COUNTRYISSN 2256-0580 World Medical Journal Official Journal of The World Medical Association, Inc. Nr. 3, October 2016 vol. 62
Contents
Currently the Earth is a Planet of Plastics ...... 81
Interview with Sir Michael Marmot, President of the World Medical Association ...... 82
Migration of Doctors and Working Time Arrangements from an International Perspective ...... 83
Women in Migration: Beyond Statistics ...... 84
The Growing Threat of Nuclear War and the Role of the Health Community ...... 86
WMA Calls on Governments to Ban and Eliminate Nuclear Weapons ...... 95
The Value of Resiliency Training in Postgraduate Medical Education ...... 95
The Role of Physicians Fighting Children Trafficking and Illegal Adoptions: the Use of Genetic Identification ...... 96
Why Should the World Medical Association not Change its Policy towards Euthanasia? ...... 99
Voluntary Euthanasia and Physician-assisted Suicide: Should the WMA Drop its Opposition? ...... 103
One Health and Antimicrobial Resistance ...... 108
Global Development of Medical Science and Publication Opportunities and Challenges ...... 112
Southeast European Medical Forum ...... 114
Paul Cibrie: Defending the Medical Profession in the Age of Internationalization . . . . . 117
Introduction to work at COP22 ...... 119 World Medical Association Officers, Chairpersons and Officials
Sir Michael MARMOT Dr . Xavier DEAU Dr . Heikki PÄLVE Dr . Otmar KLOIBER WMA President WMA Immediate Past-President WMA Chairperson of the Medical Secretary General British Medical Association Conseil National de l’Ordre des Ethics Committee World Medical Association BMA House, Tavistock Square Médecins (CNOM) Finnish Medical Association 13 chemin du Levant London WC1H 9JP 180, Blvd. Haussmann P.O. Box 49 01212 Ferney-Voltaire United Kingdom 75389 Paris Cedex 08 00501 Helsinki France France Finland
Dr . Donchun SHIN Dr . Joseph HEYMAN Dr . Miguel Roberto JORGE WMA Chairperson of the Finance WMA Chairperson WMA Chairperson of the Socio- and Planning Committee of the Associate Members Medical Affairs Committee Korean Medical Association 163 Middle Street Brazilian Medical Association 46-gil Ichon-ro West Newbury, Massachusetts 01985 Rua-Sao Carlos do Pinhal 324, Yongsan-gu, Seoul 140-721 United States CEP-01333-903 Sao Paulo-SP Korea Brazil
Prof . Dr . Frank Ulrich Dr . Masami ISHII Dr . Ardis D . HOVEN MONTGOMERY WMA Treasurer WMA Chairperson of Council WMA Vice-Chairperson of Council Japan Medical Assn American Medical Association Bundesärztekammer 2-28-16 Honkomagome AMA Plaza, 330 N. Wabash, Herbert-Lewin-Platz 1 (Wegelystrasse) Bunkyo-ku Suite 39300 10623 Berlin Tokyo 113-8621 60611-5885 Chicago, Illinois Germany Japan United States
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Official Journal of The World Medical Association Editor in Chief Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia Phone +371 67 220 661 [email protected], [email protected]
Co-Editor Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor Maira Sudraba, Velta Pozņaka; [email protected]
Journal design and cover design by Pēteris Gricenko
Layout and Artwork The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher The Latvian Medical Association, “Latvijas Ārstu biedrība”, Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions Currently the Earth is a Planet of Plastics
Plastic is known to mankind for more than 100 years, and it has be- burnt down and polluted the atmosphere with poisonous smoke, come part of our lives. It is hard to picture how many times per day thereby destroying the ozone layer, which is our sole shield against each of us has something to do with plastics. Plastics are produced in the solar and cosmic radiation. the form of resin from oil, natural gas and coal, while there are also plastics of biological origin. Elements can be arranged around carbon Plastics can be recycled 10-15 times. Umbrellas, backpacks, carpets, in a number of ways to obtain the necessary properties for the plastic. blazers, artificial cobble stones, covers for mobile phones and new PET bottles are made of recycled PET bottles. However, currently Globally, right now the four main health concerns for mankind are: it is about 12% of plastics that get recycled, while the rest is buried in 1. global heating and pollution of the planet; landfills, and the major part, especially plastic bags, end up in environ- 2. agents impeding the development of hormonal system, the ment, because part of people still are not aware that a forest, a mead- planet as a “chemical warfare”; ow or a desert, mountains or roadside is not a dumpsite. Large part 3. shortage of potable water; of plastics gets into waters and further on to seas and oceans. Most of 4. social determinacy problems and inaccessibility to health care this polluting plastic is various types of film, packets and boxes. services The main pollutants of environment are 15–50 micron thick plastic As to plastics, global doctors focus on two aspects – the world is being bags, usually available free of charge in shops. They constitute higher polluted with plastics to such an extent that the global ocean will soon environmental risk than thicker bags, because are no used repeat- be kind of plastic soup, as well as bisphenols, phthalates, brominated edly – in 89% of occasions they are discarded after one-time use. flame retardants that are serious disruptors of hormonal system. These bags quickly disintegrate in small pieces and are blown by the wind till end up in water bodies. The 15–50 micron plastic bags have Plastics contain BPA or bisphenol, and most of plastics release it when been found in the stomachs of all water birds. heated. Bisphenols make plastics harder and more endurable. Bisphe- nol A is an agent impeding the functioning of glands of internal secre- According to different estimates, 500–700 billion of plastic bags are tion; technically it is artificial oestrogen (the female hormone) which used annually worldwide. No less than one third ends up in environ- can get from a plastic bottle (including baby bottles) or a vessel into ment or ocean. The sources of ocean waste are rivers, contributing 80%, food or water. As artificial oestrogen, it affects the development of foe- and vessels, contributing the remaining 20%. The UN Environmental tus of both sexes, hampers the development of hormonal system and Programme has estimated each square mile of ocean water to contain contributes to the development of breast and prostate tumours. 46,000 floating items of waste, mainly of plastic origin. At this mo- ment, the ocean is kind of plastic soup consisting of plastic objects of It is the production of testosterone and sperm quality for males, various sizes and their remains, and forming a layer of waste with dif- increases the insulin resistance and promotes obesity. ferent density from the surface of the ocean down to the very bottom.
Phthalates are chemical substances that are added to plastics to Plastic piles up mainly in ocean gyres, which is water vortex limited make it flexible, as well as for other organoleptic reasons. Phthal- by currents, formed under no wind and high atmospheric pressure. ates cause damage to reproduction organs of foetus, damages DNS Vortex keeps the plastic soup in continuous motion. The largest in sperm, damages liver, kidneys and lungs, causes inborn defects, gyre, North Pacific Gyre, between 1350–1550 west longitude and anaemia, infertility and cancer. They have a serious impact on male 250–450 north latitude, is a 1760.000 square kilometres large field potency and inhibit spermatogenesis in boys. of plastic waste, which is equal to the aggregate area of three Iberian peninsulas (Spain and Portugal). Apart from bisphenols and phthalates, also brominated flame re- tardants and other constituents of plastics and heavy metals cause Plastics also pollute beaches and discourage tourists. Sea wildlife, disturbances to internal secretion system. like animals, birds and crustaceans, is trapped in plastic waste and gets constricted, drowned, immobilised, and dies. Plastics break down very slowly: the decomposition process takes about a thousand years. This means that all plastics that have ever In the sea, plastic is not biodegradable; however, being exposed to the been manufactured are still here on the Earth (even recycled) unless sun and mechanical forces, it gets decomposed to minute particles.
BACK TO CONTENTS 81 WMA News
In 2010, the proportion of the minute plastic particles to zooplankton are supposed to be indoors and help their mothers with cooking. was as high as 60:1. This means that 5% of a blue whale’s body weight In many countries trees have already been cut down and cooking is is plastic which he has consumed instead of plankton. done by burning trash, namely, plastics. Such smoke in the room is the cause of unbelievably high mortality of children (girls). There is nothing more dangerous for the Earth than burning plas- tics in low temperature. The end products of burning plastics are in- The World Medical Association should become the initiator of in- credibly poisonous to human beings, plants and animals. The gases troducing a global environmental tax on plastic, imposing a tax on released in burning destroy the ozone layer (plastics can be burnt all plastic bags. We trust that the World Medical Association is able only in furnaces in extremely high temperatures, notably over 1000 to lead this initiative and promote it to the UN and other global degrees, where the plastic combustion products are carbon dioxide, organisations for discussion. It is critical that it is the manufacturer sulphur dioxide and some other relatively simple compounds). which is to be taxed, because traders will be compelled to pay this tax in the price as value added tax. Relatively more girls die in childhood compared to boys. The reason Pēteris Apinis, President, is that in not so well-to-do countries boys play football, while girls Latvian Medical Association
Interview with Sir Michael Marmot, doctors have stood up and defended the ethical principle of providing health care to President of the World Medical Association all members of the population, regardless of ethnic or political persuasion. This ethical By Dr. Peteris Apinis. August, 2016 principle, too, is under threat.
I try to answer all questions concerned with 2 . Unfortunately this is not new in our the public’s health: an appeal to evidence world. Can you remember any other coun- and to notions of social justice. Overall, try going through a situation like this and evidence suggests that well-functioning how that affects the public health (e.g. Ven- democracies are good for health. There may ezuela) ? be one or two exceptions. But, certainly, the M . M . Is this unique to Turkey? As de- history of Europe, post war, shows remark- scribed above, the later stage of communism able divergence between the good health in Europe appeared to be bad for health. of Western democracies, and the relatively This can be illustrated simply by comparing poor health of communist countries of Austria, and Czechoslovakia – both impor- Central and Eastern Europe. There are am- tant parts of the previous Austro-Hungari- ple reasons for the health-promoting effects an Empire. Post war, health (as measured by of democracies: greater attention to human life expectancy) was approximately equal in rights; greater possibility for enlightened the two countries, and improved in parallel debate; a free press, which includes the free- up until the 1970s. It is consistent with the dom to be critical of the powers that be. My view that, on both sides of the Iron Curtain, own view is that satire, and other brands of material conditions for health improved. Sir Michael Marmot humour, are vital to the functioning of de- There were reductions in poverty, and im- mocracy (perhaps that is a British point of provements in school, jobs and transport. 1 . First of all, I would like to ask you about Tur- view). The trend in Turkey has been toward But, from the 1970s on, life expectancy key. We know that televisions are being closed, erosion of democracy, with a dramatic turn continued to improve in Austria, as it did judges and teachers are being removed from downwards after the aborted coup. A mili- in all countries in Western Europe. Life ex- their positions, is this affecting physicians, too? tary coup is always to be condemned. But pectancy stagnated in Czechoslovakia, as it Is Turkey becoming an authoritarian regime one might have hoped that Turkey’s presi- did in all countries of Central and Eastern where doctors are also the aim of politicians? dent would have emerged as an even more Europe. People do need the basic material M . M . Turkey. I will answer this question vigorous champion for democracy. Regret- conditions in order to enjoy good health. about Turkey’s current situation the way tably, the opposite has occurred. Turkey’s But they also need the freedom to lead
82 Migration
flourishing lives. Such freedoms were more 4 . How do these social determinants and problems. Do you think this might become likely to be delivered by healthy, functioning migration correlate with public health in a social determinant of «mental» health? Ex- democracies. Europe? How can we help to improve the plain your considerations about this. situation? M . M . There is a huge disparity between 3 . Turkey is hosting a huge number of M . M . Migrants in general, and refugees rates of crime, and fear of crime. In many, refugees from Syria, Iraq and Afghanistan. in particular, illustrate the importance of if not most, advanced countries, crime rates What do you think how this new situation taking action on the social determinants of have been falling, but the public’s fear of may affect them? health. Conditions from which people fled, crime isn’t. Each terrorist attack is appalling, M . M . What will happen to refugees in Tur- the circumstances of migration, and condi- and, rightly, fuels public anxiety about terror- key? Central to the functioning of a healthy tions in the new country can all influence ism. But, overall, the number of deaths from society is high quality data, and free and open health. One obvious way this works is that terrorist attacks is small. Take the U.S. as an discussion of the implications of what the refugees are poorer than the host popula- example. There are approximately 34,000 data show. There are two million official -Syr tion, and suffer ill health as a result. More deaths a year caused by firearms. A tiny mi- ian migrants in Turkey, and probably many generally, the conditions in which people nority of these can be linked to terrorism. more unofficial, in addition to migrants from are born, grow, live, work, and age, and ineq- You would not guess that from some of the Iraq and Afghanistan. With an authoritarian uities in power, money and resources – the public rhetoric of politicians, which fuels regime restricting the free flow of informa- social determinants of health – will all im- public anxiety. That being said, we should not tion, and taking arbitrary action against any pact on the health of refugees. be complacent about terrorism. We need to individual it sees as threats, this is a pre- add the medical voice to the argument for carious situation: it is quite conceivable that 5 . Terrorist attacks are affecting many improving the social determinants of health, refugees could be seen as threats. The result countries in the world. Fear is installing in for all members of our populations, and re- could be calamitous. people›s minds and can lead to psychological ducing racism and intolerance.
Migration of Doctors and Working Time Arrangements from an International Perspective The main aim of the first international reached representatives of 24 different na- conference of doctors’ unions was to build tions from five continents. a network between doctors’ unions around the world and to discuss common problems Participants from 11 countries made use of and challenges. In his opening speech the the opportunity to give on the first day a Chairman of the Marburger Bund, Rudolf snapshot presentation on the topic of emi- Henke, pointed out that such an exchange gration from and/or immigration of doctors of experience and information will not only to their countries. As the situation in the help to improve working conditions for different countries is diverse the speakers doctors but contribute, in the end, towards were free to focus on those issues that are better care for patients. Lutz Stroppe, a high of special interest to their union. The repre- ranking civil servant who reports to the sentative from the Sindicato Médico do Rio Ruth Wichmann German Minister of Health, emphasised Grande do Sul, for example, reported on the the important role that foreign doctors play exploitation of Cuban doctors who take part of recognition of foreign diploma and the in- in maintaining high quality medical care in in a government programme and work in tegration process of foreign doctors. In order Germany. At the same time he considered underserved rural areas in Brazil. Presenta- to facilitate the free movement of doctors the the possible negative effects the emigra- tions given by the Austrian Medical Cham- representative of Sindicato Médico del Uru- tion of doctors might have on the source ber, Swedish Medical Association and Hong guay drew upon practical experiences to ad- countries. With his welcoming speech he Kong Doctors’ Union explained the system vocate better co-operation between countries
BACK TO CONTENTS 83 Migration TURKEY
and a facilitation of the recognition process to the European Working Time Directive Employees in the Health and Social Protec- of foreign diplomas. (EWTD) the key elements of this Direc- tion of Serbia also complained that due to a tive were explained by Richard Pond, Pol- shortage of doctors, long working hours of Major push factors which make doctors leave icy Officer of the European Federation of doctors are a reality. However, so far Serbian their country such as poor working condi- Public Service Unions (EPSU). Pond also doctors are not willing to take action. Other tions, bad training opportunities, unemploy- described the continuous fight of EPSU to interesting snapshot presentations were ment or political circumstances where point- safeguard the health and safety provisions given by the Sindicato Médico del Uru- ed out by the Tanzania Medical, Dental and of this directive. guay, Bahamas Doctors’ Union, Myanmar Pharmaceutical Workers’ Union, Portuguese Medical Association Young Doctor Society National Federation of Doctors, Bahamas Examples of the transposition of the and New Zealand Association of Salaried Doctors’ Union, Myanmar Medical Associa- EWTD into national law were given by the Medical Specialists before the audiences tion Young Doctor Society and Slovak Doc- German Marburger Bund, Slovak Doctors’ engaged in a lively discussion. tors’ Trade Union. Workforce shortages in Trade Union, Portuguese National Fed- New Zealand as well as low retention rates eration of Doctors and Austrian Medical Again a resolution was adopted in which the of foreign trained doctors were elaborated on Chamber. All four presentations focused participants demanded that patient safety by the New Zealand Association of Salaried on the average maximum weekly working and the health and safety of doctors should Medical Specialists. time and the assessment of on-call periods be the guiding principles of any working as working time in theory and in practice. time regulations that cover doctors. The After the presentations, Armin Ehl, Chief Whereas the Austrian Medical Chamber participating doctors’ unions called upon Executive Officer of the Marburger Bund, explained that the use of the opt-out clause the responsible authorities to enforce exist- opened the floor for a fruitful discussion will be gradually phased out so that from July ing working time laws and expressed their which resulted in the adoption of a resolu- 2021 onwards, the average maximum weekly will to fight against any attempts to reduce tion. The participants supported the imple- working time in Austria will be 48 hours, the health and safety provisions in existing mentation of the 2010 WHO Code of appalling working time arrangements of up working time regulations. Moreover, the Practice on the International Recruitment of to 120 hours per week were reported by the union leaders wanted to reduce long work- Health Personnel. It was particularly stressed Jamaica Medical Doctors’ Association. Doc- ing hours in accordance with their members’ in the statement that all countries should tors in Jamaica severely compromised not needs and preferences. strive to train enough doctors to meet their only their own physical and mental health own internal needs. Furthermore, the par- but, as a result, are not being able to give ap- The Marburger Bund who organised the ticipants agreed that doctors’ unions should propriate care to their patients. meeting in mid-June in Berlin was delight- ensure that migrant doctors enjoy the same ed that the Sindicato Médico del Uruguay working conditions as domestically trained Long working hours are also a problem expressed an interest in holding a follow-up doctors and do not suffer any discrimination. in Hong Kong. The presentation from the conference in Uruguay next year. Also the All doctors’ unions present agreed to dissem- Hong Kong Doctors’ Union showed that Bahamas Doctors’ Union is considering inate relevant information to foreign doctors while the average weekly working time of hosting a future meeting of doctors’ unions. and to co-operate with one another in order people in Hong Kong is 50 hours many It is likely that the international co-opera- to support migrant doctors. doctors work more than 65 hours a week. A tion between doctors’ unions will thrive. recent survey conducted by the Hong Kong The main topic of the second day of the Doctors’ Union revealed that over 92% of Ruth Wichmann, Head of International conference was the working time of doctors. the participants longed for a significant re- Office of the Marburger Bund As all EU member states have to adhere duction in their working time. The Union of E-mail: [email protected]
Women in Migration: Beyond Statistics Data on the magnitude of the problem varies according to the source. Migration is intertwined with human tragedy. This Migration is a move somewhat reliant on try, and their past. Suddenly their lives short article will try to explain the human will. But the majority of the migrants are change completely and they are forced to dimension of migration, with an emphasis forced to leave their loved ones, their coun- migrate and seek refuge in a foreign country. on women.
