Ethics 1: 2016

Accreditation: MDB006-MD271-0065-1-2016 (6 ethics CEU’s level 2i)
This tutorial is worth 6 CEU’s. The 2016 ethics tutorials will cost R300 in total for both ethics tutorials. Complete the questionnaire at the end of the tutorial and get 70% or more. We immediately receive confirmation. Once the payment has been received we will email the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays and may take up to 24 hours

Medical ethics: four principles plus attention to scope

Raanan Gillon

The “four principles plus scope” approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commitments- respect for autonomy, beneficence, non-maleficence, and justice-plus concern for their scope of application. It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work. Nine years ago the BMJ allowed me to introduce to its readers’ an approach to medical ethics developed by the Americans Beauchamp and Childress,’ which is based on four prima facie moral principles and attention to these principles’ scope of application. Since then I have often been asked for a summary of this approach by doctors and other health care workers who find it helpful for organising their thoughts about medical ethics. This paper, based on the preface of a large multi-author textbook on medical ethics,3 offers a brief account of this “four principles plus scope” approach.

The four principles plus scope approach claims that whatever our personal philosophy, politics, religion, moral theory, or life stance, we will find no difficulty in committing ourselves to four prima facie moral principles plus a reflective concern about their scope of application. Moreover, these four principles, plus attention to their scope of application, encompass most of the moral issues that arise in health care.

The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and justice. “Prima facie,” a term introduced by the English philosopher W D Ross, means that the principle is binding unless it conflicts with another moral principle -if it does we have to choose between them. The four principles approach does not provide a method for choosing, which is a source of dissatisfaction to people who suppose that ethics merely comprises a set of ordered rules and that once the relevant information isfed into an algorithm or computer out will pop the answer. What the principles plus scope approach can provide, however, is a common set of moral commitments, a common moral language, and a common set of moral issues. We should consider these in each case before coming to our own answer using our preferred moral theory or other approach to choose between these principles when they conflict.

Respect for autonomy
Autonomy-literally, self rule, but probably better described as deliberated self rule-is a special attribute of all moral agents. If we have autonomy we can make our own decisions on the basis of deliberation; sometimes we can intend to do things as a result of those decisions; and sometimes we can do those things to implement the decisions (what I previously described as autonomy of thought, of will or intention, and of action). Respect for autonomy is the moral obligation to respect the autonomy of others in so far as such respect is compatible with equal respect for the autonomy of all potentially affected. Respect for autonomy is also sometimes described, in Kantian terms, as treating others as ends in themselves and never merely as means-one of Kant’s formulations of his “categorical imperative.” In health care respecting people’s autonomy has many prima facie implications. It requires us to consult people and obtain their agreement before we do things to them-hence the obligation to obtain informed consent from patients before we do things to try to help them. Medical confidentiality is another implication of respecting people’s autonomy. We do not have any general obligation to keep other people’s secrets, but health care workers explicitly or implicitly promise their patients and clients that they will keep confidential the information confided to them. Keeping promises is a way of respecting people’s autonomy; an aspect of running our own life depends on being able to rely on the promises made to us by others. Without such promises of confidentiality patients are also far less likely to divulge the often highly private and sensitive information that is needed for their optimal care; thus maintaining confidentiality not only respects patients’ autonomy but also increases the likelihood of our being able to help them. Respect for autonomy also requires us not to deceive each other (except in circumstances in which deceit is agreed to be permissible, such as when playing poker) as the absence of deceit is part of the implicit agreement among moral agents when they communicate with each other. They organise their lives on the assumption that people will not deceive them; their autonomy is infringed if they are deceived. Respect for patients’ autonomy prima facie requires us, therefore, not to deceive patients, for example, about their diagnosed illness unless they clearly wish to be deceived. Respect for autonomy even requires us to be on time for appointments as an agreed appointment is a kind of mutual promise and if we do not keep an appointment we break the promise. To exercise respect for autonomy health care workers must be able to communicate well with their patients and clients. Good communication requires, most importantly, listening (and not just with the ears) as well as telling (and not just with the lips or a wordprocessor) and is usually necessary for giving patients adequate information about any proposed intervention and for finding out whether patients want that intervention. Good communication is also usually necessary for finding out when patients do not want a lot of information; some patients do not want to be told about a bad prognosis or to participate in deciding which of several treatments to have, preferring to leave this decision to their doctors. Respecting such attitudes shows just as much respect for a patient’s autonomy as does giving patients information that they do want. In my experience, however, most patients want more not less information and want to participate in deciding their medical care.

Beneficence and non-maleficence
Whenever we try to help others we inevitably risk harming them; health care workers, who are committed to helping others, must therefore consider the principles of beneficence and non-maleficence together and aim at producing net benefit over harm. None the less, we must keep the two principles separate for those circumstances in which we have or recognise no obligation of beneficence to others (as we still have an obligation not to harm them). Thus the traditional Hippocratic moral obligation of medicine is to provide net medical benefit to patients with minimal harm that is, beneficence with non-maleficence. To achieve these moral objectives health care workers are committed to a wide range of prima facie obligations. We need to ensure that we can provide the benefits we profess (thus “professional”) to be able to provide. Hence we need rigorous and effective education and training both before and during our professional lives. We also need to make sure that we are offering each patient net benefit. Interestingly, to do this we must respect the patient’s autonomy for what constitutes benefit for one patient may be harm for another. For example, a mastectomy may constitute a prospective net benefit for one woman with breast cancer, while for another the destruction of an aspect of her feminine identity may be so harmful that it cannot be outweighed even by the prospect of an extended life expectancy. The obligation to provide net benefit to patients also requires us to be clear about risk and probability when we make our assessments of harm and benefit. Clearly, a low probability of great harm such as death or severe disability is of less moral importance in the context of non-maleficence than is a high probability of such harm, and a high probability of great benefit such as cure of a life threatening disease is of more moral importance in the context of beneficence than is a low probability of such benefit. We therefore need empirical information about the probabilities of the various harms and benefits that may result from proposed health care interventions. This information has to come from effective medical research, which is also therefore a prima facie moral obligation. The obligation to produce net benefit, however, also requires us to define whose benefit and whose harms are likely to result from a proposed intervention. This problem of moral scope is particularly important in medical research and population medicine.
One moral concept that in recent years has become popular in health care is that of empowerment-that is, doing things to help patients and clients to be more in control of their health and health care. Sometimes empowerment is even proposed as a new moral obligation. On reflection I think that empowerment is, however, essentially an action that combines the two moral obligations of beneficence and respect for autonomy to help patients in ways that not only respect but also enhance their autonomy.

Justice
The fourth prima facie moral principle is justice. Justice is often regarded as being synonymous with fairness and can be summarised as the moral obligation to act on the basis of fair adjudication between competing claims. In health care ethics I have found it useful to subdivide obligations of justice into three categories: fair distribution of scarce resources (distributive justice), respect for people’s rights (rights based justice) and respect for morally acceptable laws (legal justice). Equality is at the heart of justice, but, as Aristotle
argued so long ago, justice is more than mere equality – people can be treated unjustly even if they are treated equally. He argued that it was important to treat equals equally (what health economists are increasingly calling horizontal equity) and to treat unequals unequally in proportion to the morally relevant inequalities (vertical equity). People have argued ever since about the morally relevant criteria for regarding and treating people as equals and those for regarding and treating them as unequals. The debate flourishes in moral, religious, philosophical, andn political contexts, and we are no closer to agreement than we were in Aristotle’s time. Pending such agreement health care workers need to tread warily as we have no special justification for imposing our own personal or professional views about justice on others. We certainly need to recognize and acknowledge the competing moral concerns. For example, in the context of the allocation of resources conflicts exist between several common moral concerns: to provide sufficient health care to meet the needs of all who need it; when this is impossible, to distribute health care resources in proportion to the extent of people’s needs for health care; to allow health care workers to give priority to the needs of “their” patients; to provide equal access to health care; to allow people as much choice as possible in selecting their health care; to maximise the benefit produced by the available resources; to respect the autonomy of the people who provide those resources and thus to limit the cost to taxpayers and subscribers to health insurance schemes. All these criteria for justly allocating health care resources can be morally justified but not all can be fully met simultaneously. Similar moral conflicts arise in the context of rights based justice and legal justice.

Personal decision making
The best moral strategy for justice that I have found for myself as a health care worker is first to distinguish whether it is I or an organisation, profession, or society itself that has to make a decision. For example, “how should I respond to a particular patient who wants an abortion?” is distinct from, “what is this hospital’s organisational view on abortion?” and “what is the medical profession’s collective view on abortion?” and “what is society’s view as expressed in law and practice?”
Firstly, for decisions that I must take myself I must try to exclude decisions that have no moral basis or justification. Neither pursuit of my own self interest -for example, accepting bribes from patients, hospitals, or drug manufacturers-nor action that discriminates against patients on the basis of personal preference or prejudice can provide a just or morally acceptable basis for allocating scarce health care resources or for any other category of justice. Moreover, it is not my role as a doctor to punish patients; withholding antibiotics from smokers who do not give up smoking or refusing to refer heavy drinkers with liver damage induced by alcohol for specialist assessment on the grounds that they are at fault is not a just or morally acceptable basis for rationing my medical resources.
Secondly, I should not waste the resources at my disposal; so if a cheaper drug is likely to produce as much benefit as a more expensive one I should prescribe the cheaper one. Cost and its team mate opportunity cost are moral issues and central to distributive justice. If I believe, however, that an expensive drug is clearly and significantly better for my patient than a cheaper alternative and I am allowed to prescribe it then I believe that I should do so. Thus, like many British general practitioners, I try oxytetracycline first when treating acne, but if it does not work well I prescribe the more expensive minocycline; for depression I usually start with tricyclic antidepressants, but if they do not work well or the side effects are unacceptable I prescribe the new and expensive 5-hydroxytryptamine uptake inhibitors.
Thirdly, I should respect patients’ rights. For example, my disapproval of a patient’s lifestyle would not be a morally acceptable justification for refusing to provide a certificate of sickness if he or she cannot work because of sickness. I have no special privilege as a health care worker, however, to create societal rights for my patients. For example, while I might think that all my unemployed patients should receive sickness benefit, in Britain they have a right to receive it only if they cannot work because of sickness; I have a right, therefore, to provide a certificate of sickness only if this is the case.
Fourthly, I ought to obey morally acceptable laws. Thus, even though I may disapprove of breaking a patient’s confidence, if he or she has one of several infectious diseases I am legally obliged to notify the relevant authorities. If I believe that the law is morally unjustified I am morally entitled to break the law; but this gives me no legal entitlement to break the law, and I should be prepared to face the legal consequences of disobeying it. I should also decide exactly what I mean by a morally unjustified law. I suggest, though here do not argue, that it is the processes through which laws are enacted that confer moral legitimacy not the content of the laws. Thus if a law is enacted through a democratic political system-and hence one that fundamentally respects autonomy-which represents conflicting views within its population and makes laws on the basis of certain common moral values that reflect the four principles then that law is morally acceptable, and prima facie we are morally required to obey it.

Organizational;, Professional, and Societal Decisions
My role in taking decisions about justice that are organisational, professional, or societal should only be as a member of the relevant organisation, profession, or society. It is therefore morally consistent to pursue at different levels objectives that are mutually inconsistent. The medical directorate at the hospital where I work may have decided to prohibit the prescription of a particularly expensive drug. As a member of that directorate I may have argued in favour of prescribing the drug in special cases, but my arguments were rejected. It is morally proper for me as a clinician to accept the directorate’s decision and act accordingly even when faced with an exceptional case in which I believe the expensive drug would be preferable. It is also morally legitimate for me to point to such cases (“shroud waving”) in my political role as a member of a democratic society, arguing, for example, for more resources for health care than, say, for defence. As members of society we are still feeling our way even at the level of defining what the competing moral concerns of justice are. We must be particularly wary of apparently simple solutions to what have been perceived as highly complex problems for at least 2500 years. For example, populist solutions in distributive justice such as have occurred in Oregon in the United States and technical and simplistic economic solutions such as the system of costed quality adjusted life years (QALYs)’ are tempting in their definitiveness and simplicity; they fail, however, to give value to the wide range of other potentially relevant moral concerns. Until there is far greater social agreement and understanding of these exceedingly complex issues I believe it is morally safer to seek gradual improvement in our current methods of trying to reconcile the competing moral concerns-to seek ways of “muddling through elegantly” as Hunter advocates – than to be seduced by systems that seek to convert these essentially moral choices into apparently scientific, numerical methods and formulas. As Calabresi and Bobbitt suggested in the 1970s, rationing scarce resources that prolong life and enhance health often entails tragic choices-choices between
people and between values. Societies seek strategies to minimise the destructive effect of such choices, including tendencies to change their strategies over time. Calabresi suggests that we are like a juggler trying to keep too many balls in the air; like the juggler we must do our best to improve our juggling skills to keep more balls in the air for more of the time and to avoid letting any ball stay on the ground for too long. We must accept, however, that in the context of competing and mutually incompatible claims there will always be some balls on the ground. Moreover, we should not be surprised that there will always be some people dissatisfied after justice has been done because by definition not everyone’s claims can be met.

