies ought to be reining in the excesses of big pharma in India. But then again, multinational companies like Novartis seem to have more clout than the local regulatory agencies. India is increasingly looking like a biomedical wild west: it's not just the organ trade, or the medical tourism, or the production of fake medicines, but now the increasing disconnection between medical practices and health -- fueled by the quest for profits.

Tuesday, March 25, 2008

Uganda and its ethics minister

Uganda, apparently, has a Minister of Ethics and Integrity. The story that lead me to this interesting discovery was about a sex worker conference, sponsored by NGOs from the United States, Kenya and Uganda, that the Ugandan government recently cancelled. The Minister of Ethics, Nsaba Buturo, was on hand to explain the ethics of this decision to the press. In his words, the government position is that "... we don't take any delight at all in the idea that prostitutes are coming together to devise ways of spreading their vice." Explaining further what he means by the concept of vice, the Minister went on: "We call it a vice because in Uganda it's an illegality which is punishable by seven years [in jail]". Warming to the theme of the officially impermissable, the Minister waxed on further: "Uganda's made a decision that homosexuality, prostitution and those things are not our way of life. Anyone who violates them really will deserve what they get." In the case of homosexual conduct, that can mean life imprisonment. It is not surprising that the Minister has a high opinion of the official government view of such things -- it is not just that it pays his salary, but he also believes that God installed it.

The news agencies -- operating under their strictures of neutrality -- did not evaluate or question the validity of the Minister's statements. But it does seem unlikely that the workshop, organized by the (George Soros) Open Society Institute East Africa Initiative, had the theme How to Make Every Ugandan Woman a Sex Worker and Every Ugandan man a John, rather than (say) how to protect sex workers from the usual exploitation, disease, violence and government harassment. A Minister of Ethics -- of all people -- should know that something being illegal does not entail that it is morally wrong, given that many immoral practices or policies (think of say, colonial ones) were once legal. And there would be no need to condemn or criminalize prostitution or homosexuality if they did not form at least some part of Ugandan life, and East African observers will point out that sex work is a longstanding part of the informal economy in the region, and who knows, maybe Uganda government employees have been clients over the years.

The Minister seems to be a principled deontologist of a special sort -- one that is little concerned about the human rights of sex workers and apparently not concerned about whether his government's crackdown is likely to improve their lot. In the end, the Minister is not offering an ethical judgment based on reflection and analysis; it is simply the condescending voice of a protected elite being visited on the vulnerable poor.

Monday, March 17, 2008

Human rights abuse in the name of public health: HIV, ethics and Egypt

In the industrialized nations of the north, it is easy to take for granted the progress made in the control of the HIV virus, and some of the hard-fought, positive changes in the social, ethical and legal treatment of people living with HIV/AIDS. In the United States, regimes of increasingly effective drugs have been developed to control the virus and transform HIV/AIDS from a death sentence into a chronic disease; legal protections specific to persons with HIV/AIDS have been bolstered; social stigma, while by no means absent, has had some of its sharper corners blunted by therapeutic advances and improved public understanding of the modes of HIV transmission.

The fact that this is not the case globally was driven home by a recent report by Human Rights Watch. In Egypt, an HIV positive man -- or even a man suspected of being HIV positive -- is apparently in a far worse situation than their Canadian, American or Western European counterparts. Rather than being able to call on their government for protection, Egyptian authorities strictly enforce a national law against the 'habitual practice of debauchery', i.e. consensual sex between men. Or rather: they go beyond enforcement and towards state-sponsored sadism when it comes to suspected HIV positive gay men, chaining them to hospital beds and eventually jailing them because they are alleged to constitute a threat to public health, testing them for HIV without consent, and subjecting them to abusive and intrusive physical examinations.

Aggressive state action against homosexuals/HIV positive persons in Egypt is a fairly recent phenomenon, and requires an explanation. Hossam Bahgat ventured that the crackdown on gay men is motivated by a desire to (a) distract the public from the country's economic woes and (b) profile the government as a defender of 'Islamic values' (in order to counteract the growing Islamic opposition in the country) rather than a question of public health. There must have been something in those explanations, since Mr. Bahgat was fired from his position at the Egyptian Organization for Human Rights two days after he published them.

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Sunday, March 16, 2008

Belgians Jailed for Refusing Polio Vaccination

Polio remains a widespread problem throughout the world, despite the existence of a successful polio vaccination. What are doctors and heads of state to do when people reject the vaccination? In Belgium, refusal could now result in incarceration.

Recently, the Associated Press reported that two sets of parents in Belgium were sentenced to five months in prison and fined $8,000 because they refused to have their children vaccinated for polio. A delay was put on the sentencing to give the parents a second chance to comply with the vaccination. However, they will definitely go to prison if they still refuse. This raises many questions about freedom of choice.