84 TURKEY Migration
Women are among the most vulnerable. traffickers assault women. In the country As was highlighted by the United Nations of asylum, during the return journey and Committee on the Elimination of Dis- even in the reintegration phase, many crimination against Women (CEDAW), similar incidents have been reported [5]. migrant women face specific challenges in Women point out that human traffickers the field of health throughout the migration abuse women, there is systematic abuse cycle. Migrant women, for example, may be and violence against women both in cus- subject to sex and gender based discrimi- tody and at control points [6]. In other nation such as mandatory HIV/AIDS, or words, women’s bodies are used as battle- other testing, without their consent as well fields by conflicting parties and captured as sexual and physical abuse by agents and by the dominant powers. Women continue escorts during transit [3]. Refugee women to carry all the burden of the conflicts, war have lower status than men [4] and need and migration. more protection; especially victims of sex- ual violence, isolated, single parent women, Physicians and health care workers should lesbians and women in custody (The UN be aware of and sensitive to needs of refugee Refugee Agency (UNHCR)). women and advocate their right to health Feride Aksu Tanık and the right to access to health care. Refu- There are many variables affecting refugees’ gees with and emphasis on refugee women Hundreds of determinants such as coun- health that are not easily controlled. They should have the right to live in dignity and try of origin, the international status of include: stress caused by migration, dam- respect. The ultimate solution is the con- the country, the prestige of the country, age of refugees’ social networks, religious struction and protection of peace. Health whether they have legal documents, how and cultural factors, culturally insensitive care workers can have a crucial impact in they arrived in the country, whether they reproductive health services, discrimina- building a less violent world and ensuring are exiled, the reasons of migration, re- tion in health services provision and also the protection of peace. ligion, gender, age, profession, etc. con- a lack of information about the services tribute to determining not only the legal available. There are striking differences status but also the social prestige of the between the health status of refugees and References 1. Özgen, Neşe. Refugee and Woman: Nationalist refugees [1]. The conditions in which mi- the settled population, and their access to th grants travel, live and work can carry ex- health care. Refugees are one of the most Body politics. 10 International Cultural Stud- ies Symposium. Ege University – British Coun- ceptional risks for their physical and men- neglected groups of the world. They are cil, 4–6 May, 2005, İzmir. tal well-being. These include inequality in usually excluded from health and social 2. UNGA High Level Dialogue (HLD) on Mi- access to healthcare and services; vulner- services. gration and Development, 2013 abilities associated with migrant status, 3. WHO. Health of migrants: the way forward. marginalization and abuse, and are often Reproductive health is particularly impor- Report of a global consultation. Madrid, Spain, 3-5 March, 2010 linked to restrictive immigration and em- tant. There is an increase in fertility during 4. Özgen, Neşe, ibid ployment policies, economic and social migration. There are factors that make the 5. UNHCR, http://www.unhcr.org/turkey/home. factors, and dominant anti-migrant senti- situation more complicated such as: early php?page=15, (accessed 30.06.2016) ments in societies. These are often referred marriages, multiple marriages etc. In gen- 6. FIDH Violence Against Women In Syria: to as the social determinants for migrants’ eral family planning needs are unmet. Breaking The Silence Briefing Paper, 2013. health [2]. Based on an FIDH assessment mission in Jor- dan in December 2012 In war and migration situations, exploita- Shelter, hygiene and nutrition are the tion of women and sexual abuse increases. most problematic areas. There are serious Gender based violence is very common for Prof. Dr. Feride Aksu Tanık problems in access to food, both in terms refugees. During conflict, before escape Faculty of Medicine, of quantity and quality, the number of the the ruling parties abuse women. There are Department of Public Health meals provided are very few and irregular, reports of sexual violence and torture in- Ege University and food hygiene is poor. Basic personal hy- flicted by soldiers, gang rape and abduc- E-mail: [email protected] giene is also very poor due to poor living tion by the conflicting parties. During the conditions. escape, bandits, border guards and human
BACK TO CONTENTS 85 Nuclear War
The Growing Threat of Nuclear War and the Role of the Health Community
Ira Helfand Andy Haines Tilman Ruff Hans Kristensen Patricia Lewis Zia Mian
The Growing Risk of Crimea, the European Leadership Net- In this setting prominent leaders on both of Nuclear War work (ELN) documented a large increase sides have expressed alarm about the grow- in incidents involving close encounters ing danger of nuclear war. After the end of the Cold War the in- between nuclear capable NATO and Rus- tense military rivalry between the Soviet sian military forces. A report issued by the Speaking in January, when the Bulletin of Union and the United States/NATO was ELN concluded, “These events add up to the Atomic Scientists announced that its replaced by a much more cooperative re- a highly disturbing picture of violations Doomsday Clock would remain at three lationship, and fears of war between the of national airspace, emergency scrambles, minutes to midnight, former US Secre- nuclear superpowers faded. As recently narrowly avoided mid-air collisions, close tary of Defence William Perry stated, “The as the 2014 US Quadrennial Defence encounters at sea, simulated attack runs danger of a nuclear catastrophe today, in Review, conflict between the two former and other dangerous actions happening on my judgment is greater that it was during adversaries was not considered a realistic a regular basis over a very wide geographi- the Cold War … and yet our policies sim- possibility [1]. cal area” [3]. Further, both sides have con- ply do not reflect those dangers” [6]. His ducted large scale military exercises in Eu- assessment was echoed two months later Unfortunately, relations between Rus- rope, leading the ELN to conclude, “Russia by Igor Ivanov, Russian Foreign Minister sia and the US/NATO have deteriorated is preparing for a conflict with NATO, and from 1998 to 2004. Speaking in Brussels dramatically since then. In the Syrian and NATO is preparing for a possible con- on March 18, Ivanov warned that, “The risk Ukrainian wars, the two have supported op- frontation with Russia” [4]. The danger of confrontation with the use of nuclear posing sides, raising the possibility of open inherent in this situation is magnified by weapons in Europe is higher than in the military conflict and fears that such conflict the current Russian military doctrine of 1980’s” [7]. The increased tensions between could escalate to nuclear war. “nuclear de-escalation”. Rather than seeing the US and Russia have been matched by a nuclear weapons purely as a deterrent to similar escalation in the danger of nuclear Over the past two years, both sides have nuclear attack, this doctrine embraces “the war in South Asia. engaged in nuclear sabre rattling that is idea that, if Russia were faced with a large- reminiscent of the worst periods of the scale conventional attack that exceeded its Since the nuclear weapon tests of May 1998 Cold War. Speaking about the conflict in capacity for defence, it might respond with by India and then Pakistan, the two states Ukraine in August 2014, Russian Presi- a limited nuclear strike” in order to force have expanded many-fold their respective dent Vladimir Putin warned “it is better the other side to quickly end the conflict nuclear weapon and fissile material stock- not to come against Russia as regards a and return to the status quo ante” [5]. US/ piles, and undertaken extensive develop- possible armed conflict … I want to re- NATO military planning has always envi- ment and testing of a diverse array of ballis- mind you that Russia is one of the most sioned possible first use of nuclear weapons tic and cruise missiles (with ranges from 60 powerful nuclear nations” [2]. In the in the face of a Soviet/Russian convention- to 5000 km) to acquire the ability to deploy months following the Russian annexation al attack in Europe. and launch nuclear weapons from the air,
86 Nuclear War
from land, and from submarines at sea. They In April 2016, at the conclusion of the Nu- and again in 1980 computer errors in the have put in place command and control sys- clear Security Summit, the White House US caused American radar systems to dis- tems and doctrines that involve, in the case Press secretary expressed concern about, play, incorrectly, incoming Soviet missiles of Pakistan, first use of nuclear weapons in “the risk that a conventional conflict be- on their monitors. In September 1983, a conflict and, in the case of India, massive tween India and Pakistan could escalate to Soviet military radar incorrectly reported retaliatory strikes against population centres include the use of nuclear weapons” [18]. a NATO attack in progress. In November [8–10]. Should Pakistan use nuclear weapons of that year the Soviet leadership incor- against Indian conventional forces in such rectly concluded that a NATO military In May-July 1999, the two countries fought a situation, Indian nuclear doctrine calls for exercise was the cover for an actual attack a war which apparently included mobiliza- massive retaliation directed at Pakistani cit- that was about to be launched. On Janu- tion of nuclear weapons by Pakistan, mak- ies and Pakistan has threatened to respond ary 25, 1995, a full 5 years after the end ing it the most significant military conflict in kind. of the Cold War, Russian military radar between two nuclear armed states [11]. incorrectly identified a Norwegian Black They also went through a major military With Pakistan building ever closer mili- Brant XII rocket launched to study the crisis (December 2001 to June 2002) trig- tary and economic ties to China, and India aurora borealis as a Trident missile aimed gered by an attack on India’s parliament by becoming a strategic partner of the United at Moscow. Islamist militants believed in India to be States, such a future South Asian conflict backed by Pakistan, which included the two may quickly take on a global dimension In each of these situations preparations for countries moving a combined total of over given the increasingly tense nature of the a counterstrike were initiated and nuclear half a million troops to their border [12]. great power rivalry between China and the war was averted by minutes. The slow pace of Indian deployment and US [20]. inconclusive outcome of the stand-off led The danger of this kind of mistake oc- India’s army to begin planning and train- North Korea has a track record of repeatedly curring again is amplified by current de- ing for a more decisive and rapid conven- threatening the use of nuclear weapons; for ficiencies in Russian radar warning sys- tional attack on Pakistan [13]. Pakistan example, in March 2016 it warned it would tems. Russia has no space-based satellite began testing a short-range truck-mounted make a “pre-emptive and offensive nuclear early warning systems to alert them to the mobile missile to deliver low-yield nuclear strike” in response to joint US-South Ko- launch of nuclear-armed ballistic missiles weapons on the battlefield [14]. This latter rean military exercises [21]. It is capable of from the ocean, so their warning time development has increased long-standing enriching uranium and producing weapons- could be as short as 10 to 15 minutes. The international concerns about the security grade plutonium and has deployed short- only way for Russia to guarantee the abil- of nuclear weapons and fissile materials in and medium-range ballistic missiles as well ity to launch its forces before they are de- Pakistan given the large-scale and frequent as testing long–range missiles [22]. stroyed by a pre-emptive attack would be Islamist militant attacks on military targets to pre-delegate launch authority to field in the country and the ideological polariza- commanders. Under these conditions, the tion within the armed forces and broader Unintended Use of time pressure to make a launch decision society associated with the rise of hard-line Nuclear Weapons could greatly increase the chance of an ac- Islamist political groups over the past three cidental launch, especially if a computer decades [15]. While these growing tensions amongst nu- error caused a false warning of attack dur- clear armed states could lead to the deliber- ing a crisis [24]. Recently, military lead- Potential triggers for armed conflict be- ate use of nuclear weapons, there is also the ers have begun to warn of a new threat tween Pakistan and India include another continuing danger that they could trigger that might cause the unintended launch major attack on India by Islamist militant the unintended or accidental use of these of nuclear weapons: cyberterrorism. In a groups like the one in Mumbai in Novem- weapons. June 2015 speech, retired Marine Gen. ber 2008 that was linked to intelligence James Cartwright, former head of the agencies in Pakistan [16]. A second possible There have been at least five occasions US Strategic Command, warned that it trigger is the recurring artillery exchanges since 1979 when either Washington or might be possible for terrorists to hack along the line of control in Kashmir, and oc- Moscow prepared to launch nuclear weap- into Russian or American command and casionally the international border between ons in the mistaken belief that the other control systems and launch one or more Pakistan and India, which often claim sig- side had already launched a nuclear attack nuclear missiles, a launch which would nificant military and civilian casualties [17]. or was preparing to do so [23]. In 1979 have a high probability of triggering a
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8000 wider nuclear conflict. This danger is in- 7300 6970 tensified by the continued US and Rus- 7000 sian policy of maintaining their missiles on hair trigger alert, fully prepared for use 6000 Retired and simply awaiting an order to launch 5000 Stockpiled [25]. There is also extensive evidence that individuals with responsibility for nuclear 4000 Deployed weapons have breached safety regulations. Note: North Korea has produced fissile 3000 material for 10–12 warheads and detonated In 2003, for example, half of the US Air 4 test assemblies, but we’re not aware of public information that shows it has yet Force units responsible for nuclear weap- 2000 stockpiled weaponized warheads. ons safety failed their safety inspections. In 2007 six cruise missiles armed with 1000 300 260 nuclear warheads were mistakenly loaded 215 130 120 80 0 onto a B-52 bomber which sat on the tarmac overnight without armed guards Russia USA France China UK Pakistan India Israel before taking off and flying 1500 miles in violation of regulations which prohibit Figure . Estimated Global Nuclear Warhead Inventories, 2016 transportation of nuclear weapons by air over the USA [26]. South China Sea are causing nuclear-armed tion to the impacts of nuclear war on cli- states to increase the role of their nuclear mate, agriculture and nutrition that scien- forces. tific advances of the greatest moment have Nuclear Weapons been made in the past decade, and these are Modernization Instead of moving decisively toward deep therefore our focus here. As a result of these, cuts of their nuclear arsenals and mak- we have come to understand that it is not The nuclear danger is amplified further by ing plans for the eventual elimination of just large scale nuclear war between the US the extensive plans of all nine nuclear armed nuclear weapons, the nuclear-armed states and Russia that poses a global threat. A se- states to enhance their nuclear arsenals. are reaffirming the importance of nuclear ries of studies have shown that localized, weapons and are carrying out extensive and regional nuclear war will also have cata- Although the world’s inventory of nuclear costly modernizations of their nuclear arse- strophic effects worldwide. weapons has declined significantly over the nals [28]. (see table) past two-and-a-half decades, from around We undertook a literature search using 58,300 warheads in 1991, there remain The scope of these modernization plans has the Web of Science database Topic Search roughly 15,375 warheads today of which led observers to characterize them as the function, on 14 March 2016, covering doc- 4,200 are deployed with operational forces. beginning of a new arms race and a new uments in English published from 2005 to Nearly 1,800 warheads are on alert and Cold War [29]. 2016, using the search strategy: ((“Nuclear ready for use on short notice [27]. (Figure) Weapon*” OR “nuclear war*” OR “atomic weapon*” OR “atomic war*” OR “nuclear While Russia, the US, and Britain con- The Health Consequences conflict*”) and (Climate OR “Climate tinue to reduce their inventories, the pace of Nuclear War Change” OR environment* OR “Ozone of reduction has slowed compared with the Depletion” OR ozone OR Starvation OR past two decades. In fact, four of the world’s Given the growing danger of nuclear war, it famine OR Agriculture* OR crop* OR nuclear-armed states (China, Pakistan, In- is important to consider the health conse- Food)). dia and North Korea) are increasing their quences of such a conflict. nuclear arsenals. The scenario that has been studied most fre- The acute effects of nuclear weapons are quently is a limited nuclear war between In- There are currently no negotiations between well described in previous major reports by dia and Pakistan involving 100 Hiroshima nuclear-armed states about reducing war- WHO and the US Institute of Medicine sized warheads, small by modern standards, head inventories or curtailing operations [30,31]. While there have been important targeted on urban centers. (This is a delib- and modernizations. Instead, there are signs developments regarding ionising radiation erate underestimate of the full potential of that the deepening crises in Europe and the health effects in recent decades, it is in rela- war in South Asia: the combined arsenals
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Table . Modernization Activities of the Nine Nuclear-armed States
Russia France • replacing all Soviet-era SS-18, SS-19 and SS-25 intercon- • modernizing its SSBN fleet with the new M51 SLBM that tinental ballistic missiles (ICBMs) by the early-2020s with will soon receive a new warhead. different versions of the SS-27 and a new “heavy” silo-based • arming its bomber force with ALCMs. ICBM. • replacing Mirage 2000N aircraft with the Rafale which will • building eight new ballistic missile submarines (SSBNs) be armed with a new ALCM. with the new SS-N-32 (Bulava) missile to replace eight op- United Kingdom erational Soviet-era Delta-class SSBNs and their missiles. • developing a new SSBN class to replace the current Van- • upgrading its old Tu-160 (Blackjack) and Tu-95MS (Bear) guard-class SSBNs which will carry the life-extended Tri- bombers so they can continue to operate until a new bomber dent II D5 with a new guidance system. can replace them sometime in the 2020s. • equipping current SLBMs with enhanced warheads. • gradually replacing the old AS-15 air-launched cruise mis- sile (ALCM) with a new ALCM known as the Kh-102. Pakistan • modernizing some of its non-strategic nuclear forces, re- • deploying new and longer-range Shaheen-III ballistic mis- placing the old SS-21 short-range ballistic missile (SRBM) siles, Ra’ad ALCMs, Babur ground-launched cruise mis- with the SS-26 (Iskander), replacing the old SS-N-21 siles, and developing a nuclear SLCM. sea-launched land-attack cruise missile (SLCM) with the • deploying a tactical nuclear weapon, the 60-kilometer SS-N-30A (Kalibr), and replacing the old Su-24 (Fencer) NASR missile. fighter-bomber with the Su-34 (Fullback). • increasing production of fissile material for additional war- heads. United States • building a new fleet of 12 SSBNs to replace the current 14 India SSBNs. The new submarines will carry an improved version • deploying and developing longer-range ballistic missiles of the Trident II D5 sea-launched ballistic missile (SLBM) that can target all of Pakistan and China, including several with new guidance system and enhanced warheads. new versions of the Agni missile family. • modernizing its B-2 and B-52 bombers and developing the • conducting sea-trials of its first SSBN, which will carry new new B-21 stealth-bomber to replace the B-52s (and B-1s) types of SLBMs. from the late-2020s. • building new reactors that can produce plutonium for ad- • developing a new guided nuclear bomb (B61-12) with in- ditional warheads and expanding uranium enrichment ca- creased accuracy, and a new ALCM with longer range and pacity. enhanced warhead. Israel • designing a new ICBM with enhanced warheads to replace • modernizing its Jericho ballistic missiles and probably also the current Minuteman III ICBM by 2030. its fighter-bombers. • modernizing its non-strategic nuclear forces by replacing • Possibly equipping its new German-built Dolphin-class F-16s (and eventually F-15E) fighter-bombers with the F- submarines with a nuclear cruise missile. 35A stealthy fighter-bomber that will be carrying the new B61-12 guided nuclear bomb. North Korea • deploying two new ballistic missiles (Musudan and Hwa- China song-13) that could potentially in the future be equipped • replacing old liquid-fuel land-based missiles with DF-26 with weaponized versions of the nuclear devices it has tested. and DF-31A solid-fuel missiles on road-mobile launchers. • developing a new longer-range missile. • equipping some of its missiles with multiple warheads. • deploying a small fleet of Jin-class SSBNs with the new Jl-2 SLCBM.