Scope
We may agree about our substantive moral commitments and our prima facie moral obligations of respect for autonomy, beneficence, non-maleficence, and justice, yet we may still disagree about their scope of application-that is, we may disagree radically about to what or to whom we owe these moral obligations. Interesting and important theoretical issues surround the scope of each of the four principles. We clearly do not owe a duty of beneficence to everyone and everything; so whom or what do we have a moral duty to help and how much should we help them? While we clearly have a prima facie obligation to avoid harming everyone, who and what count as everyone? Similarly, even if we agree that the scope of the principle of respect for autonomy is universal, encompassing all autonomous agents, who or what counts as an autonomous agent? Who or what falls within the scope of our obligation to distribute scarce resources fairly according to the principle of justice? Is it everyone in the world? Future people? Just people in our own countries? And who or what has rights? Do plants have rights? Does the environment have rights? Does a work of art have rights? Do animals have rights and if so, which animals? Conversely, against whom may holders of rights claim the correlative moral obligation? Similar questions concern the scope of legal justice.

Scope for health care workers
Fortunately for health care workers some of these issues of scope have been clarified for them by their special relationship with their patients or clients. In particular, the controversial issue of who falls within the scope of beneficence is answered unambiguously for at least one category of people: all health care workers have a moral obligation to help their patients and clients. Patients or clients fall within the scope of the health care workers’ duty of beneficence. This fact is established by the personal and professional commitments of the health care professionals and their organisations-they all profess a commitment to help their patients and clients, and to do so with minimal harm. This commitment is underwritten by the societies in which they practise, both informally and through legal rules and regulations that define the health care professionals’ duties of care. Two issues of scope are of particular practical importance for health care workers. The first is the question of who falls within the scope of the prima facie principle of respect for autonomy. The second is the question of what is the scope of the widely acknowledged “right to life”; who and what has a right to life? Obviously the scope of the principle of respect for autonomy must include autonomous agents-we cannot respect the autonomy of a boot or anything else that is not autonomous. But who or what counts as an autonomous agent? When we disagree about whether or not to respect the decision of a girl of 14 to take the oral contraceptive pill we are in effect disagreeing about the scope of application of the principle of respect for autonomy. Similar questions about the scope of respect for autonomy arise in other paediatric contexts, in the care of severely mentally ill or mentally impaired people, and in the care of elderly people who are severely mentally impaired. Some patients clearly do not fall within the scope of respect for autonomy; newborn babies, for example, are not autonomous agents as autonomy requires the capacity to deliberate. But 7 year olds usually can deliberate to a degree. How much capacity for logical thought and deliberation and what
other attributes are required for somebody to be an adequately autonomous agent? Possible other, necessary attributes include an adequately extensive and accurate knowledge base, including that born of experience and of accurte perception, on which to deliberate; an ability to conceive of and reflect on ourselves over time, both past and future; an ability to reason hypothetically-“what if’ reasoning; an ability to defer gratification for ourselves as an aspect of self rule; and sufficient will power for self rule. However these philosophical questions are answered, health care workers increasingly acknowledge that the autonomy of even young children and severely mentally impaired people should prima facie be respected unless there are good moral reasons not to do so. Moreover, those reasons will depend highly on the context; a young child or a severely mentally impaired person may not be autonomous enough to have his or her decision to reject an operation respected but be autonomous enough to decide what food to eat or clothes to wear. When patients who are not adequately autonomous for all their decisions to be respected make decisions that seem to be against their interests then important issues arise about who should be regarded as appropriate to make decisions on their behalf and about the criteria that they should use to do so. The second important issue of scope for health care workers concerns the “right to life.” Who or what has this right to life? To answer the question we have to determine what is meant by the right to life. Specifically, is it simply the right not to be unjustly killed or does it also include a right to be kept alive? The scope of the first right will clearly be greater than the scope of the latter: we have prima facie moral obligations not to kill all people but we have obligations to keep alive only some people. Even with the first definition of the right to life (a right not to be unjustly killed) a question of scope arises; although all people clearly fall within its scope, do (non-human) animals? And what do we mean by people? In response to this last question much debate, often extremely acrimonious, occurs in health care ethics over the right to life of human embryos, fetuses, newborn babies, and patients who are permanently unconscious or even brain dead. It is salutary to reflect that these contentious issues are not about the content of our moral obligations but about to whom and what we owe them-that is, they are questions about the scope of our agreed moral obligations. Our answers are reasoned and carefully argued but deeply conflicting, either religiously or philosophically. Such disagreement about scope does not justify accusing those who disagree with us of bad faith or incompatible moral standards; in principle it is open to resolution within our shared moral commitment.

Conclusion
The four principles plus scope approach is clearly not without its critics. And the approach does not purport to offer a method of dealing with conflicts between the principles. But I have not found anyone who seriously argues that he or she cannot accept any of these prima facie principles or found plausible examples of concerns about health care ethics that require additional moral principles. The four principles plus scope approach enables health care workers from totally disparate moral cultures to share a fairly basic, common moral commitment, common moral language, and common analytical framework for reflecting on problems in health care ethics. Such an approach, which is neutral between competing religious, political, cultural, and philosophical theories, can be shared by everyone regardless of their background. It is surely too important a moral prize to be rejected carelessly or ignorantly; for the sake of mere opposition; or for the fun of being a philosophical “Socratic gadfly.”

Questions

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References
1 Gillon R. Philosophical medical ethics. Chichester: Wiley, 1986. (From a 26 part
series in BMJ from 1985;290: 1117-9 to 1986;292:543-5.)
2 Beauchamp TL, Childress JF. Principles of biomedical ethics. 3rd ed. New York,
Oxford: Oxford University Press, 1989.
3 Gillon R, Lloyd A, eds. Principles ofhealth care ethics. Chichester: Wiley, 1994.
4 Aristotle. Nichomachean ethics. Book 5. McKeon R, ed. The basic works of
Aristotle. New York: Random House, 1941.
5 Aristotle. Politics. Book 3, chapter 9. McKeon R, ed. The basic works of
Aristotle. New York: Random House, 1941.
6 Klein R. On the Oregon trail: rationing health care-more politics than science.
BMJ 1991;302:1-2.
7 Williams A. Economics, society and health care ethics. In: Gillon R, Lloyd A,
eds. Principles ofhealth care ethics. Chichester: Wiley, 1994:829-42.
8 Hunter DJ. Rationing dilemmas in health care. Birmingham: National Association
of Health Authorities and Trusts, 1993. (NAHAT research paper No 8.)
9 Calabresi G, Bobbitt P. Tragic choices. New York: Norton, 1978.
(Accepted 16March 1994)

Ethics 2: 2016

Accreditation: MDB006-MD271-0066-1-2016 (6 ethics CEU’s in level 2i)
This tutorial is worth 6 CEU’s. The 2016 ethics tutorials will cost R300 in total for both ethics tutorials. Complete the questionnaire at the end of the tutorial and get 70% or more. We immediately receive confirmation. Once the payment has been received we will email the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays and may take up to 24 hours

Medical Ethics at Guantanamo Bay and Abu Ghraib: The Problem of Dual Loyalty

Peter A. Clark

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigatinon of military health personnel reporting abuse, degradation, or signs of torture. Mounting information from many sources, including Pentagon documents, the International Committee of the Red Cross (ICRC), Amnesty International, Human Rights Watch, etc., indicate that medical personnel failed to maintain medical records, conduct routine medical examinations, provide proper care of disabled and injured detainees, accurately report illnesses and injuries, and falsified medical records and death certificates. Medical personnel and medical information was also used to design and implement psychologically and physically coercive interrogations. The United States military medical system failed to protect detainee’s human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism. The fundamental question raised by many Americans is how could military medical personnel have been directly involved or complicit with these human rights violations? One reason, according to Amnesty International’s Report, Combating Torture: A Manual For Action, is that since the September 11 attacks, terrorism has been linked inextricably to the public mind (in the west) to people from middle-eastern and Muslim backgrounds, generating the type of extreme prejudice that, in a poorly monitored detention environment such as Abu Ghraib, offers moral license for torturers. The result is that human rights are allowed to be overlooked and even violated in order to gain information to win the war against terrorism. In other words, the end – to win the war on terrorism – justifies any means, including techniques used to gain invaluable information. As a result, military medical personnel are placed in a position of a “dual loyalty” conflict. They have to balance the medical needs of their patients, who happen to be detainees, with their military duty to their employer. Unfortunately, this “dual loyalty” situation is not a concept that is new to military medical personnel. An extreme case in recent history occurred in Nazi death camps, where doctors supervised killings and selected which people went into the camps and which were killed. Physicians who interviewed Nazi doctors said most were normal people who went home on weekends to be fathers and husbands. They weren’t killers before serving in the death camps and didn’t continue killing afterward. Those who interviewed U. S. soldiers about atrocities in Vietnam, said there’s an internalization of the ethos of the organization that then prompts actions the person wouldn’t ordinarily perform.

In a country that deplores human rights violations around the world and even sanctions such countries for them, the United States cannot justify these actions by stating that just a small number of medical personnel succumbed to certain situations. To regain its credibility as a champion of human rights, the United States must initiate a thorough investigation of these situations in order to find the root of these systemic violations. Fundamental questions need to be answered. Is there something systemically wrong with our medical education system that allowed well-trained medical personnel to become actively involved in these abuses, or worse, to remain silent? Can new checks and balances and early warning systems be initiated that would bring needed reforms in the military medical system? Is there a need for guidelines to be established that assist medical military personnel in dealing with the issue of “dual loyalty?”

The purpose of this article is three-fold: first, to examine the “dual loyalty” conflict of the medical personell at both the Guantanamo Bay detention facility and Abu Ghraib prison; second, to give an ethical analysis of the role and behavior of medical personnel in military prisons and detention centers and the military health system in general; third, to give concrete recommendations in hope that this situation will not occur in the future.

Dual Loyalty Conflict
The “dual loyalty” conflict is a complex issue that continues to plague the medical profession. It is unavoidable and often commonplace. “It occurs when a managed care plan or hospital exerts financial control over physicians’ choices, when public health regulations require that a physician break patient confidentiality and report someone with a communicable disease, or when a psychiatrist is bound to report that his/her patient may be dangerous to a vulnerable third party.” Military medical personnel, especially in a time of war, are faced with the most ethically difficult dual loyalty of doing what is in the best interest of their patient and doing what is in the best interest of their government and fellow soldiers. This conflict has existed for as long as we have fought wars. It is the most difficult because it is the state or the military exerting the pressure on the medical professional. Recently, the military medical personnel in Afghanistan and Iraq have been confronted by the issues of “dual loyalty” and moral complicity by being accused of violating human rights, medical ethics, and the basic tenets of the medical profession. Military medical personnel were aware of situations of abuse and torture by interrogators, military police, soldiers and intelligence personnel. Confirmed and reliably reported abuses of detainees in Iraq and Afghanistan include beatings, burns, shocks, bodily suspensions, asphyxia, threats against detainees and their relatives, sexual humiliation, isolation, prolonged hooding and shackling, and exposure to heat, cold and loud noise. Other abuses include deprivation of sleep, food, clothing, and material for personal hygiene, and denigration of Islam and forced violation of its rights. Detainees were forced to work in areas that were determined not to be safe and were seriously injured. Abuses of women detainees are less well documented but include credible allegations of sexual humiliation and rape.

At Guantanamo Bay, interrogators with the assistance of military medical personnel have been accused of using aggressive counter-resistance measures in systematic fashion to pressure detainees to cooperate. These measures include: “sleep deprivation, prolonged isolation, painful body positions, feigned suffocation, and beatings. Other stress-inducing tactics have allegedly included sexual provocation and displays of contempt for Islamic symbols.” Evidence suggests that health information on the detainees was made available to behavioral science consultants and others who were responsible for carrying out interrogation strategies. According to M. Bloche and J. Marks, who investigated these abuses and documented them in an article for the New England Journal of Medicine, “since late 2002, psychiatrists and psychologists were part of a strategy that employs extreme stress, combined with behavior-shaping rewards, to extract actionable intelligence from resistant captives.” The ICRC and other human rights organizations argue that these tactics constitute cruel and inhumane treatment and even torture, which violate various international declarations and conventions.

The United States has signed and enacted numerous international declarations and conventions that prohibit torture and abuse of human rights. The U. N. Universal Declaration of Human Rights clearly stipu- lates “No one shall be subjected to torture or cruel, inhumane or degrading treatment or punishment.” The Geneva Convention states:
Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause,shall in all circumstances be treated humanely, without any adverse distinction…The following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above mentioned persons: violence to life and persons, in particular murder of all kinds, mutilation, cruel treatment and torture; …Outrages upon personal dignity, in particular, humiliating and degrading treatment…No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatever. Prisoners of war who refuse to an- swer may not be threatened, insulted, or exposed to any unpleasant or disadvantageous treatment of any kind. Other instruments such as the U. N. Body of Principles for the Protection of All Persons Under Any Form of Detention or Imprisonment, U.N. Standard Minimum Rules for the Treatment of Prisoners, the Convention Against Torture and Other Cruel, Inhumane, or Degrading Treatment or Punishment, and U. S. military internment and interrogation policies, collectively contain mandatory and voluntary standards barring U. S. armed forces from practicing torture or degrading treatments of all persons.