On one hand, polio is a terrible disease that can be easily eradicated with widespread vaccination. However, forcing citizens to become vaccinated is deemed as extreme as some. Those who refuse vaccinations for religious reasons will probably be the most troubled by mandatory vaccinations.
Miguel A. Faria, Jr. of the Medical Sentinel has addressed the ethics of forced vaccinations, stating "…the historic record also reveals that when physicians become agents of the state rather than advocates of their patients, everyone suffers. Physicians become preoccupied with preventive health measures and the 'rational allocation of scarce resources,' rather than the health of their individual patients."

The head of Belgium's vaccine center, Dr. Victor Lusayu, doesn't see it that way, however. Lusayu maintains that "The discovery of the vaccine has eliminated polio from Europe and it is simply the law in Belgium that you have to be vaccinated. ... At the end of the day, the law must be respected."

Polio vaccinations are the only vaccinations in Belgium that are required by law. France has also made the vaccination mandatory, as Europe is desperately trying to stem polio outbreaks. It is a highly contagious disease that is spread through water and children are especially susceptible, making any outbreaks all the more tragic. Whether or not these vaccination laws will improve Europe's polio problem remains to be seen.

This is a guest post by Susan Jacobs. Susan is a part-time teacher, as well as a regular contributor for NOEDb, a site for learning about and selecting an online nursing degree program. Susan invites your comments and freelancing job inquiries at her email address

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Wednesday, March 12, 2008

Thou shalt not formulate a universal code of ethics

I have been reading over H. Tristram Engelhardt's (ed.) Global Bioethics: The Collapse of Consensus lately. As its grim title suggests, the book does not indicate that there will be worldwide consensus on bioethical issues anytime soon. But it is -- and has always been -- precisely the lack of consensus that has driven many a moral philosopher or theologian to seek a kind of Ethical El Dorado, the one true set of ethical judgments that everyone (purely on the basis of being human) has to agree with. You can see the tendency at work in human rights documents, in international codes of research ethics, and in philosophical treatises. The desire for a universal morality (as opposed to the mores of some particular culture and tradition) seems to express a rage for order, and disgust with seemingly endless and messy ethical disagreement and conflict. Why can't we all get along?

The success rate, at least since Plato, has been abominable. What typically happens is that in order to become potentially universalizable, the set of judgments becomes so abstract as to become meaningless. It is almost as if one climbs a mountain top to transcend human disagreements and conflicts of value, only to find that -- while the panoramic view is great -- you have run right out of oxygen. But if more substantive content is added to the judgments, people start bickering about them again, and the reality of moral diversity comes flooding back.

I was reminded of this when a Vatican official, Monsignor Gianfranco Girotti, spoke last week about adding seven new sins to the traditional seven deadly sins. The idea, according to the Monsignor, is that globalization requires us to upgrade the categories of sin beyond the old familiar ground covered by lust, gluttony, greed, sloth, wrath, envy and pride. The new sins are:

1. “Bioethical” violations such as birth control
2. “Morally dubious” experiments such as stem cell research
3. Drug abuse
4. Polluting the environment
5. Contributing to widening divide between rich and poor
6. Excessive wealth
7. Creating poverty

Predictably, the response to the new list of sins has been mixed, even among those who are willing to play along with the notion of 'sin'. Some have argued that following the guidance of new sin #1 (don't use birth control) may in fact lead you to violate numbers 3, 5, and 7. Certainly the Catholic teachings against condom use in Africa has not helped the fight against HIV/AIDS, and the HIV/AIDS epidemic has created poverty and contributed to the widening divide between rich and poor countries. Sin #3 (drug abuse) seems just a variation on the old sin of gluttony, so not really a new one; if they are going to recast old sins in new guises, they should have added pedophilia as an updated form of sinful lust. Critics have noted that the Vatican (in regard to new sin # 6) is certainly not hurting for money, and whether stem cell research is morally dubious depends on the eye of the beholder, as well as where you are getting the stem cells from.

In short, yet another list promising moral guidance for everyone, but in reality delivering it only for those who did not need the list anyway.

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Friday, March 07, 2008

Coffee, malaria and bioethics

Quite an interesting reversal. Increasingly, when it comes to new drug development, the developing world acts as 'tasters' for the richer countries of the north, taking on the burdens of being research subjects and hoping against hope that they or their community can share in the benefits, though often the resultant drugs are for conditions that are not very prevalent in their own communities anyway.

So it is quite surprising to learn that safety and efficacy trials of new malaria vaccines will be conducted in ... Seattle. This rainy city is usually associated with grunge music, coffee and computer geeks, but it is apparently also home of a significant number of people willing to knowingly get bitten by malaria-carrying mosquitos. True, they will only be exposed to malaria strains that can be effectively treated with existing drugs, and the researchers will have fancy diagnostic tools to detect malaria infection among study participants right away. Still, it is awfully sporting (and even noble) of research volunteers in Seattle to participate in research on a disease that does not affect their community at all -- either that or they are in desperate need of quick cash for the Starbucks. Funny: when research is done in developing countries largely for the benefit of the developed world, we are liable to call it exploitation. When the reverse happens, it's called altruism. It is only against (senseless) global inequality that this makes sense.

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