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of India and Pakistan actually contain more consumption, and would not begin to offset in South Asia, the global climate effects than 220 nuclear warheads.) The direct ef- the shortfall over a full decade [38]. Fur- would be far worse. A war involving only fects in South Asia are catastrophic. Some thermore, there are currently 795 million the strategic weapons that will still be de- 20 million people would die in the first people who are already undernourished at ployed when New START is fully imple- week from the direct effects of the explo- baseline [39]. There are also some 300 mil- mented would put some 150 million tons sions, fire and local radiation [32]. lion people who enjoy adequate nutrition of soot in the upper atmosphere, and drop today, but live in countries highly depen- temperatures around the world by 8°C. In The global consequences-global climate dent on food imports which would probably the interior regions of North America and disruption and resultant famine-would be not be available as grain exporting countries Eurasia, temperatures would fall by 25 to far more devastating. The fires caused by suspended exports to feed their own people. 30°C. These conditions would persist for these nuclear weapons would loft 6.5 mil- In addition, there are nearly a billion people more than a decade. Temperatures on Earth lion tons of soot into the upper atmosphere. in China with incomes of $5 a day or less have not been that cold since the last ice The impact of this soot has been examined who are adequately fed today, but who have age. In the temperate regions of the North- by three teams of climate scientists using shared little in China’s growing prosperity ern Hemisphere, the temperature would fall three different climate models and mak- over the last several decades. All of these below freezing for some portion of every ing the conservative assumption that only people, around two billion, would be at risk day for at least two years [43]. Under these 5 million tons of soot are injected into the under the potential famine conditions that conditions food production would stop and atmosphere [33-35]. Each model shows would result from this limited, regional nu- the vast majority of the human race would significant drops in average surface temper- clear war [40]. Large scale war between the starve. ature and average precipitation across the US and Russia would be far worse. In early globe with the effects lasting for more than 2016, Russia and the US were estimated to a decade. The most sophisticated and recent possess 7300 and 6970 nuclear warheads re- Efforts to Eliminate model shows the most persistent declines in spectively, 93% of the global total of 15,375. Nuclear Weapons temperature and precipitation, which have Under the provisions of the New START not yet returned to baseline after 26 years, treaty, each of these countries will retain Understanding of the unprecedented ex- as long as the model was run. While the some 1550 strategic (long range) nuclear istential threat posed by nuclear weapons fuel density of modern cities varies, there warheads when the Treaty is fully imple- was widely recognized in the very first is nothing specific to India/Pakistan about mented in 2018. Most of these weapons resolution of the United Nations General such a scenario. Nuclear weapons are ex- are 10 to 50 times more powerful than the Assembly in January 1946, calling for the tremely efficient at igniting, over large areas, bombs which destroyed Hiroshima [41]. A elimination of atomic weapons [44]. The simultaneous fires which rapidly coalesce 2002 study showed that if just 300 of the preamble of the 1970 nuclear Non-Prolif- and inject large volumes of soot and smoke weapons in the Russian arsenal hit urban eration Treaty (NPT) opens: “Consider- into the stratosphere. targets in the US, 75 to 100 million people ing the devastation that would be visited would die in the first half hour from the upon all mankind by a nuclear war and the This climate disruption would in turn have firestorms and explosions [42]. This attack consequent need to make every effort to profoundly negative impact on food pro- would also destroy most of the infrastruc- avert the danger of such a war …” [45]. Yet duction. The maize crop in the US, the ture – the electric grid, internet, banking for most of the past 71 years, the shared world’s largest producer, would decline and public health systems, food distribution interests of humanity, based on the real an average of 12% over a full decade [36]. network – needed to support the rest of the consequences of any use of nuclear weap- In China, the world’s largest producer of population, most of whom would succumb ons, have been sidelined by the perceived grain, middle season rice would decline to exposure, starvation and epidemic disease interests of the 9 governments that pos- by 17% over a full decade, maize by 16%, in the months following. A US counterat- sess and threaten use of nuclear weapons, and winter wheat, by a truly catastrophic tack would be expected to cause the same which have dictated the pace and extent 31% [37]. level of destruction in Russia, and if NATO of nuclear arms control and disarmament. were involved in the conflict, Canada and However, the obligation to pursue effective Under current conditions, adequate human much of Europe would face similar destruc- measures towards nuclear disarmament is nutrition cannot be sustained in the face of tion. a shared responsibility of all 190 NPT sig- declines of food production of this magni- natory states, and the International Court tude. Total world grain reserves in January These direct effects are only part of the of Justice in its 1996 Advisory Opinion on 2016 amounted to only 84 days of global story, however. As is true for a limited war nuclear weapons unanimously ruled that
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there exists an obligation not only to pur- governmental meetings dedicated to the a treaty. This recommendation was taken sue in good faith, but to bring to a conclu- humanitarian impacts of nuclear weapons. forward in a resolution co-sponsored by 57 sion, negotiations leading to nuclear disar- There was no significant disagreement at states [58] and adopted by the UNGA First mament [46]. these conferences regarding the exten- Committee on 27 October 2016, with 123 sive expert evidence presented, leading to States voting yes, 38 (predominantly nucle- The contemporary ‘Humanitarian Initiative’ the conclusions 1) that any use of nuclear ar-armed and nuclear-allied) voting no, and on nuclear weapons began with Interna- weapons would be catastrophic; 2) that no 16 abstentions. The full UNGA will under- tional Committee of the Red Cross (ICRC) effective humanitarian response was pos- take a final vote in early December 2016, president Jacob Kellenberger informing the sible to even a single nuclear detonation in and the first negotiating conference will Geneva Diplomatic Corps in 2010 that the an urban centre; 3) that the risk of nuclear convene in New York on 27 March 2017. world’s largest humanitarian organization weapons use had previously been underesti- A new international treaty comprehensively would make elimination of nuclear weap- mated, is growing, and exists as long as the prohibiting nuclear weapons is thus within ons – something it first called for on 5 Sep- weapons do; and 4) that there is a legal gap sight. This is increasingly seen by a substan- tember 1945 – a renewed priority [47]. A for nuclear weapons, in that the most de- tial majority of states as the most promising few weeks later, the five yearly 2010 NPT structive and indiscriminate of all weapons and realistic step which can now be taken to Review Conference outcome document are the only weapon of mass destruction progress the eradication of nuclear weapons, referred for the first time to “deep concern not yet explicitly prohibited under interna- and the conclusion of such a treaty would about the catastrophic consequences of any tional law [54]. At the end of the Vienna constitute the most significant development use of nuclear weapons” [48]. In 2011, the conference, the Austrian government is- in nuclear disarmament since the end of the Council of Delegates, the highest govern- sued a pledge “to cooperate with all relevant Cold War. Treaties unequivocally prohibit- ing body of the Red Cross/Red Crescent stakeholders … to stigmatize, prohibit and ing unacceptable weapons and providing for Movement, called on all states “to ensure eliminate nuclear weapons in light of their their subsequent elimination has been the that nuclear weapons are never again used”, unacceptable humanitarian consequences approach successfully used in relation to ev- and “to pursue in good faith and conclude and associated risks”; to “fill the legal gap ery other kind of indiscriminate, inhumane with urgency and determination negotia- for the prohibition and elimination of nu- weapon – biological, toxin [59] and chemi- tions to prohibit the use of and completely clear weapons” [55]. As of 20 March 2016, cal weapons [60], followed by antipersonnel eliminate nuclear weapons through a legally 127 states have endorsed this Humanitarian landmines [61] and cluster munitions [62]. binding international agreement, based on Pledge, with an additional 22 states voting existing commitments and international in favour of a resolution bringing the Pledge obligations” [49]. A special issue of the to the UNGA [56]. The Role of the Health Movement’s flagship journal, the Interna- Community tional Review of the Red Cross, “The human The 2015 General Assembly also voted costs of nuclear weapons”, was recently pub- overwhelmingly to establish an Open End- Involvement of the medical community in lished. ed Working Group (OEWG) to address these efforts to eliminate nuclear weapons this legal gap, which though open to all flows from a long history of medical and Beginning in 2012, at every NPT meet- states, was opposed and boycotted by all the scientific concern about nuclear weapons. ing and UN General Assembly (UNGA), a nuclear-armed states. The Working Group After the hydrogen bomb code named growing number of states, from 16 in 2012 was charged with reporting back to the Castle Bravo was detonated at Bikini Atoll to 144 in 2015, have supported resolutions 2016 UNGA on effective legal measures with a yield of around 15 megatons (mil- affirming the centrality of humanitarian required to attain and maintain a world lions of tons of TNT equivalent), double considerations in advancing nuclear dis- free of nuclear weapons. It “recommended that predicted, there was widespread pro- armament, and the need to prevent use of with widespread support for the General test from many world leaders together nuclear weapons under any circumstances Assembly to convene a conference in 2017, with Albert Einstein and the Federation [50]. In 2013 and 2014 three successive open to all States, with the participation of American Scientists [63]. In 1957, as fact-based international conferences on the and contribution of civil society, to negoti- atmospheric testing of nuclear weapons Humanitarian Impact of Nuclear Weapons ate a legally-binding instrument to prohibit continued unabated, an appeal from Albert were held in Norway [51], Mexico [52] and nuclear weapons, leading towards their total Schweitzer for a ban on nuclear tests was Austria [53], the last with participation of elimination …”[57]. The Working Group’s broadcast to audiences in 50 nations and a 146 states. Remarkably, 68 years into the report provided detailed suggestions on spe- petition initiated by Linus Pauling, 1954 nuclear age, these were the first ever inter- cific elements that could be included in such Nobel laureate in Chemistry, also demand-
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ing a test ban was signed by 9000 scientists the detonation of a single megaton weapon In 2007, IPPNW founded the Internation- in 43 countries. Pauling was awarded the would overwhelm the resources of the en- al Campaign to Abolish Nuclear Weapons Nobel Peace Prize in 1963 for his opposi- tire UK National Health Service [69]. The (ICAN) – a broad global campaign coalition tion to nuclear testing. Also in 1957 the World Health Assembly adopted a resolu- working for a treaty banning nuclear weap- British Atomic Scientists’ Association set tion in 1983 including reference to nuclear ons. ICAN now has 440 partner organisa- up a committee to assess the risks of cancer weapons as “the greatest immediate threat tions in 98 countries, is the lead civil society arising from the fallout from atmospheric to the health and welfare of mankind” partner for the governments hosting the nuclear tests, chaired by Professor Joseph [70]. Scientific and medical evidence that Humanitarian conferences, and continues Rotblat, a medical physicist (and during civil defence programs against nuclear to grow as a major civil society coordinating the 2nd World War an atomic scientist, war provided at best an illusion of protec- initiative and partner for governments seri- working on the atomic bomb at Los Ala- tion led to their widespread abandonment ous about the humanitarian imperative for mos). It concluded that for every 1 mega- [71]. Evidence on the catastrophic health nuclear disarmament. ton exploded in the atmosphere, around effects of nuclear war brought by physi- 1000 people were likely to develop bone cians to Presidents Ronald Reagan and In Moscow in October 2015, the World cancers, and made other estimates of the Mikhail Gorbachev had profound effect, Medical Association General Assembly likely health consequences of atmospheric bringing them to declare in 1985 that “A unanimously updated its Statement on nuclear testing [64]. nuclear war cannot be won and must never Nuclear Weapons, adopted in 1998 and be fought”; to end their nuclear arms race; amended in 2008, requesting all National A series of four [65-68] influential articles agree on the elimination of intermediate Medical Associations to educate their pub- appeared in the New England Journal of range nuclear missiles; and come close to lics and governments about the health im- Medicine in 1962 describing the medical an agreement to eliminate their nuclear pacts of nuclear war and “to join the WMA effects of a thermonuclear attack on Mas- arsenals entirely. Gorbachev wrote that in supporting this Declaration and to urge sachusetts, the (limited) role of the medical without the efforts of IPPNW – awarded their respective governments to work to ban profession in dealing with the consequences, the Nobel Peace Prize in 1985 – these dis- and eliminate nuclear weapons” [74]. and the psychiatric and social aspects of civ- armament initiatives “would probably have il defence. The authors, who were members been impossible” [72]. Given the potential In April 2016, the WMA joined with of a new organization Physicians for Social for nuclear war to occur as a result of er- IPPNW, the World Federation of Public Responsibility, concluded that as no effective ror and the lack of evidence that a planned Health Associations and the International clinical response was possible, doctors “must medical response can have any perceptible Council of Nurses, in submitting to the begin to explore a new area of preventive impact on the outcome, it has been sug- UN Working Group the first such united medicine, the prevention of thermonuclear, gested that “support for deterrence with statement detailing the health and humani- chemical and biological warfare”. these weapons as a policy for national or tarian imperative to ban and eliminate nu- global security appears to be incompatible clear weapons [75]. All other global health Negotiations on a ban on nuclear testing with basic principles of medical ethics and progress and efforts could come to nought continued inconclusively until 1963 because international law. The primary medical re- if we do not succeed in eradicating nuclear of concerns about the potential to conceal sponsibility under such circumstances is to weapons before they are again used in war. clandestine tests. With evidence of wide- participate in attempts to prevent nuclear There has never been a better opportunity spread radioactive fallout and accumulation war” [73]. New evidence about the per- nor greater need for united and effective of strontium-90 in the deciduous teeth of vasive threats to health of the detonation health professional engagement to remove children around the world, public opinion of even a small percentage of the world’s the most acute existential threat to global swung strongly in favour of banning atmo- nuclear arsenals, together with the failure health and survival. spheric nuclear testing and the Limited Test of the Non-Proliferation Treaty to prevent Ban treaty was agreed in 1963, but progress the retention and modernization of nu- towards a comprehensive treaty proved clear weapons has given impetus to a new References frustratingly slow. global movement to ban nuclear weapons. 1. http://archive.defense.gov/pubs/2014_Quad- The health professions therefore have a rennial_Defense_Review.pdf (accessed May 9, 2016). In the early 1980s a number of reports on central role in advocating for the abolition 2. http://www.cnn.com/2014/08/29/world/eu- the health effects of nuclear weapons ap- of nuclear weapons, reflecting their ethical rope/ukraine-crisis/ (accessed April 21, 2016). peared including a BMA report of 1983 responsibility to protect health and prevent 3. Frear T, Kulesa L, Kearns I. Dangerous Brink- which concluded that the casualties from illness. manship: Close Military Encounters Between
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Russia and the West in 2014. European Leader- 2016, http://thebulletin.org/nuclear-battles- and maize production in the Midwest United ship Network, November 2014. south-asia9415 (accessed May 5 2016). States. Climatic Change 2013; 116: 373–87, 4. Frear T, Kearns I, Kulesa L. Preparing for the 20. Mian Z, Ramana M. Asian War Machines. doi:10.1007/s10584-012-0518-1. Worst: Are Russian and NATO Military Exer- Critical Asian Studies 2014; 46(2):345–60. 37. Xia L, Robock A, Mills M, Stenke A, Helfand. cises Making War in Europe More Likely? Eu- 21. http://edition.cnn.com/2016/03/06/asia/ Decadal reduction of Chinese agriculture after a ropean Leadership Network, August 2015. north-korea-preemptive-nuclear-strike-threat/ regional nuclear war. Earth’s Future 2015; 3:37– 5. Sokov N. Why Russia calls a limited nuclear (accessed April 18. 2016). 48, doi:10.1002/2014EF000283. strike “de-escalation”. BAS 13 March 2014. 22. http://www.nti.org/learn/countries/north-ko- 38. http://www.usda.gov/oce/commodity/wasde/ http://thebulletin.org/why-russia-calls-limited- rea/ (accessed April 18, 2016). latest.pdf (accessed January 24, 2016). nuclear-strike-de-escalation (accessed April 16, 23. Lewis P, Williams H, Pelopidas B, Aghlani S. 39. https://www.wfp.org/hunger/stats (accessed 2016). Too Close for Comfort: Cases of Near Nuclear April 17, 2016). 6. http://cisac.fsi.stanford.edu/news/stanford- Use and Options for Policy. Chatham House 40. Helfand I. Nuclear Famine: Two Billion People experts-reveal-latest-%E2%80%9Cdoomsday- Report, April 2014. at Risk. International Physicians for the Preven- clock%E2%80%9D-estimate (accessed April 16, 24. Postol T. How the US Nuclear Weapons Mod- tion of Nuclear War, 2013. http://www.ippnw. 2016). ernization Program Is Increasing the Chances org/nuclear-famine.html (accessed April 17, 7. http://www.reuters.com/article/us-ukraine-cri- of Accidental Nuclear War with Russia. lecture 2016). sis-russia-idUSKCN0WL0EV (accessed April Harvard College, February 25, 2016. 41. Kristensen H, Norris. op. cit 21, 2016). 25. http://www.sfchronicle.com/opinion/openfo- 42. Helfand I, Forrow L, McCally M, Musil R. 8. Mian Z, Ramana M. Going MAD: Ten Years of rum/article/What-happens-when-our-nuclear- Projected US Casualties and Destruction of US the Bomb in South Asia. Economic and Political arsenal-is-hacked-6333739.php (accessed April Medical Services From Attacks by Russian Nu- Weekly 2008;43(26-27):201–8. 16, 2016). clear Forces. Medicine & Global Survival 2002; 9. Mian Z. Pakistan-2015. Assuring Destruction 26. Schlosser. Command and Control. Penguin 7(2):68–76. Forever: 2015 Edition, edited by Ray Acheson, Press, London, 2013. 43. Robock A, Oman L, Stenchikov G. Nuclear Reaching Critical Will, New York, April 2015. 27. Kristensen H, Norris R. Status of World Nuclear winter revisited with a modern climate model 10. Ramana M. India-2015. Assuring Destruction Forces. Federation of American Scientist, 2016 and current nuclear arsenals: Still catastrophic Forever: 2015 Edition, edited by Ray Acheson, http://fas.org/issues/nuclear-weapons/status- consequences. J Geophys Res 2007;112:D13107, Reaching Critical Will, New York, April 2015. world-nuclear-forces/ (accessed April 16, 2016) doi:2006JD008235. 11. Lavoy P. editor, Asymmetric Warfare in South 28. Kristensen H. World Nuclear Weapon Mod- 44. United Nations General Assembly. Resolution Asia: The Causes and Consequences of the Kar- ernization Programs. http://fas.org/wp-content/ UNGA Res. 1, 24 January 1946: Establishment gil Conflict (Cambridge University Press, Cam- uploads/2014/05/Brief2015_NPT1a.pdf (ac- of a Commission to deal with the problems bridge, 2009). cessed April 16, 2016). raised by the discovery of atomic energy. 12. Ramana M, Mian Z. The Nuclear Confrontation 29. http://www.nytimes.com/2016/04/17/science/ 45. Treaty on the Non-Proliferation of Nuclear in South Asia. SIPRI Yearbook 2003: Arma- atom-bomb-nuclear-weapons-hgv-arms-race- Weapons (NPT), 1 July 1968, 729 UNTS 161. ments, Disarmament and International Secu- russia-china.html accessed April 21 2016. https://www.iaea.org/publications/documents/ rity:195–212 (Oxford University Press, Oxford, 30. World Health Organization, Effects of Nuclear infcircs/treaty-non-proliferation-nuclear-weap- 2003). War on Health and Health Service, 2nd ed. Ge- ons (accessed May 6, 2016). 13. Ladwig W III. A Cold Start for Hot Wars? The neva, 1987. 46. International Court of Justice. Legality of the Indian Army’s New Limited War Doctrine. In- 31. Institute of Medicine, The Medical Implications Threat or Use of Nuclear Weapons: Advisory ternational Security 2007/2008; 32(3):158–90. of Nuclear War, National Academy Press. Wash- Opinion of 8 July 1996. Hague: International 14. Nayyar A, Mian Z. Pakistan and the Nasr Mis- ington, 1986. Court of Justice, 1996. http://www.icj-cij. sile: Searching for a Method in the Madness. 32. Toon O, Turco R, Robock A, Bardeen C, Oman org/docket/index.php?p1=3&p2=4&k=%20 Economic and Political Weekly 2015; 50(39): L, Stenchikov G. Atmospheric effects and so- e1&p3=4&case=95 (accessed May 6, 2016). 62–6. cietal consequences of regional scale nuclear 47. Kellenberger J. Bringing the era of nuclear 15. Hoodbhoy P, Mian Z. Securing Pakistan’s Nu- conflicts and acts of individual nuclear terrorism. weapons to an end. Statement to the Geneva clear Arsenal – The Threat from Within. -Nu Atm Chem Phys 2007; 7:1973–2002. Diplomatic Corps, Geneva, 20 April 2010. clear Terrorism: Countering the Threat, edited 33. Robock A, Oman L, Stenchikov G, Toon O, https://www.icrc.org/eng/resources/documents/ by Volders B, Sauer. (Routledge Global Security Bardeen C, Turco R. Climatic consequences statement/nuclear-weapons-statement-200410. Studies Series, New York, 2016): 182–94. of regional nuclear conflicts. Atm Chem Phys htm (accessed May 6, 2016). 16. Barry E, Kumar. Mumbai Attacks Plotter Says 2007;7:2003–12. 48. 2010 Review Conference of the Parties to the Pakistan’s Spy Agency Played a Role. New York 34. Mills M, Toon O, Lee-Taylor J, Robock A. Treaty on the Non-Proliferation of Nuclear Times, 8 February 2016. Multi-decadal global cooling and unprec- Weapons. Final Document Vol 1 Part 1 Con- 17. Craig T. Clashes erupt between India and Paki- edented ozone loss following a regional nu- clusions and recommendations for follow-on stan along disputed border. Washington Post, 28 clear conflict. Earth’s Future 2015; 2:161–76, actions. NPT/CONF.2010/50 (Vol. 1). New August 2015. doi:10.1002/2013EF000205. York: United Nations, 2010. http://www.reach- 18. https://www.whitehouse.gov/the-press-of- 35. Stenke A, Hoyle CR, Luo B, et al. Climate and ingcriticalwill.org/images/documents/Disarma- fice/2016/04/04/press-briefing-press-secretary- chemistry effects of a regional scale nuclear con- ment-fora/npt/revcon2010/FinalDocument.pdf josh-earnest-4416 (accessed April 16, 2016). flict. Atm Chem Phys 2013,13:9713–29. (accessed May 6, 2016). 19. Hoodbhoy P, Mian Z. Nuclear battles in South 36. Özdoğan M, Robock A, Kucharik C. Impacts 49. International Committee of the Red Cross. Asia. Bulletin of the Atomic Scientists, 4 May of a nuclear war in South Asia on soybean Council of Delegates 2011: Resolution 1.