Even though the United States is a signatory government to these international conventions, the Bush Administration claims they have found various “loop- holes” that have allowed for a broad interpretation of the laws. These loopholes have also contributed to the “dual loyalty” conflict among the military medical personnel. For example, al-Qaeda and Taliban detainees have been called “unlawful combatants,” a term coined by the Bush Administration, which has been used to by-pass the Geneva Conventions and detain more than 600 suspected terrorists incommunicado at Guantanamo Bay. In a January 2002 memorandum from the Department of Justice to the Department of Defense, it was decided that since al-Qaeda was not a national signatory to international conventions and treaties, these obligations did not apply. It was also decided that the convention did not apply to Taliban detainees because al-Qaeda’s influence over Afghanistan’s government meant that it could not be a party to treaties. As a result, the President signed an executive order in February 2002 stating that even though the Geneva Conventions did not apply to al-Qaeda and Taliban detainees, the U.S. would continue to be a strong supporter of the Geneva Convention and its principles and that “the United States Armed Forces shall continue to treat detainees humanely and, to the extent appropriate and consistent with military necessity in a manner consistent with the principles of Geneva.” The importance of the phrasing is that it subordinates U.S. compliance to the Geneva Convention to undefined “military necessity.” In addition, an August 2002 Justice Department memorandum to the President and a March 2003 Defense Department Working Group distinguished cruel, inhumane, or degrading treatment, which could be permitted in U.S. military detention centers, from torture, which was ordinarily banned except when the President set aside the U.S. commitment to the Geneva Convention in exercising his discretionary war-making powers. Late in 2002, the Secretary of Defense approved “Counter Resistance Techniques” including nudity, isolation, and exploiting fear of dogs for interrogating al-Qaeda suspects at Guantanamo Bay. These supposed “loopholes” in the international conventions not only allowed these abuses to occur but officially authorized them, depending on how one interpreted the U. S. government policies. The problem is that these incidents are not “loopholes.” A legal loop- hole is an actual gap in the law that is legally exploited. What the Bush Administration did was misinterpret and misrepresent clear legal precedents, rather than finding gaps that could be exploited. An example would be how the Bush Administration defines torture in particularly narrow terms. Torture was defined as “where the pain is physical it must be of an intensity akin to that which accompanies serious physical injury such as death or organ failure.”

After the abuses were confirmed, the U. S. military placed some of the blame on the fact that even though the military personnel received thirty-six minutes of basic training on human rights, the detention facility military personnel did not receive additional human rights training. Civilian interrogators received no training on human rights. And some “military medical personnel in charge of detainees in Iraq and Afghanistan denied being trained in Army human rights policies.” Basic training in human rights is necessary but it would not have resolved the inconsistency for military medical personnel on how to interpret correctly these international conventions.

Inadequate training in human rights is part of the problem, but alone it cannot justify the actions or inactions of the military medical personnel. Both civilian and military medical personnel are trained in the basic medical-ethical principles that serve as the foundation of being a medical professional. Besides the medical protections guaranteed by the Geneva Convention, the Hippocratic Oath clearly states: I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death…All that may come to my knowledge in the existence of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal.

Medical personnel have the ethical and professional responsibility to do what is in the best interest of their patient. This means they must treat all injuries and diseases, they must never do anything that would cause direct harm to a patient, and they must keep all priviledged medical information confidential as a basic tenet of the physician-patient relationship. The World Medical Association’s (WMA) “Declaration of Tokyo” in 1975 states: “The physician shall not countenance, condone or participate in the practice of torture or other cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedure is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including armed conflict and civil strife.” The position of the WMA is quite clear that condoning or participating in the practice of torture is prohibited. The American Medical Association also has a definitive position on torture that was issued in December 1999:
Torture refers to the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments or punishments during imprisonment or detainment. Physicians must oppose and must not participate in torture for any reasons. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened. Physicians may treat prisoners or detainees if doing so is in their best interest, but physicians should not treat individuals to verify their health so that torture can begin or continue. Physicians who treat torture victims should not be persecuted. Physicians should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great.

Military medical professionals include pathologists, primary care physicians, psychiatrists/psychologists, nurses, battlefield clinicians and advisors to interrogators. All these medical professionals are covered by the same international conventions and codes of ethics. According to WHA and the AMA standards, military medical personnel violated both codes of ethics and the Geneva Conventions in numerous ways. First, The U. S. Army investigators concluded that the medical system at Abu Ghraib for detainees was inadequately staffed and equipped. The ICRC found that the medical system failed to maintain internment cards with medical information necessary to protect the detainee’s health, as required by the Geneva Convention. Few units in Iraq and Afghanistan complied with the Geneva obligation to provide monthly health inspections. Second, the medical system failed to assure that prisoners could request proper medical care. An example was given of a hand injury caused by torture that was left untreated. Third, the medical system failed to establish procedures, as called for by Article 30 of the Geneva Convention, to ensure proper treatment to prisoners with disabilities. One example cited was where a prisoner’s crutch due to a broken leg was taken away from him and his leg was beaten as he was ordered to renounce Islam. Fourth, the medical system failed to accurately report witnessed or suspected abuse. It was documented that a medic inserted an intravenous catheter into a corpse of a detainee who died under torture in order to create evidence that he was alive at the hospital. Fifth, death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months. In November 2003, Iraqi Major General Mowhoush’s head was pushed into a sleeping bag while interrogators sat on his chest. He died; medics could not resuscitate him, and a surgeon stated that he died of natural causes. Sixth, medical records of detainees were shared with interrogators thus violating physician-patient confidentiality. Finally, the medical system collaborated with designing and implementing psychologically and physically coercive interrogations. At Abu Ghraib, a physician and a psychiatrist helped design, approve, and monitor interrogations. At Guantanamo Bay interrogators were given access to medical records and “psychiatrists and psychologists were part of the strategy that employed extreme stress, combined with behavior-shaping rewards, to extract actionable intelligence from resistant captives.” This is in direct violation of the American Psychological Association’s Ethical Standards that prohibits engagement in any form of torture or cruel, inhumane or degrading treatment; it requires psychologists/psychiatrists to report such treatment; and prohibits the support of an interrogation by using an individual’s medical record to the detriment of the individual’s safety and well-being.

The “dual loyalty” conflict has led to abuses, but it would be a disservice not to commend the military medical personnel in Afghanistan and Iraq for their medical and humanitarian service. The military medical staffs in Afghanistan, Iraq and Guantanamo Bay have provided very fine medical care not only to American military personnel but to the Iraqi and Afghan people and to the detainees. They have saved many lives at a great risk to their own lives. It is also clear that not all military medical personnel were directly involved in the abuses or collaborated with the harsh interrogations at Guantanamo or Abu Ghraib. However, it appears that the majority knew of these abuses and human rights violations and remained silent. Steven Miles cites a clear example of this: “The entire detention centre medical command should have acted on widespread and prolonged failure to meet minimum standards for medical internment cards, tuberculosis screening, monthly health checks, etc.”,Complicity deals with both the intention of the agent and his or her role in cases of individual and collective harm. Issues of timing, proximity, certitude, knowledge and intent have some bearing on the presence or absence, and possibly on the degree, of moral complicity. The point is that if the medical personnel knew of these abuses, at their own facilities, and were aware it was abuse and did nothing, then they are complicit by their silence. However, moral complicity is different than “dual loyalty.” Being placed in the situation as primary care physicians to these detainees at a time of war, when the world is living in fear of yet another suicide bomb attack, places these military medical professionals in a delicate balancing act between loyalty to their patients and loyalty to their country. This is not to say that these two loyalties are mutually exclusive or have not been kept in balance in the past. One must also acknowledge that the problem of “dual loyalty” could be experienced by a highly ethical agent. A compelling hypothetical argument could be made in which a small deviation from medical confidentiality could make possible an important military maneuver that meant saving many innocent civilian lives. These more complicated situations are not the situations being addressed. The “dual loyalty” being discussed here is a conflict between the best interest of their patients and those of the military organization and fellow soldiers they serve with on a daily basis. The issue is that because of a lack of checks and balances, or the initiation of an early warning system, the relationship between these two loyalties became unbalanced.

Military medical personnel treating prisoners or detainees in a time of war have always and will always face this “dual loyalty” conflict. The Geneva Convention addresses this military and ethical dilemma when it stipulates: “Although [medical personnel] shall be subject to the internal discipline of the camp…such personnel may not be compelled to carry out any work order other than that concerned with their medical …duties.” This standard of behavior for military medical personnel was clearly violated and as a result detainees were injured and even killed, human rights were violated, and the role of a physician as one who acts in the best interest of his/her patient was irreparably damaged.

Ethical Analysis
All military medical personnel receive basic training on human rights, and those in charge of detainees or prisoners should be even more familiar with the Geneva Convention or Army Regulations regarding abuses. Understanding the importance of human rights and how they can be abused should make these medical professionals more aware of the problem of the “dual loyalty” conflict. As a result, when situations arise regarding a conflict in “dual loyalty” these medical professionals should be trained to recognize these situations and respond appropriately. However, at times there is a fineu line that separates these loyalties. Leonard Rubenstein, executive director of Physicians for Human Rights, explains how this can occur. A doctor approached by a commanding officer for advice on a sleep deprivation program inflicted on a prisoner can reasonably argue that he wants to be sure the program doesn’t do lasting harm. Similarly, a medic can advise an interrogator on a patient’s physical limitations to avoid serious injury during interrogation. In these situations it may seem reasonable for a doctor to offer advice, but that advice ultimately makes the doctor complicit in torture. In each case, that information can provide interrogators an idea of a subject’s weaknesses and allow them to exploit those weaknesses.

These examples show how the conduct of the military medical personnel at Guantanamo and Abu Ghraib raise new questions about the boundaries of medical ethics as they relate to the war against terrorism. Some Pentagon officials have argued that medical personnel advising interrogators were not bound by ethic strictures because they were not treating patients but rather were acting as behavioral scientists. Others argue that the clinical information given to the military and the Central Intelligence Officers was not confidential and thus not protected under the physician-patient rela- tionship. This was confirmed on August 6, 2002 when the U. S. Southern Command instructed health care providers that communications from “enemy persons under U.S. control at Guantanamo are not confidential and thus not protected under the physician-patient relationship. This was confirmed on August 6, 2002 when the U. S. Southern Command instructed health care providers that communications from “enemy persons under U.S. control at Guantanamo are not confidentialtial and are not subject to the assertion of privileges by detainees.” This statement also instructs medical personnel “to convey any information concerning…the accomplishment of a military or national security mission…obtained from detainees in the course of treatment to non-medical or other United States personnel who have apparent need to know the information. Such information shall be communicated to other United States personnel with the apparent need to know, whether the exchange of information with the non-medical person is initiated by the provider or by the non-medical person.” The only limitation is that they cannot act as interrogators. The line between civic duty/duty to employer and undermining patient trust, by putting patients at greater risk of serious abuse, appears to have been compromised despite the ethical obligation to act in the best interest of the patient and protect patient confidentiality. Ethically, it appears that some medical professionals were directly involved in abuse and torture and others were complicit in the abuse and accessories in gathering information. This author will argue that under the ethical principles of respect for persons, beneficence, nonmaleficences and justice, the participation of military medical personnel in the abuses at Guantanamo and Abu Ghraib was unethical and that an independent board of inquiry should be called to examine the full nature of these abuses.

“Respect for persons” refers to the right of a person to exercise self-determination and to be treated with dignity and respect. The principle of respect for persons divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy. Numerous abuses of detainees have been documented at both Abu Ghraib and Guantanamo, such as beatings, burns, shocks, bodily suspensions, sexual humilation, exposure to cold, etc. “Pentagon officials offer many reasons for these abuses including poor training, understaffing, overcrowding of detainees and military personnel, anti-Islamic prejudice, racism, pressure to procure intelligence, a few criminally-inclined guards, the stress of war and uncertain lengths of deploy- ment.” These abuses should be abhorrent to anyone. But for military medical personnel, who have been trained in human rights and ethical principles, these abuses should have been reported and stopped. To witness or to have known about any of these abuses and not to have reported them or tried to stop them is a direct violation of the principle of respect for persons. Every ethical document
from the Hippocratic Oath and the Geneva Conventions to the U. N. Universal Declaration of Human Rights clearly state that, “no human person should be subjected to torture or to cruel, inhumane or degrading treatment or punishment.” In addition, prisoners or detainees are truly vulnerable persons with diminished autonomy and deserve added protection. To highlight this point, as of June 2005, the International Committee of the Red Cross reported that there were 107 detainees under the age of eighteen identified during visits to six prisons controlled by coalition forces. Some detainees were as young as eight years of age. They report that juvenile detainees in Abu Ghraib and Bagram Air Base have been subjected to the same mistreatment as adults. The International Red Cross, Amnesty International, and the Pentagon itself have gathered substantial testimony of torture of children, bolstered by accounts from soldiers who witnessed or participated in the abuse. A Pentagon investigation by Major General George Fay reported in January 2004 that “a leashed but unmuzzled military guard dog was allowed into a cell holding two children. The intention was for the dog to ‘go nuts on the kids,’ barking and scaring them. The children were screaming and the smaller one tried to hide behind the larger, as a soldier allowed the dog to get within one foot of them.” Amnesty International reported that a fourteen-year old boy held in Abu Ghraib was allowed to be bitten by a guard dog on the leg. Also, children in Abu Ghraib were denied the right to see their parents or a lawyer. The military medical personnel allegedly were aware of these actions and must have treated some of these children for injuries including dog bites, etc. Not to report such action as torture or cruel, inhumane and degrading treatment or punishment defies comprehension militarily, legally, ethically, and from a humanitarian perspective.

