An independent report has highlighted ongoing violations of medical ethics at Guantánamo Bay and called on the Department of Defense (DoD) and the medical community to conform to ethical principles. The Task Force on Preserving Medical Professionalism in National Security Detention Centers claims that medical staff have been forced to act unethically.
“As a doctor who has been to Guantánamo and examined detainees, I am appalled that medical care there is controlled by command and security prerogatives,” said Vincent Iacopino, of Physicians for Human Rights, a member of the task force. “It is time for the administration to end the inhuman and degrading practice of force-feeding and restore the ability of medical staff to act independently and according to their clinical and ethical obligations.”
It discusses how medical personnel established and participated in torture. It also outlines how the DoD committed a number of ethical breaches, including improperly using health professionals during interrogations; implementing rules that permitted medical and psychological information obtained by health professionals to be used during interrogations; requiring medical staff to forgo independent medical judgment and force-feed competent detainees; and failing to adopt international standards for medical reporting of abuse against detainees.
The report also says that the CIA’s Office of Medical Services played a critical role in torture, including waterboarding. It had advised the Department of Justice that “enhanced interrogation” methods, such as extended sleep deprivation and waterboarding, were medically acceptable. CIA medical personnel were present during waterboarding, the Task Force claims.
“Putting on a uniform does not and should not abrogate the fundamental principles of medical professionalism,” said David Rothman, of the Institute for Medicine as a Profession, a sponsor of the report. “‘Do no harm’ and ‘put patient interest first’ must apply to all physicians regardless of where they practice.”
Adding to the criticism, more than 35 prominent doctors and public health professionals – including a former US surgeon general, six Nobel laureates, and 18 deans of public health and medical schools – have asked President Obama to end force-feeding at Guantánamo Bay. “Force-feeding undermines appropriate medical care and ethical responsibilities because physicians act as agents of command – a fundamental violation of professionalism,” they say in an open letter.
How can we ensure that doctors resist pressure to participate in unethical activities? Dr Craig Klugman, a bioethicist and medical anthropologist at DePaul University in Chicago, believes that medical students need much more training in ethics and character training. In a thoughtful post on the blog of the American Journal of Bioethics, he called for a reform of medical education.
“Medical education does not provide courses in moral courage, defying authority, or turning against the tide of one’s peers. In fact, medical education encourages group think, keeping your head down and knowing your place in the hierarchy, and seeking out the approval of your peers. Medical education itself has often been accused of encouraging a culture of bullying and abuse of medical students.
“In 2012, the Association of American Medical Colleges surveyed medical students and found that 47% experienced mistreatment including public humiliation, degrading language, and abuse of power (such as being asked to run superior’s personal errands). A 2012 study published in Academic Medicine found that over a 12-year period of time, a majority of students experienced mistreatment.
“That is enough time for the mistreated medical student to become the resident and even attending who mistreats her/his medical students. The bullied becomes the bully. The very traits that are ingrained into medical students through the hidden curriculum are the same ones that make them vulnerable to being used as instruments of the state to participate in torture and abuse.”
More revelations about the medical profession under the Nazis in this week’s Slate. A riveting article by Emily Bazelon demonstrates that medicine still has not acknowledged that some areas of anatomy still carry the taint of Nazi atrocities.
One of the conclusions of Nazi medicine even surfaced during the recent US election. Representative Todd Atkin, who was running for a Senate seat in Missouri, sank his campaign when he declared that research showed that women rarely conceived after rape. The claim caused a huge furore and led for calls for his resignation even from his own party.
Atkin’s claim was based on a 1972 essay by a Dr Fred Mecklenburg. He said that Nazi doctors sent women to the gas chambers to see if the stress of imminent death would affect ovulation. This was inaccurate, but a Nazi anatomist, Hermann Stieve, the head of the Institute of Anatomy at the University of Berlin, did study this issue by examining the bodies of executed political prisoners and criminals at nearby Plötzensee Prison. (Among them was an American woman married to a member of the German resistance, Mildred Fish-Harnack.)
All 31 anatomy anatomy departments in the territories occupied by the Third Reich used the bodies of executed prisoners. It seems that only one person ever resigned rather than work on them.