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Working towards the elimination of nuclear reachingcriticalwill.org/images/documents/ wma.net/en/30publications/10policies/n7/ (ac- weapons. Geneva: ICRC, 2011. http://www. Disarmament-fora/1com/1com16/resolutions/ cessed May 9, 2016). icrc.org/eng/resources/documents/resolution/ L41.pdf (accessed October 30, 2016). 75. UN General Assembly. The health and humani- council-delegates-resolution-1-2011.htm (ac- 59. Convention on the Prohibition of the Develop- tarian case for banning and eliminating nuclear cessed May 6, 2016). ment, Production and Stockpiling of Bacterio- weapons. Working paper A/AC.286/NGO/18, 50. UN General Assembly. Humanitarian con- logical (Biological) and Toxin Weapons and on 4 May 2016. https://ippnweupdate.files.word- sequences of nuclear weapons. Resolution. Their Destruction. http://www.apminebancon- press.com/2016/04/health-and-humanitarian- A/C.1/70/L.37. New York: United Nations, vention.org/overview-and-convention-text (ac- case-for-banning-and-eliminating-nuclear- 2015. http://reachingcriticalwill.org/disarma- cessed May 6, 2016). weapons_oewg-may-2016.pdf (accessed May 6, ment-fora/unga/2015/resolutions (accessed 60. Convention on the Prohibition of the Devel- 2016). May 6, 2016). opment, Production, Stockpiling and Use of 51. Ministry of Foreign Affairs (Norway). www. Chemical Weapons and on their Destruction. regjeringen.no/en/topics/foreign-affairs/hu- https://www.opcw.org/chemical-weapons-con- Ira Helfand, MD manitarian-efforts/humimpact_2013/id708603/ vention (accessed May 6, 2016). Co-President, International Physicians (accessed May 6, 2016). 61. Convention on the Prohibition of the Use, for the Prevention of Nuclear War, 52. Chair’s Summary. Second Conference on the Stockpiling, Production and Transfer of Anti- Malden, Massachusetts, 413 320 7829, Humanitarian Impact of Nuclear Weapons. Na- Personnel Mines and on their Destruction. yarit: Government of Mexico, 2014. http://www. www.icrc.org/ihl/INTRO/580 (accessed May E-mail: [email protected] reachingcriticalwill.org/images/documents/Dis- 6, 2016). armament-fora/nayarit-2014/chairs-summary. 62. Convention on Cluster Munitions. http://www. Andy Haines, MD pdf (accessed May 6, 2016). clusterconvention.org/the-convention/conven- Professor, Departments of Social and 53. Europe Integration and Foreign Affairs Fed- tion-text (accessed May 6, 2016). Environmental Health Research and of eral Ministry, Republic of Austria. Report 63. Haines A, Hartog M. Doctors and the Test Ban: and Summary of Findings of the Conference, 25 years on. BMJ 1988;297:408–411 Epidemiology and Population Health, Vienna Conference on the Humanitarian Im- 64. British Atomic Scientists’ Association. Stron- London School of Hygiene and Tropical pacts of Nuclear Weapons, 9 Dec 2014. https:// tium hazards. Bulletin of- the Atomic Scientists Medicine, London, WC1H 9SH, www.bmeia.gv.at/fileadmin/user_upload/Zen- 1957;XIII:202–3. E-mail: [email protected] trale/Aussenpolitik/Abruestung/HINW14/ 65. Ervin FR, Glazier JB, Aronow S, et al. Human HINW14_Chair_s_Summary.pdf (accessed and ecologic effects in Massachusetts of an as- Tilman Ruff, May 6, 2016). sumed thermonuclear attack on the United 54. Europe Integration and Foreign Affairs Fed- States. N Engl J Med 1962; 266:1127-37. FRACP, Nossal Institute for Global Health, eral Ministry, Republic of Austria. Humanitar- 66. Sidel V, Geiger.J, Lown B. The physician’s role School of Population and Global Health, ian Pledge. https://www.bmeia.gv.at/fileadmin/ in the postattack period. N Engl J Med 1962; University of Melbourne, Melbourne, user_upload/Zentrale/Aussenpolitik/Abrues- 266:1137-45. Co-President, International Physicians tung/HINW14/HINW14vienna_Pledge_Doc- 67. Leiderman PH, Mendelson JH. Some psychiat- for the Prevention of Nuclear War, ument.pdf (accessed May 6, 2016). ric considerations in planning for defense shel- 55. Europe Integration and Foreign Affairs Fed- ters. N Engl J Med 1962; 266:1149-55. E-mail: [email protected] eral Ministry, Republic of Austria. Support for 68. Aronow S. A glossary of radiation terminology. Pledge. https://www.bmeia.gv.at/fileadmin/ N Engl J Med 1962; 266:1145-9. Hans Kristensen user_upload/Zentrale/Aussenpolitik/Abru- 69. British Medical Association. The medical effects Federation of American Scientists, estung/HINW14/HINW14vienna_update_ of ’ nuclear war. Chichester: Wiley, 1983 Washington DC, pledge_support.pdf (accessed May 6, 2016). 70. The role of Physicians and other health 56. UN General Assembly. Taking forward mul- workers in the preservation of peace as the E-mail: [email protected] tilateral nuclear disarmament negotiations. most significant factor for the attainment of Resolution. A/C.1/70/L.13/Rev.1. New York: health for all http://apps.who.int/iris/bit- Patricia Lewis, PhD United Nations, 2015. http://reachingcriti- stream/10665/160590/1/WHA36_R28_eng. Chatham House, London, calwill.org/images/documents/Disarmament- pdf (accessed May 9th 2016). E-mail: [email protected] fora/1com/1com15/resolutions/L13Rev1.pdf 71. Leaning J, Keyes L. The counterfeit ark. Crisis (accessed May 6, 2016). relocation for nuclear war. Cambridge (MA): 57. Report of the Open-ended Working Group Ballinger, 1984. Zia Mian, PhD taking forward multilateral nuclear disarma- 72. Gorbachev MS. Perestroika. New Thinking for Program on Science and Global Security, ment negotiations, adopted 19 August 2016. Our Country and the World. New York: Harper Princeton University, Princeton, NJ, http://www.reachingcriticalwill.org/images/ & Row; 1988. E-mail: [email protected] documents/Disarmament-fora/OEWG/2016/ 73. Haines A, White c de B, Gleisner J. Nuclear Documents/OEWG-report-final.pdf (accessed weapons and medicine; some ethical dilemmas. October 30, 2016). Journal of Medical Ethics 1983: 9:200-6. 58. United Nations General Assembly. Taking for- 74. World Medical Association. WMA Statement ward multilateral nuclear disarmament nego- on Nuclear Weapons. 66th WMA General As- tiations. UN Document A/C.1/71/L.41. http:// sembly, Moscow, Russia, October 2015. www.
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WMA Calls on Governments to Ban and Eliminate Nuclear Weapons
World Medical Association (WMA) use of nuclear weapons and to work in good faith towards the Statement on Nuclear Weapons elimination of nuclear weapons; Adopted 17 October 2015 2.3 Advises all governments that even a limited nuclear war would bring about immense human suffering and substantial The WMA Declarations of Geneva, of Helsinki and of Tokyo death toll together with catastrophic effects on the earth’s ecosys- make clear the duties and responsibilities of the medical profession tem, which could subsequently decrease the worlds food supply to preserve and safeguard the health of the patient and to conse- and would put a significant portion of the world’s population at crate itself to the service of humanity. The WMA considers that it risk of famine; and has a duty to work for the elimination of nuclear weapons. 2.4 Requests that all National Medical Associations join the WMA in supporting this Declaration, use available educational Therefore the WMA: resources to educate the general public and to urge their respec- tive governments to work towards the elimination of nuclear 2.1 Condemns the development, testing, production, stockpiling, weapons. transfer, deployment, threat and use of nuclear weapons; 2.5 Requests all National Medical Associations to join the WMA 2.2 Requests all governments to refrain from the development, in supporting this Declaration and to urge their respective govern- testing, production, stockpiling, transfer, deployment, threat and ments to work to ban and eliminate nuclear weapons.
a critical trait for resident doctors. Training The Value of Resiliency Training in residents in resiliency skills equips them to effectively identify, cope with, and recover Postgraduate Medical Education from challenging experiences in their per- sonal and professional lives, while setting them up for rewarding and sustainable ca- Residency is a dynamic and stressful relationships with family and friends reers. time. Trainees must continually balance (Resident Doctors of Canada National their roles as both learners and clini- Resident Survey, 2015). The overall de- With content support from the Mental cians within a high-stakes environment. pression rate in U.S. medical students and Health Commission of Canada and the Whether it’s hearing that first code pager, residents is as high as 1 in 5 [1]. Burnout, Department of National Defence’s Road witnessing a patient death, feeling the cu- a work-related syndrome due to chronic to Mental Readiness Program, Resident mulative impact of long hours and on-call exposure to occupational stress, is preva- Doctors of Canada (RDoC) has developed responsibilities, or missing an important lent in 27–75% of residents, depending on a practical, skills-based resiliency curricu- life event at home – every resident deals specialty [2]. lum to help mitigate the negative conse- with stress. quences of stress during residency and beyond. Stress impacts physician well-being. The RDoC’s Resiliency Curriculum majority of Canadian medical residents The curriculum is based on the importance report that work-related fatigue affects Resiliency is the ability to recover from or of promoting mental resiliency in physi- their mental health, physical health, and adjust easily to adverse situations, and it is cians by fostering supportive and positive
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RDoC’s resiliency curriculum encourages an essential part of medication education. residents to learn how to become more RDoC’s next steps include developing a aware of their own mental health, and to strategy to continue delivering resiliency take action early when they start to notice training across the country, in order to shifts in their well-being. Students learn help residents manage stress, support their and practice a series of tools based on cog- peers, and ultimately provide better patient nitive behavioural therapy, performance care. psychology and mindfulness to build and strengthen their resiliency. The curriculum For more information, please e-mail also explores the barriers to seeking help, [email protected] such as concerns regarding privacy or a fear of losing control, as well as some guidelines for approaching colleagues and peers who References appear to be in distress. 1. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, Kent A, Kunkel M, Schechter J, Tate J. Depressive symptoms in medical students and residents: a multischool What’s Next? study. Acad Med. 2009; 84(2): 236-41. Kimberly Williams 2. Ishak WW, Lederer S, Mandili C, Nikravesh R, RDoC has completed a pilot project that Seligman L, Vasa M, Ogunyemi D, Bernstein learning environments. It advocates for a involved delivering and evaluating the re- CA. Burnout During Residency Training: A Literature Review. J Grad Med Educ. 2009 Dec; systematic approach to understanding and siliency curriculum in five clinical special- 1(2): 236–242. addressing anticipated stresses, and assists ties at two Canadian faculties of medicine. residents in overcoming personal adversity The overwhelming response from par- Kimberly Williams, MD by providing them with tools to better sup- ticipants has been that resiliency train- President, Resident port their peers and patients. ing is highly valuable to residents and is Doctors of Canada
The Role of Physicians Fighting Children Trafficking and Illegal Adoptions: the Use of Genetic Identification
1 . Human trafficking or practices similar to slavery, servitude or the removal of organs.” [1] According to UNODC, Article 3, para- graph (a) of the Protocol to Prevent, Sup- Human trafficking involves the forced trans- press and Punish Trafficking in Persons, fer of a person and the use of their services “trafficking in Persons is the recruitment, in order to recruit them for commercial traf- transportation, transfer, harboring or receipt of ficking. Frequently, the consent is obtained persons, by means of the threat or use of force or but through deceitful acts and false promises. other forms of coercion, of abduction, of fraud, of Many times, due to the social conditions of deception, of the abuse of power or of a position the victim, they are not aware of being ex- of vulnerability or of the giving or receiving of ploited. To make it easier, a person is traf- payments or benefits to achieve the consent of a ficked if she or he is forced or tricked into person having control over another person, for a situation in which he or she is exploited. the purpose of exploitation. Exploitation shall Child trafficking differs from human traf- include, at a minimum, the exploitation of the ficking in that no force or deception needs to prostitution of others or other forms of sexual take place in order to prove that a child has exploitation, forced labour or services, slavery been trafficked. This difference is based on Jose A. Lorente
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the fact that a child is considered incapable 1989, entered into force on 2 September the adoption procedures meet all legal re- of taking an informed decision. 1990), states in art. 24.1 that States Parties quirements in their jurisdiction. Since they recognize the right of the child to receive are trusted, the fact of providing informa- the highest attainable standard of health tion about networks related to illegal adop- 2 .Trafficking in children care and to have access to appropriate fa- tions is important. cilities for the treatment of illness and reha- Children, the most fragile members of so- bilitation of health [3]. States Parties shall Beside that, physicians should explain to ciety, can be subjected to many abuses. In- strive to ensure that no child is deprived of families about genetic testing (DNA anal- deed, one of these abuses is human traffick- his or her right of access to such health care ysis) that can be used to confirm the bio- ing, an apparently lucrative criminal activity. services. logical relationship between the children According to UNICEF, “an estimated 300 that are going to be given for adoptions million children worldwide are subjected to Besides that, and according to art. 21, and the relatives (usually parents) who are violence, exploitation and abuse including the States Parties that recognize and/or permit presenting the children for adoption. It is worst forms of child labour in communities, the system of adoption shall ensure that crucial to make sure that children are be- schools and institutions; during armed conflict; the best interests of the child shall be the ing given for adoption on a voluntary basis and to harmful practices such as female genital paramount consideration and they shall: and by their biological parents or relatives. mutilation/cutting and child marriage”. Only (a) Ensure that the adoption of a child is Genetic analysis can also help to identify in the United States are there figures to begin authorized only by accredited authorities missing children that were not previously to appreciate the magnitude of the missing who determine, in accordance with appli- identified and facilitate family reunifica- children problem within the country. Ap- cable law and procedures and on the basis tion. proximately 800,000 children are reported of all pertinent and reliable information, missing each year. Of these, approximately that the adoption is permissible in view 360,000 are runaways and 340,000 are clas- of the child’s status concerning parents, 4 . One example: the DNA- sified as “missing with benign explanation”, relatives and legal guardians and that, if PROKIDS Program: and about 100,000 are abducted either by required, the persons concerned have given family members or other known individuals their informed consent to the adoption on DNA to identify missing or are lost and/or injured (UNICEF 2004; the basis of such counselling as may be and vulnerable children Crimes 2009). While these figures are dis- deemed necessary. turbing, they relate to mostly domestic situa- After a number of successful missing per- tions and do not represent the greater inter- There is no doubt that physicians have a role sons identification initiatives, as e.g. the national problem where children are illegally to play, since their professional activities are Spanish Phoenix Program [4], DNA- sold for malevolent purposes. These numbers crucial in seeking to ensure the adherence PROKIDS was created in 2004 by Dr. Jose also mainly show domestic situations and do to children’s rights, and in particular to ar- Antonio Lorente, Director of the Genetic not represent the huge international prob- ticles 21 & 24. Physicians play a relevant Identification Laboratory of University of lem of the harmful illegal trade of children. role in two different positions during the Granada. After a pilot study from 2006 to Recent reports give information about the whole adoption process before the adoption 2008 in countries from Central America nature of trafficking of children but its real is completed. First, in countries and areas and Asia, it became a worldwide action. significance is still not clear. In 2002, the where children are going to be given for International Labour Organization (ILO) adoption, because they will deal with chil- The goal of DNA-PROKIDS is the use estimated that 1.2 million children are kid- dren who are going to be adopted, and they of human genetic identification technolo- napped and trafficked in a year [2]. must be sure that the child is healthy, with gies (i.e. DNA analysis) to identify missing no injuries that could show battering or children. DNA-PROKIDS is supporting a abuses; they must report to the proper au- number of countries in Latin America and 3 .The role of Physicians thorities any suspicious adoption activities Asia analysis to generate two independent fighting children trafficking related to minors whose identities are not databases, always according to the laws and clear or where legal safeguards are not in regulations in each country: and illegal adoptions place. Second, in countries and areas where children are going to be adopted, physicians QUESTIONED DATABASE: DNA pro- The UNICEF’s Convention on the Rights of should advise those families who are con- files of unidentified children under protec- the Child (resolution 44/25 of 20 November sidering adoption of minors to verify that tion of the authorities living in orphanages,
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NGO’s facilities, or other institutions. In all ologies, including DNA analysis. No child References cases these are children whose family is not should be given for adoption without be- 1. UNODC. https://www.unodc.org/unodc/trea- ties/CTOC, 2016. known. The legal tutor of the child must au- ing sure that his or her family is not look- 2. Hagemann, F. Every Child Counts. New Global thorize the collection of the sample. ing for him or her. Estimates on Child Labour, International Or- ganization for Migration, 2011. Counter traf- ficking and assistance to vulnerable migrants. REFERENCE DATABASE: DNA pro- The application and usefulness of DNA Annual report of activities 2011. files of relatives of missing children: par- identity testing are already well-document- 3. UNICEF Office of Research. https://www. ents, grandparents, etc. who have reported ed. To date DNA-PROKIDS participating unicef-irc.org/portfolios/crc.html, 2016. 4. Lorente JA, Entrala C, Alvarez JC, Lorente M, that his/her biologically-related child is lost. countries have analyzed over 10.500 sam- Villanueva E, Carrasco F, et al. Missing persons These samples are voluntarily provided by ples (from Mexico, Guatemala, El Salvador, identification: Genetics at work for society. Sci- ence, 2000, 290(5500), 2257–2258. the relatives and collected after an informed Paraguay, Peru, Bolivia in Latin America, 5. Ley de Alerta Alb-Keneth-Guatemala. http:// consent form has been signed. and the Philippines, Thailand, Indonesia, www.pgn.gob.gt/ley-alba-keneth, 2016. and India in Asia). DNA analyses first, and Globally, DNA-PROKIDS is composed subsequent application of accompanying Jose A. Lorente1,2, MD, PhD, Maria Saiz1, of three tiers. The first tier is at the national meta-data, have already helped to identify Maria Jesus Alvarez‑Cubero2, level with two genetic databases or indices more than 860 missing children who have Juan Carlos Alvarez1, per country, as previously described. The been returned to their families; and more Juan Jose Rodriguez‑Sendin3, MD, DNA profiles in these two indices will be than 250 illegal adoptions that have been Fernando Rivas3, MD, PhD compared routinely to assist in identifying avoided. 1. DNA-PROKIDS Program- Department missing children. The second tier implies of Legal Medicine, Toxicology and Physical coordination amongst different countries; Guatemala is the first and so far the only Anthropology. Faculty of Medicine. it is highly recommended for neighbor- country in the world that has passed a law PTS Granada. Av. Investigación ing countries in affected regions. The lack (Ley de Alerta Alba-Keneth) in 2010 to 11. 18016. Granada. Spain of coordination plays in detriment of an request DNA analysis on all unidentified 2. GENYO. Centre for Genomics and effective strategy to fight child traffick- children and to offer the analysis for free to Oncological Research. PTS Granada. Avenida ing globally. The third tier would be the the relatives of missing children [5]. de la Ilustración 114. 18016 Granada. Spain adoption of international conventions that 3. Consejo General de Colegios Oficiales should require the correct identification of More operational data and updated informa- de Médicos de España, Madrid every child by using all available method- tion can be found at www.dna-prokids.org E-mail: [email protected]