Second, critics of those in the military medical profession who were complicit in the abuses at Guantanamo and Abu Ghraib or directly involved in the interrogations argue that the physician-patient relationship is the primary focus of ethics in medicine. Trust is the bridge to the physician-patient relationship, and the burden is on the physician not only to expect the patient’s trust but also to build a solid foundation upon which the patient can place his or her trust. If this relationship becomes fractured, a loss of confidence will result, and the effect on the patient could be devastating. For prisoners and detainees to see their primary care physicians also in the role of assisting those who tortured and abused them, or to see them remain silent in the face of such human rights violations, undermines the credibility of the medical profession and is irreconcilable with the physician’s role as healer. There also seems to be a conflict of interest present between preserving the primary fiduciary relationship between physician and patient and the responsibility of an employee to an employer. One example of this is in the area of confidentiality regarding detainee’s medical records. According to the Church Report that was issued in Spring 2005, “while access to medical information was carefully controlled at Guantanamo Bay, we found in Afghanistan and Iraq that interrogators had easy access to such information.” According to Bloche and Marks this would make one believe that medical confidentiality was shielded at Guantanamo Bay. However, in the U. S. Southern Command policy statement, in effect since August 6, 2002, the official policy not only requires caregivers to provide clinical information to military and Central Intelligence Agency interrogation teams on request; it calls on them to volunteer information they believe might be of value. According to the ICRC, behavioral science consultation teams at Guantanamo met regularly with the medical staff to discuss the medical condition of prisoners. The report states that such “apparent integration of access to medical care with the system of coercion means that detainees may discover that their interrogators have intimate knowledge of their medical histories, knowledge entrusted to medical professionals that is then used to design an ‘interrogation plan’ which potentially involves torture.” Medical privacy is not an ethical absolute. “Caregivers in civilian and military settings have an obligation to report information to third parties when doing so can avert threats to health or safety of individual person, but confidentiality is the starting point.” However, despite these few exceptions, there are ethical standards that hold medical privacy as sacrosanct. There is a definite conflict between the military medical personnel’s duty to his/her patient and the medical professional’s duty to his/her employer.
Participation in the blatant breaches of confidentiality of patients not only violates the fiduciary relationship between physician and patient but shows a clear conflict between a physician who serves the interests of the state and not those of his/her patient. This violation of confidentiality may also prevent some detainees from seeking needed medical care because of the fear that the information may be used against them in inter- rogation. A basic tenet of the principle of respect for persons is that one must never use another person as a means to an end. The detainees were used as means to an end in an attempt to gain results that would help win the war against terrorism. Human rights and the basic dignity and respect that every person deserves became the casualty.
“Beneficence” is the obligation to prevent and remove harms and to promote the good of the person by minimizing the risks incurred to the patient and maximizing the benefits to them and others. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others.

The ICRC, Amnesty International and even the Pentagon investigations show that the abuses of detainees in Afghanistan, Iraq and Guantanamo violated the principle of beneficence.
The medical system failed to maintain internment cards with medical information to protect the detainee’s health as required under the Geneva Convention. The medical system failed to assure detainees could request proper medical care also required under the Geneva Convention. The medical system failed to establish procedures, as called for by Article 30 of the Geneva Convention, to ensure proper treatment of detainees with disabilities. The medical system collaborated with designing and implementing psychologically and physically coercive interrogations. Finally, the medical system failed to accurately report illnesses and injuries.

Various examples of these violations have been stated above. Whether the military medical personnel directly or indirectly participated in these abuses or knew of them and remained silent, all those involved failed to prevent and remove harms and to promote the good of their patients.

Those who support the military medical personnel’s participation in assisting of interrogators argue that it is in the prisoner’s best interest that medical personnel be involved. “Once caregivers share information with interrogators, why should they refrain from giving advice about how best to use the data? Won’t such advice better protect detainees, while furthering the intelligence-gathering mission? And if so, why not oversee isolation and sleep deprivation or monitor beatings to make sure nothing terrible happens?” This logic is skewed. By violating the trust of their patients, the military medical personnel put their patients at greater risk and in some situations may have caused their death. Some argue that having a medical professional present at interrogations may invite interrogators to be more aggressive, because they imagine that the medical professionals will set needed limitations. This did not happen. These medical professionals had direct knowledge that detainees had been abused, because they treated their burns, broken bones and other assorted injuries and then allowed these detainees to be placed back into harm’s way. These actions fail the basic tenet of the principle of beneficence. The ethical duty of every medical professional is to maximize comfort and minimize pain and suffering. Not only did these medical professionals violate this ethical maxim; they also violated the basic Hippocratic dictum, “first, do no harm.” Participation by military medical personnel in the abuses and torture subverts the profession for the nonbeneficent goals of the state. Medicine is at heart a profession of care, compassion, and healing. Medical professionals are given the responsibility to treat and heal, not to facilitate interrogations. Participation in the criminal abuse and torture of detainees is “a practice reminiscent of the crimes carried out by the likes of the Nazis’ Josef Mengele, the infamous doctor at the Auschwitz death camp.” Assisting in these actions at the command of the state not only fails the test of beneficence but also fails the test of nonmaleficence.

Finally, the principle of “justice” recognizes that each person should be treated fairly and equitably, and be given his or her due. The principle of justice can be applied to the circumstances of “dual loyalty” when military medical professionals must choose between responsibility for their patients in need of care and the demands placed upon them by the United States military. The most common rationale for medical professionals’ willingness to participate in or overlook the various incidents of abuse and torture was their sense of military duty. When military medical professionals were called upon to help interrogators to refine interrogations of detainees by providing advice on increasing stress levels or exploiting fears, or when they treated detainees who had undergone cruel and inhumane abuses, they believed they were acting in the best interests of the detainees, the nation and humanity. The argument is that the medical professionals have a moral duty to ensure that the interrogations are carried out in the most fair, humane and painless way possible. They argue that the information they provided ensured that the techniques used, like sleep deprivation, did not have any lasting harm on the detainees and the advice on a detainee’s physical limitations avoided serious injury to the detainee during the interrogation. In addition, they believed that the information gathered from the detainees would help save the lives of their fellow citizens and hopefully, help to end the war on terror. Further, these medical professionals believed they had a duty as citizens and as members of the military to participate because the techniques used were authorized and sanctioned as legitimate by the military and the state, and were therefore just. Opponents of the military medical professionals’ participation argue that the abuse, torture, and methods of interrogation violated the basic tenets of human rights law and the ethical standards of the medical profession. It may be true that medical professional’s participation could add some degree of humanness to the methods of interrogation, but this does not outweigh the greater harm of causing injury and even death to the detainees. This is not treating someone fairly and equitably. Finally, state or military approval or authorization of an act does not constitute a requirement on the part of any citizen to take action. To argue that medical professionals in the military have a duty as members of the military and citizens to participate in abuse and torture is an exaggerated sense of military and civic duty, the type that has been attributed to physicians in Nazi Germany who performed medicalized killings. Every medical professional has the right, with a well-formed conscience, to refuse any order that he/she believes is unjustified and personally unethical. The failure of medical professionals to recognize that military and civic duty can never trump medical ethical principles is clearly an injustice. It is an injustice not only to those who were abused but to humanity as a whole. If the principle of justice mandates that each person should be treated fairly and equitably, then the participation of military medical professionals in torture and cruel, inhumane or degrading treatment or punishment of detainees clearly violates the principle of justice.

Conclusion
The abuses that occurred at Abu Ghraib and Guantanamo happened because explicit ethical and legal boundaries were either not established or, if present, were not enforced for the military medical personnel. Loopholes were created that allowed the military to circumvent international conventions and even the basic principles of medical ethics. Watchdog agencies like the International Committee of the Red Cross, Human Rights Watch, and Amnesty International did call attention to these abuses, but often times these organizations are severely under-funded, which can limit their capacity for surveillance and investigation of allegations of human rights violations. To verify that this type of abuse does not occur in the future, the following recommendations are proposed:
1. The President of the United States should appoint an independent board to perform a comprehensive investigation to fully assess the performance of military medical personnel with regard to human rights abuses. This board should include U. S. military medical service representatives, human rights groups, legal and medical academics, ethicists, and health professional associations. Various Army investigations have examined a small set of human rights abuses, but what is needed is an independent comprehensive investigation that can examine the systemic cause of these abuses.
2. The military must implement a comprehensive training program for all health care professionals in international humanitarian law and for developing the skills necessary for recognizing situations of dual loyalty in which human rights are at stake. There are models available for training those who work in prisons. On a more fundamental level, training in human rights abuses should be part of every medical school curriculum. It is important that all medical professionals understand not only the roots of abuse but how to address situations when confronted with examples of abuse.
3. The military should create and implement a Military Ethics Committee that can be used to assist military medical professionals in understanding the problem of “dual loyalty” and where necessary serve as a conduit for medical professionals to not only recognize these situations and respond appropriately but also serve as an avenue for reporting potential abuses. This Committee must be independent, completely confidential, and accessible to all military medical professionals without fear of reprisals.
4. The American Psychological Association (APA) formulated a Task Force to examine their longstanding ethics policy in the light of the roles that psychologists were asked to perform with regard to a wide variety of national security concerns, including involvement in military investigations. The Task Force stipulated twelve statements that applied the APA Ethics Code to the national security-related activity of psychologists. Medical and Nursing societies should initiate similar task forces to articulate guidelines for their members.
5. The various medical associations must not only condemn in writing medical professionals who are complicit in abuse and torture, they must also place various sanctions on those who violate these rules. Until these medical associations back-up their rhetoric with concrete actions, those who fall under their jurisdiction will not take these policies seriously. For example, “a resolution has passed the House of Delegates of the AMA asking for an investigation into the abuses, but the ‘resolved’ section of the resolution does not mention physicians specifically, let alone condemn the specific instances of physician involvement in abuse. There was concern that an AMA resolution might offend the Bush Administration that had supported the AMA on liability reform.” Politics should never be allowed to circumvent issues as basic as human rights.

The abuses at Abu Ghraib and Guantanamo were medically, legally and ethically unjustified. They violated every major international human rights convention and the four basic principles of medical ethics. However, these incidents, while deplorable, can “serve as an eleventh hour wake-up call for the western world to rediscover and live by the values enshrined in its international treaties and democratic constitutions.” The United States government and American medical professionals lost a great deal of international credibility in its fight to uphold human rights worldwide as a result of these abuses. Only through immediate needed reforms will this credibility ever be restored. Failure to restore this credibility has the potential to allow the basic human rights of the most vulnerable in the world to be violated in an ever greater way.

Postscript
On November 5, 2005 the American Medical Association’s House of Delegates passed a resolution stating: That our American Medical Association ask the Council on Ethical and Judicial Affairs, with input from all appropriate AMA stakeholders, “to delineate clearly for physicians the boundaries of ethical practice with respect to par- ticipation in the interrogation of prisoners and detainees,” available at .

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References
1. Editor, “Medical Personnel at Abu Ghraib Ignored Medical Ethics and Human Rights,” News-Medical.Net (August 20, 2004): 1-5. See also U.S. Army Inspector General, Detainee Operations Inves- tigation, July 21, 2004. at
2. Id.
3. D. Silove, Review of Combating Torture: A Manual For Action (Amnesty International, London, 2003) in The Lancet 363 (2004): 1915-1916.
4. A. Powell, “Why Good Doctors Do Bad Things,” Harvard Gazette (March 3, 2005): 1-3, at (last visited April 11, 2006).
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6. S. Miles, “Abu Ghraib: It’s Legacy for Military Medicine,” The Lancet 364 (2004): 725-729. See also Article 15-6 Investiga- tion of the 800th Military Police Brigade (The Taguba Report) at (last visited April 11, 2006); Captain Donald Reese’s sworn statement and interview (Appendix of Taguba Re- port investigation), at (last visited April 11, 2006); International Committee of the Red Cross, “Report of the Interna- tional Committee of the Red Cross on the Treatment by Coalition Forces of Prisoners of War and Other Protected Persons by the Geneva Convention in Iraq During Arrest, Internment, and Inter- rogation,” (February 2004), at (last visited April 11, 2006); and L. Harding, “Focus Shifts To Jail Abuse Of Women,” The Guardian (May 12, 2004), at (last visited April 11, 2006).
7. M. G. Bloche and J. H. Marks, “Doctors and Interrogators at Guan- tanamo Bay,” New England Journal of Medicine 353 (2005): 6-8. See also, Physicians for Human Rights, “Break Them Down: Sys- tematic Use of Psychological Torture by U. S. Forces,” Physicians for Human Rights Report, Cambridge, Massachusetts, 2005.
8. Bloche and Marks, supra note 7, at 6.
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at (last visited April
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(last visited April 11, 2006).
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(last vis-
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15. Miles, supra note 6, at 727.
16. Silove, supra note 3, at 1915.
17. George W. Bush, “Memorandum for the Vice President on Humane Treatment of al-Queda and Tailban Detainees” (February 7, 2002), at (last visited April 11, 2006).
18. Miles, supra note 6, at 725.
19. Miles, supra note 6, at 725. See also, Department of Defense
Working Group on Detainee Interrogations in the Global War Against Terrorism, “Assessment of Legal, Historical, Policy and Operational Considerations,” (March 6, 2003), at (last visited April 11, 2006); Office of Assistant Attorney General, “Memorandum for Robert R. Gon- zales, Counsel to the President, Re. Standards of Conduct for Interrogation Under 18 U.S.C. 2340-2340A,” (August 1, 2002), at (last visited April 11, 2006).
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21. R. Norton-Taylor, “Complicity With Torture,” The Guardian, December 8, 2005, at (last visited April 11, 2006).
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27. It should be noted that three soldiers have been ordered to stand
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28. Miles, supra note 6, at 726.
29. Bloche and Marks, supra note 7, at 6-7.
30. American Psychiatric Association and American Psychological
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31. S. Miles, “Author’s Reply,” in Correspondence, The Lancet 364 (2004): 1852.
32. United Nations, “Geneva Conventions Relative to the Treatment of Prisoners of War,” (1949), at (last visited April 11, 2006) see also, Miles, supra note 6, at 727.
33. Powell, supra note 4, at 2-3.
34. N. Lewis, “Interrogators Cite Doctors’ Aid at Guantanamo,”
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“Unclassified Executive Summary,” June 16, 2005, at (last visited April 11, 2006).
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53.
Editor, “Medical Personnel at Abu Ghraib Ignored Medical Eth- ics and Human Rights,” Medical News (August 20, 2004): 1-2, at (last visited April 11, 2006).