Stieve was never censured and continued in his position until 1952. He was unrepentant: “In no way do I need to be ashamed of the fact that I was able to reveal new data from the bodies of the executed, facts that were unknown before and are now recognized by the whole world.”
Bazelon describes several other doctors who did similar work. Anatomical illustrations from the Pernkopf Atlas are still in use even though the models were the corpses of dissected prisoners and possibly concentration camp inmates. German universities still hold specimens taken from Nazi victims. Some have studied their holdings and acknowledged them; others have done nothing.
Bioethicist Arthur Caplan has been at the forefront of efforts to identify the victims of Nazi doctors and to deal with tainted data. “If you use it, you had better be sure you don’t have any choice,” he said. “The purpose should be life-saving or very, very important. And you have to admit you are using it, but without giving credit to the person who gave you the tainted experiments. You say, ‘This came from a prominent German scientist under the Nazis.’ But you don’t recognize them by name.”
In a related area, bioethicist Gareth Jones and anatomist Maja Whitaker, both from New Zealand are campaigning to ensure that all bodies used by anatomists have been donated. At the moment, in many countries, unclaimed bodies are given to medical schools.
A heated debate on proposals to legalise euthanasia for minors in Belgium intensified this week. The governing Socialist party has proposed the bill while the Christian Democratic Flemish party has declared that it will challenge it in the European Court of Human Rights, if it were to become law.
In an open letter to politicians, 16 paediatricians said that under-18s were capable of making mature, thoughtful decisions about death.
"Why deprive minors of this last possibility," they said. "Experience shows us that in cases of serious illness and imminent death, minors develop very quickly a great maturity, to the point where they are often better able to reflect and express themselves on life than healthy people."
The practice is already taking place, they argue, and legalisation will take it out of a “dark zone”.
Christian, Muslim and Jewish leaders also responded to the proposal. "We express our deep concern at the risk that such a grave subject will be increasingly trivialised," they said. "The euthanasia of fragile people, be they children or incapable, is totally inconsistent with their condition as human beings. We cannot accept a logic which will lead to the destruction of society's foundations.".
A British barrister and medical ethicist, Charles Foster, listed four misconceptions involved in extending euthanasia for children. He was especially critical about the issue of informed consent.
“Death, so far as we know, is terribly final. And if you’re opting for death, you need to be sure that you’ve got it right. This demands an understanding of many complex facts (such as prognosis – how your disease or condition is going to pan out – and your therapeutic and palliative options), and an evaluation of their significance. It’s hard for anyone; it’s likely to be impossible for children.
“There’s lots of evidence to show that when we find ourselves in the situations we have most feared (for instance severe disability), we find that those situations are nothing like as unbearable as we anticipated. When we are stripped of much, we value all the more what is left. Try explaining that to a child.”
The chaos of war has brought about a breakdown in health care in Syria. The latest symptom is an outbreak of polio. No polio had been reported in Syria since 1999, but on October 17 a cluster of 22 cases of “acute flaccid paralysis”, the signature symptom of clinical polio, was found from Deir Al Zour province. The UN subsequently confirmed that at least ten of these were polio cases.
Syrian doctors elsewhere have reported separate outbreaks, claiming that all of the victims are children under the age of five.
The Syrian health ministry began an immunisation drive the day after the Deir Al Zour cases were reported. Nevertheless, it is very difficult to co-ordinate distribution and administration of the vaccine in the overwhelmed hospitals around the country. Unicef estimates that 500,000 Syrian children have not been immunised against the disease, 100,000 in Deir Al Zour alone.
Health experts have implored world powers to negotiate a prompt end to the conflict, so that quality healthcare can be restored and further outbreaks avoided. “We are facing a global public health emergency that demands action at the highest level of the world’s diplomatic community,” says one expert.
Much media attention has been given in recent weeks to violent attacks on doctors in Chinese hospitals. New stories of physical assaults and verbal abuse of health workers surface every day. Apparently, little is being done by the government to stem the violence.
Late last month in the northeast town of Wenling, a patient dissatisfied with a sinus operation stabbed one doctor to death with butcher's knife, and seriously injured another.