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to follow its course in the terminal phase Why Should the World Medical Association of sickness”[3]. Moreover, according to the 2002 resolution on euthanasia: “The World not Change its Policy towards Euthanasia? Medical Association reaffirms its strong belief that euthanasia is in conflict with time, and it has changed irreversibly... Nev- basic ethical principles of medical practice ertheless, every doctor would wish to have and the WMA strongly encourages all Na- the same availability and friendliness that tional Medical Associations and physicians Michele had in his medical practice. to refrain from participating in euthanasia, even if national law allows it or decriminal- It seems to me that Van Der Meersch’s sto- izes it under certain conditions”[4]. In this ry can be a useful backdrop for the compli- paper I would like to highlight some of the cated topic of this article. Medical science arguments that justify this policy bearing changes with society, not only because today in mind that negative moral prescriptions we have more diagnostic and therapeutic are not an end in themselves, but are the means than we used to have a few decades starting point for a profound and creative ago. The introduction of technology into reflection on medical assistance at the end medical care has caused a great transforma- of life; an end of life which has benefited tion in the way of conceiving the doctor- immensely over the last decades from ad- patient relationship. Patients are each time vances in palliative care. Unfortunately, the seen by more and more professionals and teaching of this area of medical science has this represents a temptation for the doctor, been insufficient in many instances. For Pablo Requena who can easily become another stranger at this reason, this reflection is also a call for the bedside [2]. Moreover, autonomy, one a more substantial engagement in order to In Maxence Van Der Meersch’s popular of the basic principles of Bioethics, has in- stimulate an increase in undergraduate and novel Bodies and Souls Michele Doutreval, duced many doctors to shirk their duty of graduate training in this important field of a young country doctor, the son of a well- providing advice and orientation, and bar- modern medicine. known university professor in Angers, due ricade themselves behind technical means. to several turns of events, finds himself It is within this complicated medical con- Since its inception, Medical Ethics has re- working in a small town in the North of text and the prolongation of pathological jected euthanasia following a basic deon- France. One of the episodes in particular processes, that the demand for euthanasia tological principle: “doctors must not kill”. describes doctor Doutreval’s great human- can insinuate itself. So far and with few ex- Deontology, which is currently represented ity and good approach to Medicine. On his ceptions, medical science, through its con- by Kantian ethics, highlights what can be way back home after a long day at work, stituent bodies, has refused to take this path. done and what cannot be done. The ratio- he meets a man on his doorstep. The man, However, social pressure is strong in some nale for these norms may vary according to who looks clearly sorry to trouble the doctor countries and consequently it is essential to the various moral formulations, but what is at such a late hour, tells him that his little engage in a calm and well-considered de- more important here is the assumption of a daughter, Franchina Ray is dying of tuber- bate on the topic. series of obligations and prohibitions; pro- culosis and wishes to say goodbye. Michele’s hibitions of acts which contravene the good answer is concise but very illustrative: “Yes, The World Medical Association (WMA), of the person or of society. Apart from the sure. I’ll be right back”. He enters his house which defines euthanasia as “the act of de- deontological argument, utilitarian argu- to greet his wife and to tell her that once liberately ending the life of a patient, even at ments have also been added to recent de- again they will not be able to spend the the patient’s own request or at the request of bates on euthanasia. Their argument claims night together. Then he sets out on his way close relatives”, has condemned euthanasia that a particular action is to be considered to the sick girl’s house where he stands by since 1987 in a clear and explicit way, stat- wrong not because there is a norm prohib- her side until she dies. The episode ends ing that “it is unethical”. It then goes on to iting it, but rather because the action goes with the remark that it was late when the clarify what is and what is not euthanasia, against the greatest good for the great- doctor finally got back home [1]. Medical by adding that “This does not prevent the est number of the people. For the case in science has certainly changed in the century physician from respecting the desire of a point, the utilitarian or consequentialist that separates us from doctor Doutreval’s patient to allow the natural process of death argument rejects the practice of euthanasia.
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Even though utilitarianism does not con- suspicion that doctors would anticipate plying euthanasia to specific cases; but the sider the practice immoral in itself, and in their patients’ death. European experience shows the great influ- fact considers it justified in some cases, it ence the legalisation of this practice has on accepts that allowing it would result in seri- Throughout the centuries, the moral prin- the doctor-patient relationship. Ultimately ous abuses. This form of argumentation has ciple “doctors must not kill” has been passed this means increasing the power of medi- entered the bioethical bibliography using on from generation to generation as a ba- cine to decide end-of-life situations which the term “slippery slope”. sic pillar of the doctor’s vocation. For some, are extremely complex and which could find the idea of converting this rule into a mere in euthanasia a far too easy “solution” [11]. prima facie principle, or a simple piece of “Doctors must not kill” advice that can be ignored in certain cir- Another important aspect when consider- cumstances, constitutes an alteration, not of ing euthanasia that goes beyond the doctor- The deontological principle condemning eu- some peripheral element of Medicine but patient relationship is the weighty matter thanasia finds its paradigmatic expression in of its very essence: “The very soul of medi- of critically ill patients having to make a the Hippocratic Oath, which has constituted cine is on trial” [8]. Lonnie Bristow, former decision, and in a certain sense justify, their the basis of Medical Ethics from the origins president of the AMA, in a statement read desire to carry on living. Although its pro- of medical science to this day. This text, dat- before the Congressional Committee of ponents insist that the choice of euthanasia ing back to the 4th century BC, states: “I will the United States voiced the same opinion: must be free from coercion, in practice this neither give a deadly drug to anybody if “Laws sanctioning physician assisted sui- hardly ever happens. If the sick person is asked for it, nor will I make a suggestion to cide serve to undermine the foundation of aware that her/his condition constitutes a this effect”[5]. This is a brief statement, like the physician-patient relationship, which burden to their family and the community, the rest of the statements that are mentioned is grounded in the patient’s trust that the it is logical that she/he would wish to spare in the Oath, which instructs doctors not to physician is working wholeheartedly for the them the burden and decide for euthanasia provide patients with any means to end their patient’s health and welfare” [9]. for this reason. In 2002, Tonti-Filippini, an lives. Actually, what the Oath condemns is Australian bioethicist (who recently passed what we know today as “assisted suicide”. Daniel Callahan, in his thought provoking away), wrote an open letter in plain and di- However, medical tradition has always seen book The Trouble Dream of Life, holds that rect language to the then Prime Minister it as a prohibition of any lethal act on the part the request for euthanasia is a manifestation of his Country, Mike Rann, concerning a of the doctor. The anthropologist Margaret of patients’ and society’s lack of trust in the legislative proposal in favour of euthanasia. Mead explains that Greek medicine distin- healthcare system. Euthanasia would repre- He pointed out that for people like himself, guished the doctor from the magician, when sent the illusion of being in control of ill- who found themselves in a situation eligible the definitive separation between to kill and ness at all times and of being able to put an for euthanasia, the last thing they needed to cure was achieved [6]. end to life, when considered the best choice, was precisely such a possibility. What they without having to succumb to the domi- needed was human contact, support and As concerns the current debate on euthana- nance of technology that can keep people good medical care, since their critical state sia, this ethical rule is extremely important, alive as long as possible. Fundamentally, of health was already dulling their will to for it was written in a social and philosophi- there is a feeling of mistrust towards the fight…and to live [12]. It seems to me that cal context that widely favoured suicide. doctor and his medicine. What the author this aspect of the matter is rarely taken into Platonists as well as cynics and stoics were finds paradoxical is that in order to protect serious consideration, whereas it should give in favour of euthanasia in the event of ill- itself from this technological assault, society healthcare professionals food for thought. ness, and in some cases it was actually seen would so easily choose this path and happily as an act of courage. Aristotle and Epicu- entrust the doctor with the power of delib- rus held a less positive outlook on suicide, erately ending a life [10]. This view appears Slippery slope though left certain space for its justification as the bottom line in Herbert Hendin’s in- [7]. This is a significant fact, for even though teresting book Seduced by Death, in which The debate on euthanasia has increasingly it was a relatively common and socially jus- the history of euthanasia in the Netherlands given greater weight to moral arguments tified practice, Medical Ethics considered is described directly by the people who have based on consequences caused by actions it important for doctors to avoid in order been involved in it and which concludes and on healthcare policies. The “slippery not to contradict their profession which is with the message that it is not worth fol- slope” argument holds that if a law is passed precisely to cure and not to kill the patient. lowing this path. The author is of the per- allowing euthanasia for a number of very It was also important in order to avoid any sonal view that there is no moral issue in ap- concrete cases and with strict conditions,
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this would not prevent abuse. Experience tinuous deep sedation amounted to 5.6% of cases in which chronically unconscious pa- proves, moreover, that in time the restric- all deaths, whereas in 2005 the number had tients are considered to be better off dead. tions are weakened and euthanasia ends up risen to 7.1%. Increased numbers have also being applied to patients who in principle been recorded in cases referred to as “volun- Some authors claim that “the Dutch experi- should have been excluded. tary stopping of eating and drinking” which, ence” demonstrates a sufficiently transpar- according to the Royal Dutch Medical Associ- ent system in which the incidence of eu- Before we move on to study this issue, let us ation (2011), account for up to 2500 deaths thanasia abuses would not occur frequently look at some data. Even though these num- a year. Although the Dutch Medical Associa- [17]. However, a considerable number of bers do not represent “a fall down the slope”, tion considers this practice distinct from as- authors have found flaws in the system, and they certainly deserve special attention, as sisted suicide, in our opinion there is hardly the inability of avoiding a slip down the they are illustrative of this situation bear- any difference between the two [15]. These “slippery slope”. Raphael Cohen-Almagor, ing in mind that when the law in favour of statistics help give an idea of the situation another author who has made an in-depth euthanasia was approved in the Netherlands regarding euthanasia and similar practices study of euthanasia in the countries that and Belgium in 2002 the thought was that at the end-of-life in the country with the have legalised it, is of the same opinion. In it would apply to a very limited number of most experience of such issues. one of his articles, he writes that, although cases. As a matter of fact in the Netherlands some deny slipping on the “slippery slope”, it was legalised in 1984 as a result of a deci- Going back to the “slippery slope” argu- the two major studies carried out in Hol- sion of the Dutch Suprme Court. In the de- ment, special mention should be made of land in 1990 and 1995 show that frequently, bates previous to the ratification of the law, the works of Professor John Keown, who it is the doctors who first propose eutha- they talked of limit cases in which medical has produced one of the most in-depth nasia or the patient’s family members who care, it was held, was incapable of provid- studies of the debate over voluntary eutha- initiate the discussion process; these initia- ing a satisfactory answer. Instead what has nasia from a legal perspective, and who of- tives in turn have a marked influence on the been witnessed over the years has been an fers a good overview of this tool of moral decision-making process. In other cases, pa- annual increase in the practice of euthanasia reasoning [16]. He distinguishes two main tients’ requests are not adequately evaluated; as more and more justifications have been aspects of the argument: an empirical and a and more seriously, and in quite a number of given for it. It is true that, in the years fol- logical one. The first is a simple observation: cases, people who did not ask for euthanasia lowing the approval of the law in favour of in those places in which euthanasia was ap- end up dead [18]. euthanasia in the Netherlands, there was a proved for persons with incurable illness as- slight decrease in the number of cases com- sociated with intolerable suffering and who The entire system controlling euthanasia in pared to the previous years. In 2001, deaths would repeatedly request for an end to their the Netherlands and Belgium relies on the from euthanasia and assisted suicide repre- lives, it is has been seen that, over the years, information gleaned from questionnaires sented 2.6% of all deaths, whereas in 2005 euthanasia has been performed on patients completed by doctors for each case and sent they represented 1.7% [13]. Nevertheless, with curable illnesses, who did not have in- to the relevant Commission for evaluation. after the numbers settled, there has been a tolerable suffering or who had not requested This control system fails in the assessment considerable increase over the last few years. to die. The logical aspect of the argument, of less clear cases or when not all the legal In the 2003 report of the Regional euthana- holds that the specific precautions, which provisions have been followed. In a study sia review committees which gives data from are taken with the specific purpose of reduc- published in the British Medical Journal in the first year of the promulgation of the law, ing the practice of euthanasia to only limit 2010, Smets et al. analysed questionnaires 1815 cases of euthanasia and assisted sui- cases, disappears not only because of the sent to doctors in Flanders covering a pe- cide were recorded; in 2004, they increased practical question at the moment of imple- riod in which there had been 137 certified to 1886 and in 2005, they reached 1933 mentation, but also because of a theoretical cases of euthanasia out of a total of 6202 cases. In the 2015 report, the total number reason. What justifies euthanasia in certain deaths. The conclusion of the study was that of deaths by euthanasia and assisted suicides limit cases, making reference to patient au- only half of the cases of euthanasia were re- was 5516 [14]. It is also worth noting as tonomy or to the fact that some patients ported to the Commission. In some cases, Van Der Heide does in her 2007 article that would be better off dead, can also be used to the error was due to the fact that doctors did apart from the recorded increase in cases of justify its practice when patients voluntarily not consider the death as due to euthanasia; euthanasia over the years, there has been a ask for it even if they do not have intoler- in others it was due to the feeling that com- parallel increase in cases of continuous deep able suffering such as in the case for elderly pleting the documentation was an admin- sedation intended as a means to hasten pa- people. Similarly, non-voluntary euthanasia istrative burden, or that not all the legal re- tients’ death. In 2001, the deaths from con- would be also considered justifiable in those quirements had been applied. Some doctors
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even claimed that euthanasia was a private In 2014, Belgium abolished the age limit on request for help can be answered in many matter between the doctor and patient [19]. euthanasia. A similar problem arises when different ways, but not all the answers are euthanasia is granted to people with psychi- equally beneficial. As we said at the begin- A number of monographs have been writ- atric illnesses, and in particular those who ning, closing the door on euthanasia should ten on the subject of the “slippery slope” [20]. suffer from depression. In these cases, it is represent a starting point for substantially Due to limited space, we will only mention very hard to ascertain that the request to improving professional training in the ter- three major points: euthanasia for the el- die is the result of a well informed decision minal care of patients. derly people who are not suffering from any made with the minimum amount of interior incurable illness; euthanasia for newborns freedom required for such a decision. Therefore, we believe that WMA should or minors and euthanasia for patients with not change its policy on euthanasia. A pol- depression. The first point is a clear example icy based on a Medical Ethic thousands of of the “slippery slope” argument in action. At A final thought years old, which does not involve any exter- the beginning, the law required an incurable nal control of medical care but rather is a illness, which would cause intolerable suffer- Although many points and much of the de- constant stimulus to better the care of pa- ing. However, according to the 2015 “Code bate on euthanasia could still be analysed tients in the final moments of their lives, al- of Practice” of the Regional euthanasia review and addressed, based on what has been said ways guaranteeing their personal autonomy. committees in the Netherlands, the practice of so far, it appears quite clear that euthanasia is euthanasia is granted to those elderly peo- presented as a “help” and even as a “solution” I am very grateful to Dr. Paul Kioko and ple who think that their lives are no longer for a few hopeless cases. We can conclude Prof. John Keown for their invaluable help worth living and would rather die than con- that, from both a medical and ethical point with the final draft of this article. tinue living. The text goes as far as pointing of view, it represents an inadequate solution out that this question was the issue of previ- to a real problem; a solution that, as we have ous debate but which has been resolved as it seen, leads doctors and patients to get used References has been noted that intolerable suffering is to it and to consider it as one more therapeu- 1. Maxence van der Meersch. Bodies and Souls. not only caused by terminal illnesses but also tic option. This in turn explains the growing New York: Pellegrini & Cudahy, 1948. 2. David J. Rothman. Strangers at the Bedside: by many geriatric conditions [21]. It is easy number of euthanasia cases every year. A History of How Law and Bioethics Trans- to understand how difficult it is for doctors formed Medical Decision Making. New Brun- to evaluate such a request. There are very few We believe that Medicine has much more swick: AldineTransaction, 2008. objective elements foreseen by law on which to offer and that, today, its ability to deal 3. WMA. Adopted by the 39th WMA in Madrid, a request could be based to justify a more or with many symptoms is incomparably bet- Spain, October 1987 and reaffirmed by the 170th less autonomous decision to end one’s life, ter than it was a few years ago. In many Council meeting in Divonne-les-Bains, France, independent of one’s health. articles that describe the experience of eu- May 2005 and by the 200th WMA Council ses- sion in Oslo, Norway, April 2015: http://www. thanasia in the Netherlands and Belgium, wma.net/es/30publications/10policies/e13/ Euthanasia is also problematic when con- pain, and generally pain caused by cancer, is (consulted on 15.09.2016). sidered at the opposite extreme of age. In the one of the major reasons why people ask for 4. WMA.Adopted by the 53rd WMA General As- first years of the debate on euthanasia and euthanasia [24]. In some cases, it is true that sembly in Washington, May 2002 and reaffirmed during the drafting of the first legislation, treating this kind of pain might be very dif- in view of the revision by the 194th Council the practice of euthanasia was intended for ficult, but modern palliative care is capable meeting in Bali, Indonesia, April 2013: http:// adults, who could provide a valid consent. In of alleviating the majority of this type of www.wma.net/es/30publications/10policies/ e13b/ (consulted on 15.09.2016). the Dutch situation, it only took a few years pain. The problem is that, often, physicians 5. Hippocrates. The Hippocratic Oath. In Ludwig to extend euthanasia to those over 16 with- do not possess the appropriate competence Edelstein Supplements to the Bulletin of the out their parents consent, and to those be- to do so. The fifth report of the Federal Com- History of Medicine. Baltimore: Johns Hopkins tween 12 and 16 with parental consent [22]. mission for Control and Assessment of Eutha- Press, 1943; 3. Neither did it take long to justify euthanasia nasia in Belgium (2010-2011) indicates 6. Cfr. Nigel M. de S. Cameron. The New Medi- for newborns born with serious conditions that, of all the doctors who had received cine: Life and Death after Hippocrates. New ed Chicago; London: Bioethics Press, 2001; 162. [23]. Although it may be true that these are requests for euthanasia, only 10% had been 7. William Frankena. The ethics of respect for life. very complex cases, in which the best inter- trained in palliative care. This figure appears In O. Temkin, W.K. Frankena, S.H. Kadish ests of the child are being sought, it is also to us to suggest that the solution to requests (eds.) Respect for life in medicine, philosophy, true that in their justification the basic mor- for euthanasia, which in reality are always and the law. Baltimore: The Johns Hopkins Uni- al element of autonomous decision is lost. a request for help, lies in this direction. A versity Press, 1977; 37-38.