Ethics 1: 2014

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Ethics 1: 2014

Medical professionalism in the United States is facing a crisis, just as serious as the crisis facing the health care system, and the two crises are interrelated and can be directly correlated to the South African health care industry. Endangered are the ethical foundations of medicine, including the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and compassionately, and to avoid conflicts of interest that could undermine public trust.

Medical Professionalism in a Commercialized Health Care Market

Arnold S. Relman, MD

MEDICAL PROFESSIONALISM IN THE UNITED STATES is facing a crisis, just as serious as the crisis facing the health care system, and the 2 crises are interrelated. To understand today’s crisis in medical professionalism requires knowing what a profession is and what role it plays in modern society. Freidson considered a profession to be 1 of 3 options modern society has for controlling and organizing work. The other 2 options are the free market and management by organizations such as government or private businesses. Freidson suggested that medical work was totally unsuited for control by the market or by government or business and, therefore, the practice of medicine could only be conducted properly as a profession. According to Freidson, a profession is highly specialized and grounded in a body of knowledge and skills that is given special status in the labor force, its members are certified through a formal educational program controlled by the profession, and qualified members are granted exclusive jurisdiction and a sheltered position in the labor market. Perhaps most important, professionals have an ideology that assigns a higher priority to doing useful and needed work than to economic rewards, an ideology that focuses more on the quality and social benefits of work than its profitability. Although this ideology is the most important part of medical professionalism, it is what is now most at risk.

The science and technology of medicine and the special place that medical practice holds in the labor market are not presently threatened. The expanding professional health care responsibilities of nurses and the increase in other health workers such as physician assistants and technicians are changing the mix of the health care workforce, but the central role of the physician as the manager and provider of medical services is not likely to be challenged. Endangered are the ethical foundations of medicine, including the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and compassionately, and to avoid conflicts of interest that could undermine public trust in the altruism of medicine. It is this commitment, what Freidson called the “soul” of the profession, that is eroding, even while its scientific and technical authority grows stronger. Ironically, medical science and technology are flourishing, even as the moral foundations of the medical profession lose their influence on the behavior of physicians. This undermining of professional values was an inevitable result of the change in the scientific, economic, legal, and social environment in which medicine is now being practiced.

A major reason for the decline of medical professional values is the growing commercialization of the US health care system. Health care has become a $2 trillion industry, largely shaped by the entry and growth of innumerable private investor–owned businesses that sell health insurance and deliver medical care with a primary concern for the maximization of their income. To survive in this new medical market, most nonprofit medical institutions act like their for-profit competitors, and the behavior of nonprofits and for-profits has become less and less distinguishable. In no other health care system in the world do investors and business considerations play such an important role. In no other country are the organizations that provide medical care so driven by income and profit-generating considerations. This uniquely US development is an important cause of the health cost crisis that is destabilizing the entire economy, and it has played a major part in eroding the ethical commitments of physicians. Many physicians have contributed to this transformation by accepting the view that medical practice is also in essence a business. Medical practice is now widely viewed as a demanding and technical business that requires extensive, credentialed education and great personal responsibilities—but a business nevertheless. This change in attitude has important consequences. In business, increasing shareholder value through increased revenue and increased profit is the primary goal. However, medical professionalism requires that physicians give even greater primacy to the medical needs of patients and to the public health of the society in which their patients live. When physicians think of themselves as being primarily in business, professional values recede and the practice of medicine changes. Physicians have always been concerned with earning a comfortable living, and there have always been some who were driven by greed, but the current focus on money making and the seductions of financial rewards have changed the climate of US medical practice at the expense of professional altruism and the moral commitment to patients. The vast amount of money in the US medical care system and the manifold opportunities for physicians to earn high incomes have made it almost impossible for many to function as true fiduciaries for patients. The essence of medicine is so different from that of ordinary business that they are inherently at odds. Business concepts of good management may be useful in medical practice, but only to a degree. The fundamental ethos of medical practice contrasts sharply with that of ordinary commerce, and market principles do not apply to the relationship between physician and patient. Such insights have not stopped the advance of the “medical-industrial complex,” or prevented the growing domination of market ideology over medical professionalism. Other forces in the new environment have also been eroding medical professionalism. The growth of technology and specialization is attracting more physicians into specialties and away from primary care. The greater economic rewards of procedural specialties are particularly appealing to new graduates who enter practice burdened with large educational debts. Specialization is not necessarily incompatible with ethical professional practice, but it often reduces the opportunities for personal interactions between physicians and patients and thus weakens the bond between physicians and patients. It is too easy for even the best specialists to behave simply as skilled technicians, focused exclusively on their patients’ narrow medical problems and unmindful of their professional obligations to the whole person they are serving.

The law also has played a major role in the decline of medical professionalism. The 1975 Supreme Court ruling that the professions were not protected from anti-trust law undermined the traditional restraint that medical professional societies had always placed on the commercial behavior of physicians, such as advertising and investing in the products they prescribe or facilities they recommend. Having lost some initial legal battles and fearing the financial costs of losing more, organized medicine now hesitates to require physicians to behave differently from business people. It asks only that physicians’ business activities should be legal, disclosed to patients, and not inconsistent with patients’ interests. Until forced by anti-trust concerns to change its ethical code in 1980, the American Medical Association had held that “in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients” and that “the practice of medicine should not be commercialized, nor treated as a commodity in trade.” These sentiments reflecting the spirit of professionalism are now gone. Professionalism is also compromised by the failure of physicians to exercise self-regulation that would be supported by law. Many physicians are reluctant to identify incompetent or unethical colleagues. Such behavior also undermines the public’s trust in the profession.

Yet another deprofessionalizing force has been the growing influence of the pharmaceutical industry on the practice of medicine. This industry now uses its enormous financial resources to help shape the postgraduate and continuing medical education of physicians in ways that serve its marketing purposes. Physicians and medical educational institutions aid and abet this influence by accepting, sometimes even soliciting, financial help and other favors from the industry, thus relinquishing what should be their professional responsibility for self- education. A medical profession that is being educated by an industry that sells the drugs physicians prescribe and other tools physicians use is abdicating its ethical commitment to serve as the independent fiduciary for its patients. The preservation of independent professionalism and its ethical commitment to patients still are very important be- cause physicians are at the center of the health care system and the public must be able to depend on and trust physicians. There is currently much concern about the paternalism and elitism of medicine, and this concern is often used to justify policies seeking to establish so-called consumer- directed health care. Although there undoubtedly is a need for patients to have more information and responsibility for their health care choices, without trustworthy and accountable professional guidance from physicians, the health care system could not function. In the absence of physicians’ commitment to professional values, health care becomes just another industry that may, by continuing along its present course, be heading toward bankruptcy.

REFERENCES

1. Freidson E. Professionalism: The Third Logic. Chicago, IL: University of Chicago Press; 2001.
2. Relman AS. A Second Opinion: Rescuing America’s Health Care. New York, NY: Public Affairs; 2007.
3. Special section: commercialism in medicine. Camb Q Healthc Ethics. 2007; 16(4):368-445.
4. Arrow KJ. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53(5):941-973.
5. Relman AS. The new medical-industrial complex. N Engl J Med. 1980;303 (17):963-997.
6. Bodenheimer T. Primary care: will it survive? N Engl J Med. 2006;355(9): 861-863.
7. Goldfarb v Virginia State Bar, 421 US 773 (1975).
8. American Medical Association. Opinions and Reports of the Judicial Council. Chicago, IL: American Medical Association; 1966.
9. DeAngelis CD. Rainbow to dark clouds. JAMA. 2005;294(9):1107.
10. Relman AS. Separating continuing medical education from pharmaceutical marketing. JAMA. 2001;285(15):2009-2012.
11. Herzlinger RE, ed. Consumer-Driven Health Care: Implications for Providers, Payers and Policy-Makers. San Francisco, CA: Jossey-Bass; 2004.
12. Cohen JJ, Cruess S, Davidson C. Alliance between society and medicine: the public’s stake in medical professionalism. JAMA. 2007;298(6):670-673.

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Ethics 2: 2014

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Ethics 2: 2014

Conflicts of interest between Health Professionals moral and ethical obligations to their patients is often in direct opposition to the desire of pharmaceutical companies and their representatives to sell their products. This poses massive challenges to the principles of medical professionalism. The conflicts occurs when Health Professionals have motives or are in situations which result in a compromise of these obligations. Although medical organizations, the manufacturers, and the government have instituted regulations, research into the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary. Although the following article pertains specifically to the USA, it is equally applicable to health professions in South Africa and the world over

Health Industry Practices That Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers

Troyen A. Brennan, MD, MPH David J. Rothman, PhD, Linda Blank, David Blumenthal, MD, MPP Susan C. Chimonas, PhD, Jordan J. Cohen, MD, Janlori Goldman, JD Jerome P. Kassirer, MD Harry Kimball, MD James Naughton, MD Neil Smelser, PhD

American Medical Association special communication, 2006

THE CURRENT INFLUENCE OF market incentives in the United States is posing extraordinary challenges to the principles of medical professionalism. Physicians’ commitment to altruism, putting the interests of the patients first, scientific integrity, and an absence of bias in medical decision making now regularly come up against financial conflicts of interest. Arguably, the most challenging and extensive of these conflicts emanate from relationships between physicians and pharmaceutical companies and medical device manufacturers.

As part of the health care industry, pharmaceutical and medical device manufacturers promote the welfare of patients through their commitment to research and product development. Their investments in discovering, developing, and distributing new pharmaceutical agents and medical devices have benefited countless patients. Most companies also support continuing medical education (CME). How- ever, their ultimate fiduciary responsibility is to their shareholders who expect reasonable returns on their investments. Indeed, manufacturers are acutely aware of the conflict between patient vulnerability and profit incentives.

Recent congressional investigations, federal prosecutions, and class achtion lawsuits have brought to light documents demonstrating how company practices frequently cross the line between patient welfare and profit-seeking behavior. Concerned physicians, journalists, and federal prosecutors are exposing still other aspects of an unhealthy relationship between manufacturers and the medical profession. These transgressions have prompted pharmaceutical firms to regulate themselves more stringently. That effort is commendable, but physicians’ behavior is a large part of the problem and industry efforts to date have not resolved the crisis. The standing of the profession, as much as the integrity of the pharmaceutical and medical device industries, is jeopardized by allowing obvious conflicts to continue.

The serious threat that this state of affairs poses for professionalism, and for the trust that patients have in physicians, makes the need for effective guidelines on industry-physician relationships both apparent and urgent. Marketing and market values should not be allowed to undermine physicians’ commitment to their patient’s best interest or to scientific integrity.
To remedy the situation and pre- vent future compromises to professional integrity, academic medical centers (AMCs) must more strongly regulate, and in some cases prohibit, many common practices that constitute conflicts of interest with drug and medical device companies. The guidelines we suggest are designed to promote broader professional self- regulation.

Why AMCs?
Academic medical centers, which include medical schools and their affiliated hospitals, should provide leadership for medicine in the United States. Just as pharmaceutical manufacturers look to AMCs for influential advice and support, so does the medical profession. Academic medical centers also have a major responsibility for training medical students and house staff. Research reveals that the habits learned or acquired during training persist into practice. Objectivity and scientific integrity should be central tenets of physician training. Academic medical centers are also in a position to take immediate action. They are sufficiently well organized to gain commitments to a set of new principles in relatively short time. Moreover, independent research into the impact of medications and devices on population health is concentrated in AMCs; therefore, unwarranted influence by manufacturers must be avoided. For these reasons, academic medicine should take the leadership in reforms, and other physicians and medical institutions should adopt their standards.