Another doctor was stabbed to death by a patient in the north east town of Harbin. Family members of a deceased patient in Guandong province mercilessly beat two of the presiding doctors, leaving one with kidney damage.
Doctors are gravely concerned about the lack of security in hospitals. As one Wenling doctor reported, there are very few security guards in the hospitals. "These security guards had no training. Actually, they can't protect us," he said.
One reason for the rise in violence has been the increase volume of patients in hospitals after government reforms to make healthcare available to 90% of the population. Hospital doctors are under intense pressure and often can devote no more than five minutes to each patient. Another is rampant corruption. Some doctors make care conditional on bribes. If treatment goes wrong, relatives are furious and can become violent.
New research from Cambridge University has confirmed that some patients in a vegetative state are aware of the external world. In the new study, a patient showed signs of attentive awareness that had not been detected before. He was able to focus on words signalled by the experimenters as auditory targets as successfully as healthy individuals.
The researchers tested 21 patients diagnosed as vegetative or minimally conscious and eight healthy volunteers with EEGs. Lead researcher Dr Srivas Chennu commented, "Not only did we find the patient had the ability to pay attention, we also found independent evidence of their ability to follow commands – information which could enable the development of future technology to help patients in a vegetative state communicate with the outside world.
The team also found that three other minimally conscious patients reacted to novel but irrelevant words, but were unable to selectively pay attention to a target word.
Dr Tristan Bekinschtein of the Medical Research Council Cognition and Brain Sciences Unit is optimistic about the results: "These findings mean that, in certain cases of individuals who are vegetative, we might be able to enhance this ability and improve their level of communication with the outside world.”
The new procedure is a simple blood test. The test will look for fragments of DNA from the placenta and the foetus in the mother's bloodstream. These fragments can in turn be scanned for chromosomal anomalies.
Invasive screening methods, either amniocentesis or chorionic villus sampling, result in a miscarriage in 1 out of every 100 tests.
Dr Anne Mackie, from the UK National Screening Committee, said that "Early indications suggest that using Non-Invasive Prenatal Testing (NIPT) to screen women who are found to be at a higher risk of having a baby with Down's syndrome would enable earlier and safer detection of the condition."
The new test is bound to be quite controversial. An estimated 90% of women who learn that their child has Down syndrome choose to have an abortion. The outcome of the test will not be healthier children with Down syndrome, but fewer of them.
Surprisingly for a supporter of assisted suicide, she acknowledged that the notion of “slippery slope”, which is often ridiculed by supporters of voluntary euthanasia and assisted suicide, is real.
"The underlying fear of the slippery slope and the effect that legalising assisted suicide would have on the elderly and vulnerable is a justifiable one; however, the terminally-ill patient's autonomy should also be respected. It is right to protect the vulnerable and the disabled who could be influenced or pressurised to end their life for fear of being a burden on others.”
Nearly 300,000 people who participated in clinical trials have been exposed to harm without any personal or social benefit, according to research published in the BMJ. An analysis of 585 large, randomized clinical trials registered with ClinicalTrials.gov found that 29% had not been published in scientific journals and that about 78% of these had no results available on the website.
Non-publication of clinical trials is a controversial issue. Industry-funded clinical trials – such as those paid for by pharmaceutical companies – have come under fire on allegations that they are often not published if results are unfavourable.
The authors say that non-publication constitutes “a failure to honor the ethical contract that is the basis for exposing study participants to the risks inherent in trial participation”. They point out that ethical standards such as the US government’s “Common Rule” and the Declaration of Helsinki stress the importance of making results available. “When trial data remain unpublished, the societal benefit that may have motivated someone to enroll in a study remains unrealized.”
The study authors examined the outcomes of 585 large, randomized trials with at least 500 participants registered with ClinicalTrials.gov and completed before January 2009. (ClinicalTrials.gov is a website that provides easy access to information on clinical studies on a wide range of diseases and conditions.)
Of these, 29% had not been published by November 2012. Non-publication was more common among trials that received industry funding (32%) compared to those without industry funding (18%).