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8. W. Gaylin et al.‘Doctors Must Not Kill’. JAMA www.knmg.nl/over-knmg/contact/about-knmg. en Oregón – USA. Rome: Pontifical University 259, No.14 (April 8, 1988): 2139–40. htm (consulted on 15.09.2016). of the Holy Cross, 2003; Javier Vega Gutiérrez, 9. Massachusetts Medical Society on the Ballot on 16. John Keown. Euthanasia, Ethics and Public Pol- La pendiente resbaladiza en la eutanasia: una Prescribing Medication to End Life (November icy: An Argument against Legalisation. Cam- valoración moral. Rome: Pontifical University of 6, 2012), p. 6. bridge: Cambridge University Press; 2002. the Holy Cross, 2006. 10. Daniel Callahan. The Troubled Dream of Life: 17. Bregje D. Onwuteaka-Philipsen et al.Trends in 21. Regional euthanasia review committees. Code of In Search of a Peaceful Death. Washington DC: End-of-Life Practices before and after the Enact- Practice. The Hague, April 2015: https://www. Georgetown University Press, 2000. ment of the Euthanasia Law in the Netherlands euthanasiecommissie.nl/actueel/nieuws/2016/ 11. Herbert Hendin. Seduced by Death: Doctors, from 1990 to 2010: A Repeated Cross-Sectional mei/27/code-of-pratice-translated-in-english Patients, and Assisted Suicide. New York: W. W. Survey. Lancet, 380, No.9845 (September 8, (consulted on 15.09.2016). Norton, 1998. 2012): 908–15; Bernard Lo. Euthanasia in the 22. More information on the practice in the Nether- 12. Published in the Herald Sun (21.11.20110): Netherlands: What Lessons for Elsewhere? Lan- lands can be found on https://www.government. http://www.heraldsun.com.au/blogs/andrew- cet 380, No.9845 (September 8, 2012): 869–70. nl/topics/euthanasia (consulted on 15.09.2016). bolt/a-dying-man-explains-why-euthana- 18. This study shows 1000 cases of speeding death 23. Eduard Verhagen and Pieter J.J. Sauer. The Gro- sia-is-so-dangerous/news-story/ec8b23ae- without request in 1990 and 900 cases in 1995: ningen Protocol — Euthanasia in Severely Ill 24376e980085f88ef0837b3e (consulted on Raphael Cohen-Almagor. Non-Voluntary and Newborns. New England Journal of Medicine, 15.09.2016) Involuntary Euthanasia in the Netherlands: 352, No.10 (March 10, 2005): 959–62. 13. Agnes van der Heide et al. End-of-Life Prac- Dutch Perspectives. Issues in Law & Medicine 24. See for example the Code of Practice (2015), p.13. tices in the Netherlands under the Euthanasia 18, No. 3 (2003): 239–57. Act. The New England Journal of Medicine 356, 19. Tinne Smets et al. Reporting of Euthanasia in No. 19 (May 10, 2007): 1957–65. Medical Practice in Flanders, Belgium. Pablo Requena 14. This data can be consulted on the website del 20. David Lamb. Down the Slippery Slope: Argu- Associate Professor of Moral Regionale toetsingscommissies euthanasie: ing in Applied Ethics. New York: Croom Helm, Theology and Bioethics https://www.euthanasiecommissie.nl/ consulted 1988; Iñigo Ortega Larrea. Eutanasia: ética y ley 15.09.2016). frente a frente.Rome: Pontifical University of the Pontifical University of the 15. Royal Dutch Medical Association. The Role of Holy Cross, 1996; Roberto Aguado Aguarón. El Holy Cross in Rome the Physician in the Voluntary Termination of cuidado del enfermo en la fase terminal: un es- Vatican Medical Association Life. Amsterdam: KNMG, 2011; 34–36. https:// tudio moral a partir de la práctica de la eutanasia E-mail: [email protected]
Voluntary Euthanasia and Physician- assisted Suicide: Should the WMA Drop its Opposition? Introduction and why they all fail [2]. As the first two arguments are typically at the forefront of The WMA has long opposed the decrimi- the case for decriminalisation, more space nalisation of voluntary euthanasia (VE) will be devoted to them. and/or physician-assisted suicide (PAS) [1]. Its opposition to lethal injections and/or prescriptions for lethal drugs, reinforced by Seven Arguments for that of national medical associations, has Decriminalisation proved a political bulwark against decrimi- nalisation. Precisely because of this, cam- paigners for VE/PAS will increasingly be 1 . Respect for pressuring the WMA, and national medical Autonomy John Keown associations, to drop their opposition, and adopt at least a ‘neutral’ position. “The law should respect a patient’s right to (a) limits to respect for autonomy decide the time and manner of their death, at The short answer to this argument is there This paper will outline seven arguments least if they are ‘terminally ill’ and/or experi- is no such right. While autonomy is an im- that will likely be pressed on the WMA; encing ‘unbearable suffering’.” portant capacity, respect for autonomy has its
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limits and the law places all sorts of reason- quest early death… The message which so- of requesting it? The absence of a request in able restrictions on our autonomy. Patients no ciety sends to vulnerable and disadvantaged the latter case is no reason for denying the more have the right to a lethal injection from people should not, however obliquely, en- ‘benefit’. In short, anyone who supports VE their physician than they have to the amputa- courage them to seek death, but should as- is, logically, committed to supporting NVE. tion of a healthy limb. Patients have a right to sure them of our care and support in life [7]. refuse treatment, but that is a negative right, not a positive right; a shield, not a sword. Similarly, philosopher Onora O’Neill has 2 . Compassion argued: Legalising ‘assisted dying’ amounts One key limit on respect for autonomy is the to adopting a principle of indifference to- “Physicians have a duty of compassion, a duty principle of the inviolability of life (or the wards a special and acute form of vulner- to relieve their patients’ suffering, even if that ‘sanctity of life’) [3]. Laws in most countries ability: in order to allow a few independent means administering a lethal injection.” of the world continue to prohibit a choice folk to get others to kill them on demand, to be killed. This prohibition is grounded in we are to be indifferent to the fact that many (a) limits to compassion a recognition of our fundamental equality- less independent people would come under There is a duty to relieve suffering but, like in-dignity, however sick or disabled we may pressure to request the same [8]. the duty to respect autonomy, it is not unlim- be. As the preamble to the UN Declaration ited. It is trumped by the duty not intention- of Human Rights puts it: “Recognition of It is no surprise, then, that disability groups ally to kill patients. This duty not to kill has the inherent dignity and of the equal and (like ‘Not Dead Yet’) [9] are at the forefront formed the bedrock of professional medical inalienable rights of all members of the hu- of opposition to decriminalisation. They see ethics since the Hippocratic Oath [10]. The man family is the foundation of freedom, more clearly than many that, despite the core vocation of the physician is to heal, to justice and peace in the world” [4]. We all emphasis placed by euthanasia campaigners make whole, not to make dead [11]. enjoy the ‘right to life’, the inalienable right on choice, the case for VE/PAS rests funda- not to be intentionally killed. In its 1994 re- mentally on the judgement that certain pa- This vocation includes a duty to alleviate port unanimously rejecting the case for VE/ tients have lives that are not ‘worth living’, suffering even if, as an unintended side-ef- PAS, the UK’s House of Lords Select Com- that they would be ‘better off dead’. fect, life is shortened. But it rules out inten- mittee on Medical Ethics defended the pro- tional killing. Once physicians embrace kill- hibition on intentional killing, observing: (c) judging patients ‘better off dead’ ing as a ‘therapeutic’ intervention, this surely That prohibition is the cornerstone of law Typical legal proposals for decriminalisation endangers the trust that patients now have, and of social relationships. It protects each would not allow patients obtain VE/PAS on that their physician will never judge them to one of us impartially, embodying the belief request: patients would also have to satisfy be ‘better off dead’. As Alexander Capron, that all are equal [5]. some other criterion, such as ‘unbearable the leading US health lawyer, once starkly suffering’. In other words, doctors would put it, he never wanted to have to wonder And, in any event, how many requests for have to judge which autonomous requests to whether the physician entering his room VE/PAS would be truly autonomous, espe- grant, and which to refuse. And how would was wearing the white coat of the healer or cially when suicidal ideation is often asso- the doctor decide, other than on the basis of the black hood of the executioner [12]. ciated with clinical depression? The Select a judgment that the patient would, or would Committee concluded: [W]e do not think not, be ‘better off dead’? (“I think patient A’s (b) palliative care it possible to set secure limits on voluntary suffering is so severe that death would ben- Not only is killing unethical; it is unneces- euthanasia…It would be next to impossible efit her, but that patient B’s suffering is in- sary. The enormous progress that has been to ensure that all acts of euthanasia were sufficient to render his life no longer worth made in palliative care, not least since the truly voluntary, and that any liberalisation living.”) Moreover, once a doctor is prepared establishment of the hospice movement by of the law was not abused [6]. to make that judgment, that certain patients Dame Cicely Saunders 50 years ago, means would be ‘better off dead’, why shouldn’t the that no patient need suffer unbearably. Even (b) protecting the vulnerable doctor make the same judgment in relation in rare cases of refractory pain, there is the Concern for the vulnerable is another pow- to incompetent patients and end their suf- option of palliative sedation. In 2014, a poll erful reason for limiting individual auton- fering, by performing ‘non-voluntary’ eu- of the Royal College of Physicians showed omy. The Select Committee stated: We are thanasia (NVE)? If death can be a benefit that over 60% of its members agreed that also concerned that vulnerable people – the for a patient with ‘unbearable suffering’ who patients could die with dignity under the elderly, lonely, sick or distressed – would feel requests it, why can’t it equally benefit a pa- existing law, and that relaxation of the law pressure, whether real or imagined, to re- tient with ‘unbearable suffering’ incapable is not needed [13].