Defining Conflicts of Interest With Industry
Conflicts of interest occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician’s roles are or will be compromised. In terms of industry influences, financial conflicts of interest occur when physicians are tempted to deviate or do deviate from their professional obligations for economic or other personal gain. The bias thus introduced violates both the best interests of patients and the standards of scientific integrity. Policing such conflicts clearly lies within the scope of professional responsibilities set forth in the Physician Charter on Medical Professionalism.
Traditionally, marketing by pharmaceutical and device companies has centered on company representatives or “detail persons” who visit individual physicians and provide information on new products. This practice has increased in scale and many other marketing strategies are also used. Approximately 90% of the $21 billion marketing budget of the pharmaceutical industry continues to be directed at physicians, despite a dramatic increase in direct-to-consumer advertising. In 2000, for example, the industry sponsored 314 000 events specifically for physicians. Moreover, industry contracted with many hundreds of physicians to serve on advisory boards or speakers bureaus. The purpose behind such industry contacts with physicians is unmistakable: drug companies are attempting to promote the use of their products.

The following list, while not exhaustive, indicates the interactions with industry that must be addressed: gifts, even of relatively small items, including meals; payment for attendance at lectures and conferences, including on- line activities; CME for which physicians pay no fee; payment for time while attending meetings; payment for travel to meetings or scholarships to attend meetings; payment for participation in speakers bureaus; the provision of ghostwriting services; provision of pharmaceutical samples; grants for research projects; and payment for consulting relationships.

These interactions have been examined by a variety of physician and industry groups, including the American Medical Association, the American College of Physicians, the Accreditation Council for Continuing Medical Education (ACCME), and the Pharmaceutical Research and Manufacturers of America. The Office of the Inspector General of the Department of Health and Human Services has also released guidelines endorsing the Pharmaceutical Research and Manufacturers of America code. In our view, the guidelines produced by these various groups and organizations are not sufficiently stringent and do not adequately uphold a professional commitment to patient welfare and research integrity. None of these groups establishes monitoring mechanisms or pinpoints responsibility for compliance. The profession itself must exert much tighter control over the relationships between manufacturers and physicians.

Myths of the Small Gifts and Full Disclosures
Most of the recommendations from medical and industry groups share 2 key assumptions. The first is that small gifts do not significantly influence physician behavior. The second is that disclosure of financial conflicts is sufficient to satisfy the need to protect patients’ interests. Although these 2 assumptions are widely accepted among physicians, compelling research findings using a variety of methods have called their validity into question.
Psychologists, sociologists, and economists have explored human behavior in a conflicted situation using innovative experimental techniques.15 Their research has established that behavior is not entirely rational, individuals are not always conscious of their motives, and many popular beliefs about how individuals act in light of specific information are simply wrong. Social science research demonstrates that the impulse to reciprocate for even small gifts is a powerful influence on people’s behavior. Individuals receiving gifts are often unable to remain objective; they reweigh information and choices in light of the gift. So too, those people who give or accept gifts with no explicit “strings attached” still carry an expectation of some kind of reciprocity. Indeed, researchers suggest that the expectation of reciprocity may be the primary motive for gift-giving.
Researchers have specifically studied industry gifts to physicians. Receiving gifts is associated with positive physician attitudes toward pharmaceutical representatives. Physicians who request additions to hospital drug formularies are far more likely to have accepted free meals or travel funds from drug manufacturers. The rate of drug prescriptions by physicians increases substantially after they see sales representatives, attend company-supported symposia, or accept samples. The systematic review of the medical literature on gifting by Wazana found that an overwhelming majority of interactions had negative results on clinical care.

The assumption that disclosure to patients is sufficient to resolve problems created by physicians’ conflicts of interest is also unfounded. First, physicians differ in what they consider to be a conflict, which makes the disclosure of conflicts incomplete. Because declarations of conflict are usually unverified, their accuracy is uncertain. Second, recipients of information who are not experts in a particular field often find it impossible to identify a biased opinion that they read or hear about that subject. Third, disclosure may be used to “sanitize” a problematic situation, suggesting that no ill effects will follow from the disclosed relationship. Rather than eliminate the conflict, it is easier to disclose it and then proceed as though it did not exist.

More Stringent Regulation
Because gifts of even minimal value carry influence and because disclosure is an inadequate safeguard, the guidance presently provided by the medical profession, the pharmaceutical industry, and the federal government fails to protect the best interests of patients and the integrity of physician decision making. For these reasons, many current practices should be prohibited and others should be more strictly regulated to eliminate potential sources of unwarranted influence.

Gifting: All gifts (zero dollar limit), free meals, payment for time for travel to or time at meetings, and payment for participation in online CME from drug and medical device companies to physicians should be prohibited. A complete ban on these activities by eliminating potential gray areas greatly eases the burden of compliance. It also frees physicians from deciding whether a gift is appropriate and removes a principal mode by which detail persons gain access to physicians’ offices and influence their decision making.

Pharmaceutical Samples: The direct provision of pharmaceutical samples to physicians should be prohibited and replaced by a system of vouchers for low-income patients or other arrangements that distance the company and its products from the physician. The availability of free samples is a powerful inducement for physicians and patients to rely on medications that are expensive but not more effective. Samples also provide company representatives with access to physicians. The increasing reliance on direct-to-consumer advertising by drug companies only heightens the tension between current marketing practices and good patient care. Drug companies believe that the interactions between sales representatives and physicians serve several purposes, which include introduction of physicians to new medications, encouragement to use the most effective medications, improvement of the likelihood that they will follow good practice guidelines, and access to medications for low-income patients. From the perspective of medical professionalism, however, far better methods for securing these goals exist, all of which would be free of the pitfalls of marketing strategies.

Drug Formularies: Hospital and medical group formulary committees and committees overseeing purchases of medical devices should exclude physicians (and all health care professionals) with financial relationships with drug manufacturers, including those who receive any gift, inducement, grant, or contract. These policies would help ensure that decision making for formulary drugs and medical devices is based solely on the best available scientific evidence.

Continuing Medical Education: The widespread influence of drug manufacturers on current CME activities makes more stringent regulation necessary. Manufacturers should not be permitted to provide support directly or indirectly through a subsidiary agency to any ACCME-accredited pro- gram. Manufacturers wishing to support education for medical students, residents, and/or practicing physicians should contribute to a central repository (eg, a designated office at an AMC), which, in turn, would disburse funds to ACCME-approved programs. This arrangement would permit the central repository and the ultimate recipients of funds to remain free from influence by any one donor company. To ensure accountability and to acknowledge generosity, the amount of funds contributed and the eventual use of the funds should be posted on a publicly available Web site.This policy would likely reduce the contributions made by drug and device companies to CME programs. Companies acknowledge that they carefully evaluate the market impact of expenditures and support only those demonstrating an increased use of their products. Other ways of funding CME programs will have to be identified.

Funds for Physician Travel: Pharmaceutical and device manufacturers interested in having faculty or fellows attend meetings should provide grants to a central office at the AMC. That office could then disburse funds to faculty and training program directors. Trainees would no longer be directly dependent on industry largesse for educational opportunities.

Speakers Bureaus and Ghostwriting: Faculty at AMCs should not serve as members of speakers bureaus for pharmaceutical or device manufacturers. Speakers bureaus are an extension of manufacturers’ marketing apparatus. Because AMC faculty have a central role in the training of new physicians and represent their own institution, they should not function as paid marketers or spokespersons for medicine-related industries. By adhering to this recommendation, academic leaders will be upholding the principle that faculty opinion should be data driven and not for hire. For these same reasons, faculty should be prohibited from publishing articles and editorials that are ghostwritten by industry employees.

Consulting and Research Contracts: Because the process of discovery and development of new drugs and devices often depends on input from academic medicine, consulting with or accepting research support from industry should not be prohibited. However, to ensure scientific integrity, far greater transparency and more open communication are necessary. Accordingly, consulting or honoraria for speaking should always take place with an explicit contract with specific deliver- ables, and the deliverables should be restricted to scientific issues, not marketing efforts. So-called “no strings attached” grants or gifts to individual researchers should be prohibited. A contract with no identified deliver- ables is tantamount to a gift and should be regarded as such. To promote scientific progress, AMCs should be able to accept grants for general support of research (no specific deliverable products) from pharmaceutical and device companies, provided that the grants are not designated for use by specific individuals. As long as the institution stands between the individual investigator and the company making the grant, the likelihood of undue influence is minimized but certainly not eliminated. To better ensure independence, scientific integrity, and full transparency, consulting agreements and unconditional grants should be posted on a publicly available Internet site, ideally at the academic institution. This is important because company-funded research is more likely to produce positive results and on occasion companies have restricted the dissemination of research results unfavorable to their products. One might argue that such an approach simply transfers the pressure surrounding financial conflicts to the institution and, as in the case of Oliveri at the University of Toronto, institutions have given in to pressure from pharmaceutical firms. But the requirements of public access and peer pressure will more effectively operate at the institutional level and such a policy is preferable to banning all contact between manufacturers and academic centers.

Going Forward
The benefits of such policies may convince the leadership of AMCs and medical schools to adopt them. We realize that some AMCs will be concerned that voluntarily adopting more stringent regulations may put them at a competitive disadvantage compared with those that do not. However, we hope their leadership will recognize that we call for changes in current AMC practices that are, in many respects, modest. For example, existing guidelines prohibit all gifts from industry except those that are small; going one step further and eliminating token gifts should not cause great disruption and may bring greater clarity. Grants and consulting are not prohibited but must be transparent and subject to peer review. Although such steps may cause significant challenges for medical schools and affiliated institutions, students, physicians, and the public deserve unbiased medical education, research, and clinical care. Industry has good reason to accommodate itself to these policies and will continue to seek assistance from academic consultants and researchers. Commercial entities working with AMCs cannot be pleased about the diminished respect and growing public mistrust of their activities in the current environment. Medical schools must be prepared to monitor compliance and enforce the rules we have outlined. There will be costs associated with oversight and perhaps a decline of collegiality among faculty. But these negative aspects will depend to some extent on the prevalence of violations. If AMC leaders educate colleagues and build a consensus around these principles, compliance will follow.

What then might the world of medicine look like if these proposals are widely adopted? First, decisions by physicians on which prescription to write and which device to use might become more evidence-based; medical societies’ practice guidelines might be- come less subject to bias. A greater reliance on objective sources for accurate and up-to-date information would also promote better patient outcomes. Second, total expenditures on prescription drugs might decline. An in- creased use of generic products, in- creased use of comparable but less expensive patent-protected products, and, in some cases, a decreased reliance on pharmaceutical agents might be observed. Third, although AMCs and professional societies would have to find alternative sources for funding programs, the absence of industry representatives at AMC meetings and lunches and in corridors would increase the sensitivity among medical students and house staff to the values of medical professionalism and scientific integrity. Rules would be standardized, not, as now, with some departments prohibiting drug company lunches, others allowing them; some hospitals permitting the sales representatives to see their physicians, others not. Medical society meetings would also assume a more professional tone and the substance of the programs would become more scientific. Ultimately, the implementation of these proposals will substantially reduce the need for external regulation to safeguard against market-driven conflicts of interest, and the medical profession will reaffirm very publicly its commitment to put the interests of patients first.