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(c) ‘unbearable suffering’? 3 . Legal Hypocrisy decriminalisation did not imply condona- Although euthanasia advocates typically use tion [27]. The explanation for decriminali- emotionally-charged cases of dying patients “The law allows doctors to end lives by withhold- sation lay elsewhere. with painful symptoms to front their cam- ing/withdrawing life-prolonging treatment or paign, the reality is that after decriminalisa- by administering drugs which, as a side-effect, Legislators increasingly appreciated, thanks tion VE and PAS come to be condoned a shorten life, so it is hypocritical of the law to pro- to the development of the specialty of psy- much wider range of cases. hibit them from performing VE/PAS.” chiatry, that suicidal ideation is associated with psychiatric disturbance, and that the The Dutch Supreme Court decriminalised Leaving aside the fact that, properly ti- suicidal would be better diverted from sui- VE/PAS in 1984 (the guidelines gaining trated, palliative drugs do not in fact hasten cide by the mental health system than by statutory force in 2002) [14]. In 1994 the death [23], the short answer to this argument the criminal justice system. Moreover, the Court held that purely mental suffering is that there is a cardinal ethical and legal dis- crime stigmatised family members and led could qualify [15]. The Dutch government tinction between intending and merely fore- to the unfortunate consequence of pros- proposes to permit assisted suicide for el- seeing the shortening of life. The US Supreme ecuting attempted suicides [28]. derly people with a ‘completed life’; and Court rejected the argument that respecting a even under the present law elderly people patient’s refusal of life-prolonging treatment is Moreover, assisting or encouraging suicide who are ‘tired of life’ may obtain VE/PAS, the same as PAS, noting that in PAS the phy- remained a serious crime, which confirms provided they can also point to some medi- sician intends to assist the patient’s death, but that there is no ‘right to suicide’ and that cal condition in support of their request this is not necessarily so with respecting a refus- suicide remains contrary to public policy. (and what elderly person does not have al of treatment [24]. Chief Justice Rehnquist some medical condition?) [16] In Belgium, noted that the fact that General Eisenhower the ‘bracket creep’ has been even faster, from foresaw on D-Day that he was sending many 5 . Public Opinion Polls VE to PAS (the euthanasia review commis- American soldiers to certain death did not sion endorses PAS even though the statute mean he intended their death: his purpose “Opinion polls show that a clear majority of the mentions only VE); from adults to compe- was to liberate Europe from the Nazis [25]. public want the law to allow VE/PAS. The law tent minors; and from physical to mental should reflect the will of the people.” suffering [17]. Cases such as the purblind Even the Dutch and the Belgians euthana- twins [18], the distressed transsexual [19], sia laws, which reject the Hippocractic ethic It does seem that polls tend to show a clear and the grieving mother [20], have all illus- against medical killing, agree that eutha- majority in favour of decriminalisation. But, trated the disturbing elasticity of the legal nasia involves intentional, and not merely first, polls can be misleading. Much can de- criteria. foreseen, life-shortening [26]. pend on the phrasing of questions and on the amount of background information, if any, Moreover, the official reports from the US This distinction drawn by the law and by given to those polled. One expert commit- State of Oregon, where PAS has been prac- professional medical ethics is not, then, tee concluded that the polls tended to reflect tised for almost 20 years, show that the two hypocritical: it is Hippocratic. ‘kneejerk’ reactions to VE/PAS, not informed main reasons for requesting PAS have not opinion [29]. Second, it may well be that the been suffering but ‘losing autonomy’ and majority of the public support the restoration a decreasing ability ‘to engage in activities 4 . A Right to Suicide of capital and corporal punishment. Is that a making life enjoyable’ [21]. sound argument for their restoration? “In many countries suicide has been decrimi- (d) compassion for the incompetent nalised. This means that the law now recognises If compassion justifies killing suffering pa- a right to commit suicide. If there is a right to 6 . Legal Failure tients who request it, why does it not justify commit suicide, it should be legal to assist some- killing suffering patients who cannot re- one to exercise that right.” “The law is ineffective. VE/PAS are practised quest it? Why should compassion be con- illegally. Decriminalisation would bring them fined to the competent? Yet again, we see The argument is misconceived. It does not out into the open and subject them to effective the logical link between VE and NVE. The follow that decriminalisation represents a legal control.” Dutch courts endorsed VE/PAS in 1984. condonation of suicide, let alone recogni- Twelve years later, logically, they endorsed tion of a ‘right to suicide’. In the UK, for ex- All criminal laws are broken to some extent, NVE, in the form of infanticide [22]. ample, legislators made it crystal clear that sometimes (like speeding laws) to a con-
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siderable extent, but that is hardly by itself As for Oregon, there have been no compre- rejected the case for decriminalisation, most a reason to repeal them. And there is little hensive surveys, so any claims that its law recently in 2015, when the House of Com- evidence that laws against VE/PAS are any is achieving effective control lack substan- mons voted by a margin of 3-1 against a Bill less effective than many other criminal laws. tiation. Its so-called ‘safeguards’, which are to decriminalise PAS [41]. Another exam- For example, research by Professor Clive even laxer than those in the Low Countries, ple is the World Medical Association itself. Seale found that the incidence of VE/PAS have been aptly described by Professor Cap- in the UK was ‘extremely low’ (and signifi- ron as “largely illusory” [35]. cantly lower than in the Netherlands, which Conclusion permits them) [30]. There will be breaches The regulatory mechanism in all three ju- of the law, to a greater or lesser extent, in risdictions depends on self-reporting by Campaigners for VE/PAS will, on the basis different jurisdictions, depending on a range physicians. It is, therefore, intrinsically inef- of some or all of the above seven arguments, of cultural factors. This is not by itself an ar- fective. How many physicians are going to increasingly urge that the WMA should gument for repeal (especially when repeal is report that they have broken the law? drop its opposition to VE/PAS. Those ar- very likely to provoke a substantial increase guments are, however, unpersuasive. The in the incidence of VE/PAS). In 2015 the Supreme Court of Canada WMA’s opposition is as well-grounded as it controversially created a legal right to VE/ is well-established. Moreover, the claim that decriminalisa- PAS [36]. In arriving at this decision, which tion brings VE/PAS ‘out into the open’ was out of line with decisions of the Su- Moreover, if the WMA were to shift to a and subjects them to ‘effective legal con- preme Courts of the US and the UK, the ‘neutral’ position, the move would be widely trol’ is belied by the experience of the two court agreed with the trial judge’s factual perceived as at least a tacit endorsement of main jurisdictions to have decriminalised finding that the risks of decriminalisation VE/PAS. It would be used by campaign- VE/PAS: the Netherlands and Belgium. ‘can very largely be avoided through carefully ers as a powerful lever to prise open the The Dutch in particular have carried out designed, well-monitored safeguards’ [37]. door to decriminalisation worldwide, de- valuable surveys into end-of-life decision- However, three judges of the Irish High criminalisation which would not only sub- making. Those surveys have shown that Court, who later carefully reviewed the same vert the traditional healing vocation of the doctors have failed to report thousands of evidence as the trial judge, rejected her find- medical profession, but would lead to VE/ cases to the Dutch monitoring authorities. ing [38]. And rightly so. Given that no ju- PAS becoming increasingly perceived as a In 1990 only 20% were reported, and al- risdiction has ‘carefully designed, well moni- part of normal medical practice, and even a though more recently the proportion has tored safeguards’, and given the disturbing patient’s right, as appears to be happening grown to 80% [31], this means that around experience of the Low Countries, one can in the Low Countries. And with VE/PAS 1 in 5 cases of VE/PAS is still being il- only guess what led the Canadian judges to transformed from a crime to a ‘treatment’, legally certified by Dutch physicians as their strange conclusion [39]. doctors would be expected to deliver it, or death by ‘natural causes’. Belgian surveys at least to refer patients to colleagues pre- have disclosed that only 50% of cases are pared to do so. The recent call by two lead- reported to the authorities [32]. 7 . Religion ing advocates of decriminalisation that doc- tors in Canada be legally required to refer It is not surprising that the Dutch law has “Opposition to decriminalisation is essentially patients, and for students with objections to now been criticised, twice, by the UN Hu- religious, and religious views should not be im- referral to be denied admission to medical man Rights Committee. In 2001 the Com- posed in secular societies.” school [42], is but a foretaste of what medi- mittee expressed concern not only about cal professionals worldwide can expect if the adequacy of the regulatory system, but This last argument is as lame as it is fre- the law in their countries is relaxed. about the extension of the law to minors, quent. The key arguments against legalisa- and the practice of infanticide [33]. In 2009 tion, not least that it would undermine ‘the it remained concerned about the extent of cornerstone of law and of social relation- References VE/PAS and the fact that a physician could ships’ by endorsing intentional killing, and 1. World Medical Association. WMA Resolu- terminate a patient’s life without any in- that it would threaten vulnerable patients, tion on Euthanasia [Internet] [cited 2016 Oct 3] Available from: http://www.wma.net/ dependent review by a judge or magistrate are philosophical, not theological [40]. en/30publications/10policies/e13b/ to guarantee that the decision was not the Moreover, many secular bodies have op- 2. For a fuller treatment of these arguments see subject of undue influence or misapprehen- posed decriminalisation. One example is Keown, John. Against Legalising Euthanasia; sion [34]. the UK Parliament, which has repeatedly For Improving Care. In Jackson, Emily and
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Keown, John. Debating Euthanasia. Oxford: 16. Lemmens, Willem et al, ‘The Dangers of Eu- 25. Ibid. 803. Hart Publishing, 2011, hereafter ‘DE’, 83-174. thanasia on Demand’. The Chicago Tribune. 26. Nys, Herman. A Presentation of the Belgian See also Keown, John. Debating Euthanasia: A 17 October 2016. Cf. ‘The Royal Dutch Medi- Act on Euthanasia Against the Background of Reply to Emily Jackson. In: Heneghan, Mark cal Association. The Role of the Physician in the Dutch Euthanasia Law. European Journal of and Wall, Jesse. Law, Ethics and Medicine: Es- Voluntary Termination of Life (KNMG posi- Health Law 2003; 10: 239, 240. says in Honour of Peter Skegg (2016) 65-95. See tion paper, June 2011). This paper states (at 40): 27. See Keown, John. Euthanasia, Ethics and Public also Keown, John. Euthanasia, Ethics and Public “Before deciding to grant a request for euthana- Policy. Cambridge: Cambridge University Press, Policy. Cambridge: Cambridge University Press, sia or assisted suicide, the physician must gain or 2002: 64-6. 2002; (2nd ed forthcoming 2017). facilitate insight into the suffering and be con- 28. See ibid. 286-87. 3. See generally Keown, John. The Law and Eth- vinced that the suffering is unbearable and has 29. See DE 113-14. ics of Medicine: Essays on the Inviolability of at least in part a medical basis.” The paper con- 30. Seale, Clive. National survey of end-of-life deci- Human Life. Oxford: Oxford University Press, tinues (at 41) that, even if the patient is refused sions made by UK medical practitioners. Pallia- 2012; chapter 1. euthanasia, the patient may decide to refuse food tive Medicine 2006; 20: 3, 6. 4. United Nations. The Universal Declaration of and drink, and that “the physician is obligated, in 31. Griffiths, John et al. Euthanasia and Law in Eu- Human Rights (1948) [Internet] [cited 2016 such cases, to supervise the patient and to allevi- rope. Oxford: Hart Publishing, 2008: 199. Oct 3] Available from: www.un.org/en/univer- ate the suffering by arranging effective palliative 32. Chambaere, K et al. Recent Trends in Euthana- sal-declaration-human-rights/ care.” All Dutch patients would now appear to sia and Other End-of-Life Practices in Belgium. 5. Report of the Select Committee on Medical have a right to medical assistance in suicide, at New Engl J Med 2015; 372; 1179-81. Ethics. London: HMSO. Paper 21-I of 1993- least by palliated self-starvation. 33. UN Press Release. Human Rights Commit- 94; para. 237. 17. See generally Montero, Étienne. The Belgian tee Concludes Seventy-Second Session. (HR/ 6. Ibid. para. 238. experience of euthanasia: 14 years of legal CT/610; 2001 July 30). 7. Ibid. para. 239. implementation. In: Jones, David Albert et al, 34. UN Human Rights Committee. Consideration 8. ‘A Note on Autonomy and Assisted Dying’. Un- Euthanasia and Assisted Suicide: Lessons from of Reports Submitted by States Parties Under published memorandum (quoted in DE at 93) Belgium. Cambridge: Cambridge University Article 40 of the Covenant. (CCPR/C/NLD/ circulated to members of the House of Lords Press, forthcoming. (I am grateful to Professors CO/4, 25 August 2009) para. 7. during its consideration of Lord Joffe’s Assisted Jones and Montero for a view of this essay). See 35. Capron, Alexander M. Legalizing Physician- Dying for the Terminally Ill Bill, which fell in also Montero, Étienne. Rendez-Vous Avec La Aided Death. Camb Q Healthc Ethics 1996; Mort: Dix ans d’euthanasie légale en Bélgique. 2006. 5(1); 10. Limal: Anthemis, 2013; (available in Spanish 9. [Internet] [cited 2016 Oct 3] Available from: 36. Carter v. Canada (Attorney-General) [2015] as: Cita Con La Muerte: 10 años de eutanasia http://notdeadyet.org SCC 5. legal en Bélgica. Madrid: Ediciones RIALP, 10. “I will not give a lethal drug to anyone if I am 37. Ibid. at [117]. asked, nor will I advise such a plan…”. Hip- 2013). 38. Fleming v Ireland [2013] IEHC 2 at [88] – pocratic Oath. History of Medicine Division, 18. Waterfield, Bruno. Euthanasia twins ‘had noth- [105]. Remarkably, the Canadian Supreme National Library of Medicine, National Insti- ing to live for’. The Daily Telegraph. 14 January Court simply ignored the Irish judges’ rejection tutes of Health. [Internet] [cited 2016 Oct 3] 2013. of the Canadian trial judge’s finding. Available from: https://www.nlm.nih.gov/hmd/ 19. Waterfield, Bruno. Belgian killed by euthanasia 39. See Keown, John. A Right to Voluntary Eutha- greek/greek_oath.html after a botched sex change operation. The Daily nasia? Confusion in Canada in Carter. Notre 11. See Kass, Leon R. I Will Give No Deadly Drug: Telegraph. 1 October 2013. Dame JL, Ethics & Pub Pol’y 2014; 28; 1. Why Doctors Must Not Kill. In: Foley, Kathleen 20. The subject of a disturbing documentary on 40. An early, and now classic, philosophical case and Hendin, Herbert (eds) The Case against Australian channel SBS. Allow Me to Die. 24 against decriminalisation, by a ‘self-styled lib- Assisted Suicide: For the Right to End of Life November 2015. [Internet] [cited 2016 Oct 3] eral’ law professor, is Kamisar, Yale. Some Non- Care. Baltimore: The John Hopkins University Available from: http://www.sbs.com.au/news/ Religious Views against Proposed Mercy-Killing Press, 2002:17-40, and Pellegrino, Edmund D. dateline/story/allow-me-die. Legislation. Minnesota Law Review 1958; 42(6); Compassion is Not Enough. In ibid. 41-51. 21. Oregon Health Authority. Oregon Death with 12. Quoted in DE 104. Dignity Act: 2015 Data Summary. Table 1. End 969-1042. [Internet] [cited 2016 Oct 3]. Avail- 13. RCP affirms position against assisted dying [In- of life concerns. [Cited 2016 Oct 3] Available able from: http://repository.law.umich.edu/cgi/ ternet] [cited 2016 Oct 3]. Available from: htt- from: https://public.health.oregon.gov/Provider- viewcontent.cgi?article=2065&context=articles ps://www.rcplondon.ac.uk/news/rcp-reaffirms- PartnerResources/EvaluationResearch/Death- 41. Gallagher, James and Roxby, Philippa. Assisted position-against-assisted-dying withDignityAct/Documents/year18.pdf Dying Bill: MPs reject ‘right to die’ law. BBC 14. See generally Keown, John. Euthanasia, Ethics 22. Keown, John. Euthanasia, Ethics and Public News 11 September 2015. and Public Policy. Cambridge: Cambridge Uni- Policy. Cambridge: Cambridge University Press, 42. Savulescu, Julian and Schuklenk, Udo. Doctors versity Press, 2002: part III; Cohen-Almagor, 2002: 119-20. And see Verhagen, Eduard and Have no Right to Refuse Medical Assistance in Raphael. Euthanasia in the Netherlands: The Sauer, Pieter JJ. The Groningen Protocol – Eu- Dying, Abortion, or Contraception. Bioethics Policy and Practice of Mercy Killing. Dordrecht: thanasia in Severely Ill Newborns. New Engl J 10.1111/bioe.12288. Kluwer, 2004; Griffiths, John et al. Euthanasia Med 2005; 352: 959-62. Professor John Keown, 23. Twycross, Robert. Where there is hope there is and Law in Europe. Oxford: Hart Publishing, MA, DPhil, PhD, DCL 2008; part I. life: a view from the hospice. In: Keown, John 15. Keown, John. Euthanasia, Ethics and Public (ed) Euthanasia Examined. Cambridge: Cam- Kennedy Institute of Ethics Policy. Cambridge: Cambridge University Press, bridge University Press, 1995: 141, 161-62. Georgetown University 2002: 87. 24. Vacco v Quill 521 US 793, 800-02 (1997). E-mail: [email protected]
BACK TO CONTENTS 107 Antimicrobial Resistance
One Health and Antimicrobial Resistance
Caline Mattar Ana Sofia Ore Steen K. Fagerberg Reshma Wunna Tun Elizabeth Wiley Helena J. Chapman Ramachandran
Introduction al Action Plan on Antimicrobial Resistance, Since the 1990s, globalization has facilitated which articulated five main objectives. Ob- the spread of infectious diseases, especially Antimicrobial Resistance (AMR) is a grow- jective four more notably focuses on opti- through increased travel for humans, expand- ing concern globally and a significant threat mizing the use of antibiotics in both human ed geographic boundaries for commerce and to public health. It has been demonstrated to and animal health [2]. At this stage of the trade for animal products and other goods, be on a steady rise and new mechanisms of action plan implementation, it is critical for and anthropogenic changes to the physi- resistance are emerging every day, exhausting all stakeholders to engage and commit to cal environment such as deforestation or air the antibiotic options currently available. combat the rampant AMR threat. and water pollution [5]. These new environ- ments have facilitated the emergence and re- AMR has both health and economic im- emergence of infectious diseases which add plications. The UK Review on AMR has The Intersection of to the global health burden. These “emerg- estimated that the costs of AMR will be Antimicrobial Resistance and ing diseases” are novel pathogens or existing staggering – by 2050 the annual death toll pathogens that have increased in number or of AMR will surpass cancer, and the lost the “One Health” Concept expanded in geographic distribution within global production will equal the equivalent the environment [6]. Zoonotic infections, or of the United Kingdom’s gross domestic Infectious pathogens, whether by endemic those pathogens transmitted from animals product (GDP) or 100 trillion USD [1]. or epidemic trends, continue to produce sig- to humans, are estimated to represent up to nificant morbidity and mortality across com- 75% of these emerging diseases [7]. Zoonot- Increasing evidence that the overuse and munities. The World Health Organization ic disease transmission may include contact misuse of antibiotics in food animal produc- (WHO) reported that infectious diseases rep- with domestic or wild animals or exposure tion is contributing to this rise in resistance resented 12 million deaths (23%) in 2000 and to animal products, vectors or contaminated has also emerged. In November 2015, re- 9.5 million deaths (17%) in 2012, of all causes environments. searchers in China discovered mcr-1, a gene of global mortality in humans [3]. These esti- conferring plasmid mediated resistance to mates may be underreported, however, since In order to strengthen the global control and colistin in pigs, which since has been found they do not account for pathogens that cause prevention of emerging diseases, the “One in humans as well. chronic diseases (e.g., rheumatic heart dis- Health” approach should be implemented ease caused by Streptococcus) or other disease into public health practice. Recognized since The root cause of rising resistance has many complications (e.g., hepatocellular carcinoma the 1800s, yet more recently coined the term, facets and involves a multitude of stake- caused by chronic hepatitis B or C infec- the “One Health” concept links human health, holders from different sectors, however tion) [4]. As global mortality trends due to animal health and the environment. Six pri- today, an overwhelming proportion of the infectious diseases have declined over the past mary factors have been described to drive the worldwide consumption of antibiotics is decade, public health leaders should quickly spread of these emerging diseases: 1) human for animal use. This puts the veterinary and identify economic, environmental, political population growth and mobility (e.g., chol- agricultural sector use at the essence of the and social challenges encountered in disease era, influenza A virus); 2) food production fight against AMR. In May of 2015, the control and form multi-sectoral collabora- through agriculture and livestock farming World Health Assembly adopted the Glob- tions to continue this downhill disease trend. (e.g., Escherichia coli, Salmonella enterica);
108 Antimicrobial Resistance
3) wildlife trade by legal or illegal means to monitor food production or veterinary to the development and spread of resistant (e.g., influenza virus); 4) environmental fac- health risks due to inadequate leadership, bacteria. In 1940, antibiotic use to increase tors such as land use changes and manmade political or economic conflict, or natural di- the amount of meat produced in animals was influences on loss of biodiversity (e.g., malar- sasters [14; 15]. Since complex epidemiol- found to be effective. This constituted the first ia, leishmaniasis); 5) technological advance- ogy describes pathogen transmission in the step into widely using antibiotics as growth ments such as improved disease detection or human-animal interface, which challenges promoters, despite some early studies like unintentional or intentional release of labo- the formal assessment of AMR [16], estab- Levy et al. [20] showing an increase in antibi- ratory agents (e.g., anthrax, brucellosis); and lishing the infrastructure of the surveillance otic resistance. This study tested a long course 8) poor leadership and infrastructure across system should be a priority for the health of low-dose tetracycline in chickens; this led public and private sectors (cholera, tubercu- sector. As such, by using the “One Health” to single drug resistance which rapidly devel- losis) [8; 9]. Among these factors, the com- approach, public health leaders can collabo- oped into multidrug resistance that spread mon element lies in the potential of increased rate across disciplines to reduce zoonotic beyond individual animals exposed and into proximity to domestic or wild animals. First, transmission and AMR, thereby improving humans. A more recent study performed by companion animals, primarily dogs and cats, disease control and prevention strategies. Price et al. [21] found evidence that Methi- may enhance the human-animal emotional cillin-resistant Staphylococcus aureus (MRSA) bond, but remain a threat for various zoonot- acquired tetracycline and methicillin resis- ic disease transmission, such as bartonellosis, Antibiotics for non- tance in livestock. This has been confirmed giardiasis and toxoplasmosis [10]. Second, Therapeutic Use by another study [22] which found MRSA in animal husbandry or caring for and manag- meat and poultry in the United States. ing livestock represents a significant source When discussing AMR, another essential of food security and economic sustainability point to mention would be Antibiotics for Many governments have taken actions into for livestock owners and families. Thus, public non-therapeutic use, which is a practice pe- this matter. One of the first countries to ad- health programs can effectively prepare and culiar to the animal sector. dress this issue was Denmark. By 1995 they educate their local communities about health banned avoparcin, one of many antibiotics hazards if they understand this interplay be- Non therapeutic indications for antibiotic used for growth promotion; this was the be- tween zoonotic disease transmission and un- use in animal agriculture and aquaculture ginning of a series of regulations which lead derlying cultural, economic and environmen- involve administering antimicrobial drugs to the European Union (EU) in 1998 banning tal influences related to animal contact. to healthy animals for prophylaxis or growth feeding of antibiotics to animals that are valu- production. Hypothesized mechanisms in- able to human health. Less than 10 years later AMR has been reported in emerging infec- clude a more rapid growth of animals while the EU banned all antibiotics and related drugs tious diseases, emphasizing this intimate preventing disease. Studies have linked an- to livestock for growth promotion purposes. connection to the “One Health” concept tibiotic induced changes to changes in me- and human, animal and environmental tabolism, adiposity and higher fat mass [17]. Denmark also created DANMAP in 1995, health [11]. More specifically, three specific In some countries gross weight of antibiot- their own system for monitoring antibiotic challenges should be addressed. First, food- ics used in animals is higher than the gross resistance in farm animals with the objective borne zoonoses are increasing in incidence weight used in humans and the classes of of following the outcomes of banning anti- and becoming more resistant to antibiot- antibiotics used are mostly the same [18]. biotic drugs for growth promotion which ics [12]. Thus, food safety education and through VETSTAT, a monitoring system proper hygiene when handling domestic or There are several pathways for transmission which task was to gather and process records livestock animals can inform communities of antibiotic resistant bacteria from food of drug use in animal herds. They also creat- about the health risks of food-borne zoo- animal production to humans. These might ed the Yellow Card scheme which decreased noses. Second, specific driving factors that include transmission of resistant pathogens the total consumption of antibiotics in pigs influence the spread of emerging diseases from food animals to producers and proces- by implementing a monitoring system with in target communities should be identi- sors, through contaminated food or animal penalties and regular visits to producers. fied [13]. Public health practitioners can products, environmental releases from pro- then be prepared to act promptly and ap- duction facilities, poor control of waste man- When measuring its effect, antimicrobial propriately to reduce disease transmission agement and non-domesticated animals [19]. agent usage dropped and AMR for growth or propagation to new geographic areas. promotion also decreased. These actions did Third, low- and middle-income countries Clinical studies have confirmed that the use of not have a negative effect in Danish swine may not have elaborate surveillance systems antibiotics in agricultural settings contributes and poultry production.