REFERENCES
1. Schafer A. Biomedical conflicts of interest: a defense of the sequestration thesis-learning from the cases of Nancy Oliveri and David Healy. J Med Ethics. 2004; 30:8-24.
2. Studdert DM, Mello MM, Brennan TA. Financial conflict of interest in physician relationships with the pharmaceutical industry: self-regulation in the shadow of federal prosecution. N Engl J Med. 2004; 351:1891-1900.
3. Matthews AW, Martinez B. Emails suggest Merck knew Vioxx’s dangers at early stage. Wall Street Jour- nal. November 1, 2004:A1.
4. Kassirer JP. Why should we swallow what these studies say? Washington Post. August 1, 2004; Outlook:B3.
5. Kassirer J. On the Take: How Medicine’s Complic- ity With Big Business Can Endanger Your Health. New York, NY: Oxford University Press; 2004.
6. Angell M. The Truth About Drug Companies. New York, NY: Random House; 2004.
7. Avorn J. Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs. New York, NY: Knopf; 2004. 8. McCormick BB, Tomlinson G, Brill-Edwards P, Detsky AS. Effect of restricting contact between pharmaceu- tical company representatives and internal medicine residents on post-training attitudes and behavior. JAMA. 2001;286:1994-1999.
9. Erde EL. Conflicts of interest in medicine: a philo- sophical and ethical morphology. In: Speece RG, Shimm DS, Buchanan AE, eds. Conflicts of Interest in Clini- cal Practice and Research. New York, NY: Oxford Uni- versity Press; 1996:12-41.
10. American Board of Internal Medicine Foundation; American College of Physicians-American Society of Internal Medicine Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-246.
11. Blank L, Kimball H, McDonald W, Merino J. Medi- cal professionalism in the new millennium: a physi- cian charter 15 months later. Ann Intern Med. 2003; 138:839-841.
12. Kerber R. Drug makers target consumers with their ads. Boston Globe. March 10, 2004:C1.
13. The National Institute for Health Care Manage- ment Research and Educational Foundation. Prescrip- tion drugs and mass media advertising, 2000. Avail- able at: http://www.nihcm.org/finalweb /DTCbrief2001.pdf. Accessibility verified January 3, 2006.
14. Blumenthal D. Doctors and drug companies. N Engl J Med. 2004;351:1885-1890.
15. Cain DM, Loewenstein G, Moore DA. The dirt on coming clean: possible effects of disclosing conflicts of interest. J Legal Stud. 2005;34:1-24.
16. Cialdini RB. Influence: Science and Practice. New York, NY: Harper Collins College Publishers; 1993:21.
17. Dana J, Loewenstein G. A social science perspec- tive on gifts to physicians from industry. JAMA. 2003; 290:252-255.
18. Sandberg WS, Carlos R, Sandberg EH, Roizen MF. The effect of educational gifts from pharmaceutical firms on medical students’ recall of company names of products. Acad Med. 1997;72:916-918.
19. Brotzman GL, Mark DH. Policies regulating the activities of pharmaceutical representatives in resi- dency programs. J Fam Pract. 1992;34:54-57.
20. Chren MM, Landefeld CS. Physicians’ behavior and their interactions with drug companies: a con- trolled study of physicians who requested additions to a hospital drug formulary. JAMA. 1994;271: 684-689.
21. Lurie N, Rich EC, Simpson DE, et al. Pharmaceu- tical representatives in academic medical centers. J Gen Intern Med. 1990;5:240-243.
22. Orlowski JP, Wateska L. The effects of pharma- ceutical firm enticements on physician prescribing pat- terns: there’s no such thing as a free lunch. Chest. 1992; 102:270-273.
23. Peay MY, Peay ER. The role of commercial sources in the adoption of a new drug. Soc Sci Med. 1988;26: 1183-1189.
24. Cleary JD. Impact of pharmaceutical sales repre- sentatives on physician antibiotic prescribing. J Pharm Technol. 1992;8:27-29.
25. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283: 373-380.
26. Surowiecki J. The talking cure. The New Yorker. December 9, 2002:54.
27. Bowman MA, Pearle DL. Changes in drug pre- scribing patterns related to commercial company fund- ing of continuing medical education. J Contin Educ Health Prof. 1988;8:13-20.
28. The Pharmaceutical Research and Manufactur- ers of America (PhRMA). HHS OIG compliance pro- gram guidance for the pharmaceutical industry: key insights from regulators and compliance experts. In: PhRMA Congress Conference, Spring 2003; June 8-9, 2003; Washington, DC.
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30. Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical re- search: a systematic review. JAMA. 2003;289:454- 463.
31. Gibson E, Baylis F, Lewis S. Dances with the phar- maceutical industry. CMAJ. 2002;166:448-450.
32. Lipton S, Boyd EA, Bero L. Conflicts of interest in academic research: policies, processes and attitudes. Account Res. 2004;11:83-102.

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Ethics 1

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This tutorial is worth 3 CEU’s. The 2013 ethics tutorials will cost R200 for 2 ethics tutorials (R400 in total for all 4). Complete the questionnaire at the end of the tutorial and get 70% or more. Once the payment has been received we will email the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays and may take up to 24 hours

Last year was marked by high profile international doping scandals. Things hit closer to home when on 6 November, cycling South Africa announced the suspension of professional cyclist David George after he tested positive for the banned substance Erythropoietin (EPO). Doping is an ethical dilemma that ‘rocks’ the very base of competitive sport. the following tutorial will examine these ethical considerations and take an in depth look at banned substances, their abuse and methods to combat this in professional sport.

History

‘When humans compete against one another, either in war, in business, or in sport, the competitors, by definition, seek to achieve an advantage over their opponent. Frequently they use drugs and other substances to gain the upper hand. Furthermore, there have always been individuals who in the pursuit of victory have transcended social norms.’ Charles E. Yesalis

While doping has gained more recognition and press in recent times it is by no means a current phenomenon. The use of drugs in sports has had a long and well documented history going as far back as Greek and Roman times where Early Olympians used extracts of mushrooms and plant seeds and Gladiators took substances to make their fights more vigorous and bloody.

In the last third of the nineteenth century, the use of stimulants among athletes was commonplace, and moreover, there was no attempt to conceal drug usage. Swimmers, distance runners, sprinters and cyclists used a wide assortment of drugs including strychnine, cocaine, caffeine and alcohol, to gain an edge over their opponents. 1886 marked the first recorded doping death with cyclist Arthur Linton overdosing on trimethyl. This was followed, in 1904, by the near death of Marathon runner Thomas Hicks at the Olympics in St Louis after mixing brandy and strychnine.

The 1930s marked the advent of Amphetamines which were created by the military to assist pilots and soldiers. By 1933 the word doping had become part of the English language. At the Rome Olympics (1960) amphetamine-taking Danish cyclist Knut Jensen collapsed, fractured his skull and died. This was followed in the 1967 Tour de France by another amphetamine death when Britain’s Tommy Simpson died of dehydration as a result. In response to this, Jacques Anquetil, a five-time winner of the Tour de France, stated: ‘For 50 years bike racers have been taking stimulants. Obviously we can do without them in a race, but then we will pedal 15 miles an hour [instead of 25]. Since we are constantly asked to go faster and to make even greater efforts, we are obliged to take stimulants’

In the 1950s the Soviets begin to use male hormones and the commencement of systematic use of anabolic steroids in sport has been largely attributed to the massively successful Soviet weightlifting teams in the early 1950s. Statistical analysis of the performance of the Soviet lifters during this period is consistent with anabolic steroid usage. The 1976 Olympics marked The culmination of a decades long series of documented clinical trials in The Germany Democratic Republic utilizing anabolic steroids on their athletes. It is estimated that some 9,000 former athletes, perhaps more, were doped, often unwittingly, in the program. Due to obvious ethical constraints this to date, remains one of the few documented, systematic reviews of performance enhancing drugs. Under a national plan, “State Plan 14.25,” the East German government “called for the administering of male hormones to male and female athletes.” The swimmers, and many other Olympic athletes, took the German manufactured steroid Oral-Turinabol, often believing they were vitamins. As a result in 1976 East German swimmers won 11 out of 13 Olympic events. The documented effects of this program down the line include: cancer, ovarian cysts, liver damage, heart disease, infertility and other ailments. Victims of the East German doping program were financially compensated after an extended legal battle in 2000. It may be a rather cynical sentiment, but doping trends in professional sport seem to suggest athletes will disregard the health risks in order to excel. It would be interesting to see how many of the athlete’s involved, would have willingly chosen to be part of the program to gain the high level of performance documented in the studies.

1972 marked a new era for doping when a Swedish doctor, Björn Ekblom, pioneered ‘blood doping’ which entailed removing blood, increasing the concentration of red blood cells in a centrifuge and then restoring it through transfusion. This obviously enhanced the oxygen transportation capacity of the blood. This was given further impotence in the late 80’s with the development of Erythropoietin (EPO) which effectively enhances red blood cell production.

And so begins a fairly consistent tale of drug test failures of professional, high profile athletes. Notables include: Ben Johnson – Seoul Olympics (1988). Diego Maradona – Soccer World Cup (1994). Linford Christie (1999)

The 2000s are dominated by numerous high profile cycling busts, culminating in the ban for life and stripping of all titles, of 7 time Tour de France winner, Lance Armstrong. His doping strategies were termed “the most sophisticated, professionalized and successful doping program cycling has ever seen” by the US anti doping agency and highlight the extent to which professional sport people are willing to go in order to excel.

Estimates of doping prevalence varies massively according to the research. The simple answer is nobody knows. Estimates range from the World-Anti Doping Agency (WADA) official statistic of 2% right up to 35% depending on the approach. When athletes are asked about doping statistics, they guess around 10%. A recent German study showed that actual doping rates were eight times the positive test rate, so in the case of WADA’s 2% one could estimate a rate of 16% of athletes doping. Based on WADA’s, likely very low statistics, that means at least 200 (of the 10,000 or so) athletes in London were doping. If the German statistics hold true, this figure moves to 1600.

The International Association of Athletics Federations (IAAF) became the first International Sporting Federation to prohibit doping, doing so in 1928. However, soon after World War II with the advent of amphetamines, it became clear that many athletes in a wide range of sports were using drugs to enhance their performance. The aforementioned death of cyclists 1960 and 1967, as a result of drugs, brought doping into the public spotlight. as a result, the International Olympic Committee approved a ban on doping in 1968. The Committee defined the first list of Prohibited Substances and the first tests for stimulants were performed at the Winter Olympics in 1968. Steroids only became detectable in 1974. At the same time International Sports Federations initiated doping controls and the IAAF became the first to perform out-of-competition tests. Subsequently national Anti-Doping Agencies instituted doping controls and testing within their borders. Our local agency, the South African Institute for Drug Free Sport is responsible for testing within South Africa.

On 08/07/1998 the world was rocked by a doping scandal when Willy Voet, a masseur for the Festina cycling team was stopped at the Franco-Belgium border during the Tour de France. He was found to be in possession of more than 400 doping products. As a result of this and numerous other doping scandals, The World Anti- Doping Agency (WADA) was created in 1999 to harmonize and strengthen anti-doping actions and rules across all sports and countries. WADA also took over the role of publishing the list of Prohibited Substances, which is continually under review and formally updated on 1 January each year.

Doping Testing Procedures

As mentioned above the national anti-doping agencies are responsible for the testing procedures. They develop a Test Distribution Plan according to:
1) Physical demands of the sport and possible performance-enhancing effect that doping may elicit
2) Available doping analysis statistics
3) Available research on doping trends
4) The history of doping in the sport and/or discipline
5)Training periods and the competition calendar
6) Information received on possible doping practices

Athletes may be tested either in or out of competition. An example of how athletes would be selected for in competition or event testing could be: Placed finishers, such as the top three finishers and randomly selected athletes, such as 5th, 7th, 12th, 18th, 19th, etc. Out of competition testing occurs according to the above criteria of the Test Distribution plan. Athletes who are part of the Testing Pool must provide a 60-minute time slot each day between 6 a.m. – 11p.m. Athletes, have to be available for testing without any advance notice in an out-of-competition setting and are subject to testing 365 days a year and do not have “off-seasons” or cutoff periods in which testing does not occur.

Currently Blood and urine samples are taken for lab testing. Through regular testing an athlete’s biological passport is created. This is basically an accurate Indicator of the athlete’s personal parameters. It is the equivalent of a physiological fingerprint. This allows anti-doping agency to quickly recognize if an athlete is utilizing performance enhancing substances when their test results stray outside of their normal criteria. Laboratory results that compared samples taken during Lance Armstrong’s return to cycling in the 2009 Tour de France to his biological passport, strongly point to his use of blood manipulation, including EPO or blood transfusions.

Anti-doping agencies are increasingly utilizing ‘intelligence’ gained from team members, other athletes, medical staff etc. to optimize their testing resources and to convict athletes transgressing the rules. Lance Armstrong is a case in point. The current evidence against Armstrong derives largely from the fact that 12 of his former teammates and support team gave evidence that Armstrong was centrally involved in systematic doping in the teams he was part of. He either admitted to them, or they directly observed him using and encouraged them to use: erythropoietin, blood transfusion, cortisone, testosterone and human growth hormone from 1996 to 2005. For this, Armstrong was charged by the US Anti-Doping Agency with possession, distribution, use, administration and trafficking in prohibited substances. Additionally, he was charged with assisting, encouraging, aiding, abetting, covering up and other complicity in anti-doping rule violations. Olympic Gold medallist Marion Jones is another example. She was tested as frequently as Armstrong, but did not return a single positive test. She was found guilty and banned as a result of the BALCO scandal which uncovered systematic doping, largely by US athletes, using “designer steroids” that avoided detection. This wes only discovered through good intelligence work.

Common Substances and side effects

In 2008, Bernard Kohl who placed 3rd in the Tour de France tested positive for CERA (EPO) and was banned for 2 years. After being found guilty, Kohl handed over his ‘doping diary’, revealing the extent and level of doping in professional cycling.

“I was tested 200 times during my career, and 100 times I had drugs in my body,” he said, according to the New York Times. “I was caught, but 99 other times, I wasn’t. Riders think they can get away with doping because most of the time they do. Even if there is a new test for blood doping, I’m not even sure it will scare riders into stopping. The problem is just that bad.”

“People know in cycling that’s it’s not possible to win the Tour de France without it. It’s three weeks, 3,000 km and you climb Mount Everest four times. That’s just not possible.”

When asked in 2010, whether Alberto Contador had used doped to win the Tour de France, Kohl wouldn’t directly speculate but noted that the average speeds ridden at the Tour might cause one to think so.

“Floyd Landis won the Tour de France and his average speed was 40 kph,” Kohl said. “This year it was Contador and it was also about 40. It was nearly the same average speed. Landis was doped.”

Interestingly, after a protracted battle, on february 6 this year, Contador was stripped of his 2010 title after testing positive for Clenbutarol.

In a scientifically designed doping program aimed at maximally enhancing performance and more importantly avoiding detection, Kohl’s admitted to using blood transfusions, EPO, anabolic steroids, cortisone, human growth hormone, insulin, HCG, thyroid hormone, and designer testosterone.

Substances are prohibited if they meet at least two of the following criteria:

1)Potential to enhance sports performance
2) Actual or potential health risk to an athlete
3) Its use violates the spirit of sport.

The following list is far from exhaustive but gives a brief glimpse into some of the commonly used doping substances and their effects / side effects.

ACTH or Corticotrophin
ACTH or Adreno-cortical stimulating hormone, stimulates the adrenal grand to produce cortisol, a natural steroidal hormonal with multiple physiological effects including anti-inflammatory properties to facilitate recovery.

Possible side effects: Water retention, edema, Hyperglycemia, Blood hypertension, Osteoporosis, Decrease in resistance to infections

Amphetamines
Amphetamines were first synthesized in 1887. The effects of the drug include a sense of well-being, a decrease in the perception of fatigue, an increase in self-confidence, in motor function and a decrease in appetite. As there are no positive long term effects, amphetamines are usually consumed just prior to competition. Due to their effects (perceived and real) they are very addictive.

Possible side effects: Confusion, Tremors, Delirium, Psychosis, Paranoid delirium, Insomnia, Nausea, Vomiting

Anabolic substances (steroids)
This class of doping substances includes all steroids that possess anabolic properties including testosterone. This in essence means they cause a marked, non-isolated increase in the muscular mass. In sports such as weightlifting and bodybuilding, these substances are often used in weeks preceding a competition. Cyclists seem to use anabolic substances in smaller quantities to facilitate muscular recovery. The side effects associated with the extensive of anabolic steroids have been scientifically observed and documented:

Possible side effects: Anomalies in the function of the liver and liver cancer, Hypercholesterolemia, prostate cancer, myocardial infarction, Diabetes, testicular atrophy, Feminization : gynecomastia (breast development in men) and high-pitched, castrato-like voice, Behavioral modifications including aggressiveness and groundless violence, Acne, Muscular rupture, Hair loss, Irreversible virilization or masculinization in women including Husky voice and Hirsutism (appearance of body hair in regions that are normally hairless.

Beta-blockers
They are beta receptor antagonists that prevent binding of adrenaline in adrenergic beta receptors. Beta blockers can be misused in certain sports, for example shooting, archery and golf to control the effects of nervousness, hand tremor and high heart rate

Possible side effects. The undesirable effects of beta-blockers stem from their inhibitory properties. Issues may include: bronchial spasms, Hypoglycemia, Troubles with digestion, Cardiac insufficiency, Cardiac rhythm problems

Codeine, opiates and other morphine derivatives
The use of pain killers is frequent in all sports. Professional obligations often necessitate competing with injuries.

Possible side effects: Addiction, Nausea, Vomiting, Withdrawal syndrome

Corticosteroids
Corticosterioids are potent systemic anti-inflammatory and immunosuprresant. There is a long and well documented history of corticosteriod abuse amongst sport people.

Possible side effects: side effects are numerous and serious.

Erythropoietin
Erythropoietin (often shortened to EPO) is a naturally occurring hormone, secreted by the kidneys, whose function is to regulate red blood cell production. It effectively stimulates bone marrow to produce more red blood cells (RBC) and therefore haemoglobin. The use of EPO started in the 1980’s as a quicker, cleaner alternative to blood doping. EPO is most commonly used amongst endurance athletes as a higher RBC count means better oxygen transportation and so a higher rate of aerobic respiration and decreased fatigue.
EPO is used in medical practice in cases of severe anemia and during treatment of chronic renal insufficiency, such as in dialysis patients.

Possible side effects: Increased viscosity of the blood with increases the risk of heart attack and stroke. The lack of knowledge regarding dosage and side effects of EPO has been linked to the death of a number of competitive cyclists in the late 80’s.

Chorionic gonadotropin (hCG)
This natural product is classified as a stimulant because it causes an increase in the production of endogenous testosterone. When exogenous anabolic substances are put into the male body, natural negative-feedback loops cause the body to shut down its own production of testosterone. This causes testicular atrophy and decreased endogenous testosterone. hCG is commonly used during and after steroid cycles to maintain and restore testicular size as well as normal testosterone production.

Possible side effects: largely related to excessive testosterone production so similar to anabolic sustances The associated dangers depend on dosage and vary according to sex. May also include Hypertension thrusts when the substance is introduced too rapidly, Vascular thrombosis, Convulsions.

Human growth hormone (hGH)

Growth hormone is used for the anabolic effects. It is thought to increases muscle mass and strength, and helps hasten recovery and repair Uncertainties remain about the safety of exogenous hGH. We still do not know what influence it may have on normal individuals, even though there is a good deal of information about side effects of endogenous hGH hyper secretion in acromegaly. This condition has an associated 50% mortality at age 50 and 89% mortality at age 60. hGH found on the black market may be extractive growth hormone (extracted from the pituitary gland of corpses). The method used to purify the hormone does not guarantee the removal of other biological molecules which can cause adverse reactions

Possible side effects: Tumefaction of soft tissue, arthritis, Thickening of the skin, Hirsutism (hair growth over the entire body), Increase in perspiration, Peripheral neuropathies, Myopathies, Hypertrophy of the viscera : spleen, salivary glands, liver, kidneys, heart, Glucose intolerance / diabetes mellitus

Insulin
Although it’s more usually associated with the regulation of blood glucose, the hormone insulin can also act as a powerful anabolic agent, helping to increase glycogen synthesis and lean muscle mass. Insulin is commonly used in conjunction with the anabolic steroids, obviously due to the anabolic effects but also to decrease the insulin resistance caused by anabolic steroids and growth hormones.

Possible side effects: Tremors, anxiety, myocardial infarction, Numerous drug interactions

Overdose: hypoglycemia may result from poorly estimated insulin dosage, a mistake in feeding or a unforeseen physical effort that is not compensated. The symptoms of hypoglycemia include hunger, sweat, asthenia, tremors, confusion, problems with vision, headaches, etc. Unless treated promptly, hypoglycemia may result in a coma

Drug effects in sport

With the lack of research into many aspects of doping one may assume that numerous athletes are utilizing banned substances in response to a fear that their fellow competitors have a marked advantage over them. Their are however a few fascinating studies that cast light on just how effective doping may be.

Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government Werner W. Franke1* and Brigitte Berendonk2 Clinical Chemistry 43:7 1262–1279 (1997)

“Several classified documents saved after the collapse of the German Democratic Republic (GDR) in 1990 describe the promotion by the government of the use of drugs, notably androgenic steroids, in high performance sports (doping). Top-secret doctoral theses, scientific reports, progress reports of grants, proceedings from symposia of experts, and reports of physicians and scientists who served as unofficial collaborators for the Ministry for State Security (“Stasi”) reveal that from 1966 on, hundreds of physicians and scientists, including top-ranking professors, performed doping research and administered prescription drugs as well as unapproved experimental drug preparations. Several thousand athletes were treated with androgens every year, including minors of each sex. Special emphasis was placed on administering androgens to women and adolescent girls because this practice proved to be particularly effective for sports performance. Damaging side effects were recorded, some of which required surgical or medical intervention. In addition, several prominent scientists and sports physicians of the GDR contributed to the development of methods of drug administration that would evade detection by international doping controls.”

As mentioned previously this remains the only, large scale, scientific reviews of doping in professional sport. It provides obvious graphical data of the effect of androgynous substances on performance of athletes, particularly in the throwing disciplines.

Effects of an androgenic-anabolic steroid, Oral-Turinabol, on the shot-put performance (in meters, y-axis) of a female athlete (code identification 1/68 in a, 1/69 in b, and 1/72 in c) The blocks on the x-axis signify ‘cycles’ of doping with resultant spikes in throwing performance

Decreased performances in women’s strength-dependent events worldwide, after implementation in 1989 of some (though still insufficient) out-of-competition doping controls: ordinates present meters of performance of the world best (upper curve) and the average of the ten best (lower curve) athletes in the javelin throw (A), discus throw (B), and shot-put (C) for the years 1987–1993.

This visible decline in throwing and strength related sport performance after the introduction of random out-of-competition testing is obviously as a result of decreased doping . Decreased is the operative word; today’s best athletes are unlikely to be free from doping but are just doping less and better than previously. Another interesting discovery by GDR scientists was that “androgenic initiation” has permanent effects in girls and women and hence once a higher performance level is reached it does not return to pre-steroid levels on cessation if the doping. In this regard, many of today’s top athletes still profit from their previous doping.

The shot put world record is held by Natalya Lisovskaya of Soviet Union on 7 June 1987 with a throw of 22.63 m.
2004 Olympics: 21.06 m. Gold medalist disqualified for doping

2008: 20.56 m
2012: 21.36m. Gold medalist disqualified for doping

Medvedyev, et.al. did a statistical analysis of the world records established in weightlifting particularly in the snatch and the clean and jerk. The results showed that the rate of improvement of world records in weightlifting accelerated from the period 1967 – 1973 up to 1980. This was followed by an even faster rate of improvement from 1980 up to 1988. The only plausible reason was the widespread use of performance enhancing drugs.As with the throwing disciplines, in the wake of stricter, more sophisticated testing procedures established in 1989 there was an obvious drop in the results at the major world events of 1990 and 1991.

J J Thomsen, et al of the Copenhagen Muscle Research Centre did an interesting study on the effects of EPO on a group of non-professional cyclists. Their results were an eye opener. ‘With rHuEpo (recombinant human erythropoietin) treatment VO2max increased (P<0.05) by 12.6 and 11.6% in week 4 and 11, respectively, and time-to-exhaustion (80% VO2max) was increased by 54.0 and 54.3% (P<0.05) after 4 and 11 weeks of treatment, respectively’

Ethical Considerations

“The use of drug use in sport is both unhealthy and contrary to the ethics of sport. It is necessary to protect the physical and spiritual health of athletes, the values of fair play and of competition, the integrity and the unity of sport, and the rights of those who take part in it at whatever level.” IOC, 1990

“Equal conditions for all” definition of fair play, Oxford English Dictionary.

Beyond the health risks examined earlier, drug use by athletes clearly violates sporting ethical considerations and this remains the largest focus of the anti doping movement. Although it appears that athletes have been using performance enhancing substances for as long as sport has existed, the drive to professionalism and increased financial incentives has certainly blurred the lines. Increasingly athletes seem to have a “cheat-or-lose” philosophy.

The benefit of sport include: character building, dedication, perseverance, endurance and self-discipline. Sport helps us learn from defeat as much as from victory, and team sports facilitate co-operation, imparting moral and social values. It is also about integrating us as individuals, to bring about a healthy society. These considerations have clearly taken a back seat in numerous professional sporting settings. In present day professional sport the pressured on all concerned is immense. An athlete nowadays is faced with meeting expectations of the coach, teammates, family, friends, sponsors and spectators. Coaches are also faced with similar pressure.

Beyond doping being against the ethical ‘idea’ of sport, it goes against the philosophy of “equal conditions for all”. This means sport moves beyond skill levels, training etc. and becomes about who can throw the most resources at the problem. Sport is in essence replaced by a competition between doctors and biochemists and the regulating authorities! One of the more striking ethical considerations as health professionals is how complicit doctors and other health practitioners are in the procurement and provision of banned substances. The violates the basic ethical principles of medicine in many ways. Doctors are willingly providing substances that may well have negative implications on athletes

Pharmaceutical companies are also likely to blame, with many professionals having access to products before they come on the market. There has also been calls from WADA for pharmaceutical companies to place markers in their drugs to assist with testing, to no avail. Although cynical, this likely has a financial reason. In Italy, sales of a certain EPO drug far exceed documented cases of heart disease!

There is an emerging counter argument for the legalization of drugs in sport. Key points of this argument include:
Leveling of the playing field
Higher level of performance and increased spectatorship.
Better control of doping substances

This argument is totally incongruent with the ethical considerations cited earlier. From a health perspective, even if doping were legalized there still would have to be some forms of control and athlete’s would likely still be pushing the boundaries to gain competitive advantage.

Conclusion

The incidence of doping in sport likely exceeds estimations many fold. With increasing incentive to win, both from a fame and financial perspective, the anti-doping sector faces an uphill battle. Until punishments become truly prohibitive (lifetime ban for all guilty parties) and until sporting powers that be stop turning a blind eye and fully co-operate, it is likely to continue to be a battle of resources between sports people and anti-doping agencies.

Accreditation: PPB004-MD271-0120-1-2013

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References (please contact for full list)
1) Medvedyev, A.S., Medvedyev, A. A., Masalgin, N.A., Sarsania, S. K., “Prognosis of World Records in Weightlifting and the Use of Performance Enhancers” Teoriya I Praktika Fizicheskoi Kultury, 8:39 – 43:1994, Translated by Andrew Charniga, Jr.
2) Medvedyev, A.S.,” Prognosis of World Records in Weightlifting”, Teoriya I Praktika Fizicheskoi Kultury, 3:2000, Translated by Andrew Charniga.
3) Charles E. Yesalis, S. Bahrke. History of Doping in Sport, International Sports Studies, vol. 24, no. 1, 2002
4) WADA http://www.wada-ama.org/en/
5) South African Institue for Drug Free Sport http://www.drugfreesport.org.za/
6) Werner W. Franke, Brigitte Berendonk. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government, Clinical Chemistry 43:7 1262–1279 (1997)
7) www.forbes.com
7) www.time.com
9) Gabrielle Russell, Christopher J. Gore, Michael J. Ashenden, Robin Parisotto, Allan G. Hahn. Effects of prolonged low doses of recombinant human erythropoietin during submaximal and maximal exercise, European Journal of Applied Physiology
March 2002, Volume 86, Issue 5, pp 442-449
10) Bowers, Larry D. Abuse of Performance-Enhancing Drugs in Sport, Therapeutic Drug Monitoring: February 2002 – Volume 24 – Issue 1 – pp 178-181