BACK TO CONTENTS 109 Antimicrobial Resistance
Despite their efforts, the use of antibiotics tion. A major part of Danish export is based number of deaths in the years 2013-2015, for therapeutic indications in animals and an on swine production, and the demand of ani- in particular due to MRSA ST398. increase in meat imports makes resistance a mal export is increasing. Increased produc- continuing problem [23]. In 2003 a scientific tion has led to a rise in the use of antibiotics, A series of screenings and quarantine regu- assessment by the Food and Agriculture Or- especially tetracyclines, which holds a central lations for people living in close proximity ganization and the WHO determined that role in the treatment of animal infections in to animal production facilities was imple- the use of antibiotics in the agricultural set- Denmark. A consequence of rising demands mented, and a mandatory screening for ting is the principal contributing factor to the is an increased number of animals per area farmers at the admission to hospitals was emergence and dissemination of AMR [24]. in piggeries, and hence, a higher possibility initiated. From October 1, 2014, it became of animal-to-animal transmitted infections. mandatory for all Danish farmers to create Many recommendations have been made This has led to a general increase in the use of and implement an approved strategy for to incorporate surveillance in all countries broad-spectrum antibiotics, which started in prevention of transmissions approved by a using antibiotics for non-therapeutic uses, 2009. Despite that, the total use of antibiotics veterinarian, and among other initiatives it but only a limited number of countries have in 2014 was 86 tonnes which is five percent became a requirement that only sick ani- complied. Monitoring in most of the EU lower than in 2013 when adjusted for the in- mals are to be treated with antibiotics [29]. member states is performed by the Europe- creased export [25]. In the past five years, the an Food Safety Authority (EFSA). Starting total use in swine production has been stable, The Danish Models has been proven to be in 2011, a combined report with animal and and there has been a small increase in the use successful in terms of creating awareness human data is now being compiled. of antibiotics for pig finishers, but a signifi- of the problem of AMR development, and cant decrease in the use of systematic use of the initiative implemented over the past All improvements in monitoring and regula- cephalosporins for pigs in general. Based on 20 years such as the Yellow Card, new re- tion lead up to the concept of integrated sur- these data, it is fair to conclude that Danish strictive legislation, and research and sur- veillance of antimicrobial resistance in food- farmers are balancing the use of antibiotics veillance have created a strong platform and borne bacteria. This covers testing of bacteria responsibly, but that the guidance of DAN- tradition to battle the emerging challenges. from food animals, foods, environmental MAP surveillance and regulations are critical sources and clinically ill humans and the to secure a sustainable development. antibiotic resistance found during the proce- Conclusion dures that encompass this elements. WHO The pressure on lowering use of antibiotics has recommended the use of this integrated has created an incentive to use zinc-based It is evident today that the issue of AMR surveillance in all countries to monitor and agents, such as zinc oxide or zinc chloride. cannot be restricted to the silo of human control the spread of resistant bacteria in These agents have been used increasingly or animal health. At this point, it is critical animal products [18]. One of the biggest instead of antibiotics, but most recent stud- for healthcare professionals, researchers and challenges to perform and share this infor- ies indicate that the use of zinc possesses policy makers to join efforts with the veteri- mation globally is the lack of harmonization a risk of developing MRSA strains in the nary and agriculture professionals, to gain a between reports in different countries. This is treated animals [26], and are at this point better understanding of the “One Health” one of the objectives of the WHO Advisory being monitored carefully. approach, more specifically in the context of Group on Integrated Surveillance of Anti- AMR, which is an urgent threat to global and microbial Resistance (WHO-AGISAR). Another more direct challenge is the in- public health. Stronger policies and innova- Their main objective being to minimize the creasing numbers of cases of MRSA and tive research to address the use of antibiotics public health impact of AMR associated ESBL bacterial strains in Danish pigger- and to explore new solutions to minimize with food producing animals. ies where DANMAP described increases the development of resistance in the ani- in MRSA in their 2011 report [27]. In the mal and agricultural sector are needed. The following years, the same agency docu- World Medical Association and the World The Current State of mented several new cases of both MRSA Veterinary Medicine Association have initi- the Danish Model and ESBL, and scientists documented the ated this dialogue several years ago, and will rise of the multidrug resistant MRSA strain continue this academic exchange during the Even though the Danish Ministry of Agri- ST398 [28] within the meat production fa- second One Health Conference in Novem- culture continuously focuses on the preven- cilities. Alongside this, new cases of animal- ber 2016. On the United Nations system tion of the development of AMR, several human transmitted infections appeared level, a much anticipated high-level AMR scenarios are challenging the Danish posi- country wide, leading to an increasing meeting will occur in September 2016, with
110 Antimicrobial Resistance
hope that decision makers will acknowledge in emerging infectious diseases. Nature. 2008; ance genes among livestock-associated methicil- 451(7181):990-994. lin-resistant Staphylococcus aureus isolates. Vet the importance of a multisectoral approach 14. Blancou J, Chomel BB, Belotto A, Meslin FX. Microbiol. 2016; 191:88–95. to the issue at hand. Emerging or re-emerging bacterial zoonoses: 27. Korsgaard H, Agersø Y, Hammerum AM, Factors of emergence, surveillance and control. Skjøt-Rasmussen L (eds). DANMAP 2011 - Vet Res. 2005; 36(3):507-522. Use of antimicrobial agents and occurrence of 15. Fisman DN, Laupland KB. The ‘One Health’ antimicrobial resistance in bacteria from food References paradigm: time for infectious disease clinicians animals, food and humans in Denmark. Den- 1. O’Neill J. Tackling drug-resistant infections to take note? Can J Infect Dis Med Microbiol mark: Danish Integrated Antimicrobial Resist- globally: Final report and recommendations. 2010; 21(3):111-114. ance Monitoring and Research Programme; 2016. http://amr-review.org/sites/default/ 16. Wegener HC. Antibiotic resistance – linking 2012. http://www.danmap.org/~/media/pro- files/160525_Final%20paper_with%20cover. human and animal health. In: Choffnes ER, jekt%20sites/danmap/danmap%20reports/ pdf. (Accessed June 27, 2016). Relman DA, Olsen L, Hutton R, Mack A. Im- danmap_2011.ashx. (Accessed September 13, 2. World Health Organization. Global action plan proving food safety through a One Health ap- 2016). on antimicrobial resistance. Geneva, Switzer- proach: A workshop summary. (pp. 331-349). 28. Agersø Y, Hasman H, Cavaco LM, Pedersen land: World Health Organization; 2015. Washington DC: Institute of Medicine; 2012. K, Aarestrup FM. Study of methicillin resistant 3. World Health Organization. Global health es- 17. Cho I, Yamanishi S, Cox L, Methé BA, Zavadil Staphylococcus aureus (MRSA) in Danish pigs timates 2014 summary tables: Deaths by cause, J, Li K, et al. Antibiotics in early life alter the at slaughter and in imported retail meat reveals a age and sex, 2000-2012. Geneva, Switzerland: murine colonic microbiome and adiposity. Na- novel MRSA type in slaughter pigs. Vet Micro- World Health Organization; 2014. http://www. ture. 2012; 488(7413):621-6. World Health Or- biol. 2012; 157(1-2):246-250. wpro.who.int/entity/drug_resistance/resources/ ganization. Antimicrobial resistance: Global re- 29. New requirements for zoonotic infection pro- global_action_plan_eng.pdf. (Accessed Septem- port on surveillance 2014. Geneva, Switzerland: tection in pigs (MRSA). 2014. https://www. ber 10, 2016). 18. World Health Organization; 2014. foedevarestyrelsen.dk/Nyheder/Aktuelt/Sider/ 4. Morens DM, Folkers GK, Fauci AS. The chal- 19. Silbergeld EK, Graham J, Price LB. Industrial Nye-krav-om-zoonotisk-smittebeskyttelse-i- lenge of emerging and re-emerging infectious food animal production, antimicrobial resist- svinebes%C3%A6tninger-(MRSA).aspx. (Ac- diseases. Nature. 2004; 430(6996):242-249. ance, and human health. Annu Rev Public cessed September 10, 2016). 5. Smolinski MS, Hamburg MA, Lederberg J Health. 2008; 29:151-169. (eds). Microbial threats to health: Emergence, 20. Levy SB, FitzGerald GB, Macone AB. Changes detection, and response. Washington DC: Na- in intestinal flora of farm personnel after intro- Caline Mattar M.D, tional Academies Press; 2003. duction of a tetracycline-supplemented feed on 6. Morse SS. Factors in the emergence of infectious a farm. N Engl J Med. 1976; 295(11):583–588. Washington University in diseases. Emerg Infect Dis. 1995; 1(1):7-15. 21. Price LB, Stegger M, Hasman H, Aziz M, St Louis, St Louis, MO, USA 7. World Health Organization. Veterinary public Larsen J, Andersen PS, et al. Staphylococcus au- health. 2016. http://www.who.int/zoonoses/ reus CC398: Host adaptation and emergence of vph/en/. (Accessed September 10, 2016). methicillin resistance in livestock. mBio. 2012; Ana Sofia Ore M.D, 8. Keusch GT, Pappaioanou M, Gonzalez MC, 3(1):e00305-11. Beth Israel Deaconess Medical Xcott KA, Tsai P (eds); Committee on Achiev- 22. Waters AE, Contente-Cuomo T, Buchhagen J, Center, Boston, MA, USA ing Sustainable Global Capacity for Surveillance Liu CM, Watson L, Pearce K, et al. Multidrug- and Response to Emerging Diseases of Zoonot- resistant Staphylococcus aureus in US meat and ic Origin; National Research Council. Sustain- poultry. Clin Infect Dis. 2011; 52(10):1227- Steen K. Fagerberg, M.D, ing global surveillance and response to emerging 1230. Aarhus University, Denmark zoonotic diseases. Washington DC: National 23. Levy S. Reduced antibiotic use in livestock: How Academies Press; 2009. Denmark tackled resistance. Environ Health 9. Rabozzi G, Bonizzi L, Crespi E, Somaruga Perspect. 2014; 122(6):A160-A165. Wunna Tun MBBS, C, Sokooti M, Tabibi R, Vellere F, Brambilla 24. Food and Agriculture Organization of the Unit- University of Medicine 1, G, Colosio C. Emerging zoonoses: The “One ed States; World Health Organization; World Yangon, Myanmar Health approach”. Saf Health Work. 2012; Organization for Animal Health. Joint FAO/ 3(1):77-83. OIE/WHO expert workshop on non-human 10. Day MJ. Human-animal health interactions: antimicrobial usage and antimicrobial resistance: Reshma Ramachandran, M.D, M.P.P, The role of One Health. Am Fam Physician. Scientific assessment. Geneva, Switzerland: Johns Hopkins University, 2016; 93(5):345-346. World Health Organization; 2003. Baltimore, MD, USA 11. Robinson TP, Bu DP, Carrique-Mas J, Fèvre EM, 25. Høg BB, Korsgaard H, Sönksen UW, Hammer- Gilbert M, Grace D, et al. Antibiotic resistance is um AM (eds). DANMAP 2014 – Use of anti- the quintessential One Health issue. Trans R Soc microbial agents and occurrence of antimicrobial Elizabeth Wiley, M.D, J.D, M.P.H, Trop Med Hyg 2016; 110(7):377-380. resistance in bacteria from food animals, food Johns Hopkins University, 12. Newell DG, Koopmans M, Verhoef L, Duizer and humans in Denmark. Denmark: Danish In- Baltimore, MD, USA E, Aidara-Kane A, Sprong H, Opsteegh M, tegrated Antimicrobial Resistance Monitoring Langelaar M, Threfall J, Scheutz F, van der Gies- and Research Programme; 2015. http://www. sen J, Kruse H. Food-borne diseases – the chal- danmap.org/~/media/Projekt%20sites/Dan- Helena J. Chapman M.D, M.P.H, lenges of 20 years ago still persist while new ones map/DANMAP%20reports/DANMAP%20 University of Florida, continue to emerge. Int J Food Microbio.; 2010; 2014/Danmap_2014.ashx (Accessed September 139(Suppl 1):S3-S15. 13, 2016). Gainesville, Florida, USA 13. Jones KE, Patel NG, Levy MA, Storeygard A, 26. Argudin M, Lauzat B, Kraushaar B, Alba P, Ag- Balk D, Gittleman JL, Daszak P. Global trends erso Y, et al. Heavy metal and disinfectant resist- E-mail: [email protected]
BACK TO CONTENTS 111 Medical Science AUSTRALIA
journals were in their infancy, print was Global Development of Medical Science still dominant, and advertising revenue was still strong. In 2016, the Editor of and Publication Opportunities and the Canadian Medical Association Journal (CMAJ) was fired reportedly because the Challenges impact factor of the Journal and submis- sions were both falling [2]. Richard Smith, results will influence and perhaps change the former editor of the British Medical my field. But the world of research and Journal (BMJ) has recently blogged most publishing as we know them is changing, if not all national Journals potentially face and here I will discuss some of the emerg- failing too if they do not adapt, as submis- ing outcomes. sions fall because authors will only send their best work to more prestigious Jour- More and more medical research is pro- nals (blogs.bmj.com/bmj/2016/03/02). The duced and published each year. As an expe- underlying business model of traditional rienced journal editor I know authors want Journals is indeed under threat; there is in- to publish in the most prestigious journal creasing competition from other Journals, possible. The reasons are obvious; publish- and falling advertising revenue as advertis- ing in one of the best journals in the field is ers flee from print (and Journals) to inter- more likely to be noticed, the paper may be net rivals. Print is declining although older more likely to be read, and it adds greater readers still prefer it. Despite all of these weight to a promotion application, to name trends I expect the top Journals will sur- a few. In many parts of the world authors vive (or be the last to disappear). Journal base their decision to submit on the jour- rankings (like University rankings) matter Nicholas J. Talley nals impact factor (a metric based on the and for Journals despite all the acknowl- number of cited articles in the prior two edged limitations and flaws, the impact Everything changes but we live in a time years divided by the number of published factor remains the most widely accepted of quiet revolution, a time when medical citable articles in the journal); the higher measure authors consider and Editors live knowledge is exploding and instant com- the impact factor, the more prestigious the and die by. munication and interconnectivity are al- journal in the eyes of many, a fact editors tering our world. More than 1.8 million recognise and fret over annually. The New Not everyone can publish their work in one peer review articles are now published ev- England Journal of Medicine is top of the list of the top Journals. The new world of open ery year in over 28,000 scholarly journals with currently the world’s highest impact access Journals had the noble aim of de- [1]. Sweeping changes are impacting the factor (59.558 in 2015). However, the im- mocratising research, of trying to ensure all practice of medicine and medical research, pact factor is obviously a flawed measure; sound research is published (even if negative and in turn impacting the world of Journal even in the New England Journal of Medi- or relatively uninteresting) and made avail- publishing. Scientific journals have a long cine, only a minority of articles are highly able for everyone, applying an author pays and proud history since the first scientific cited which drives up the impact factor model. A noble aim but flawed. By 2015, journal was published; the longest lived while many papers attract little attention. over 10,000 journals were listed in the Di- Journal is the Philosophical Transactions Further, journal editors can manipulate rectory of Open Access Journals. There are started by the Royal Society of London the metric (e.g. by publishing more or only now high ranking open access megajournals in 1665 and there are now thousands of reviews which are statistically much more such as PLoS Medicine which have shaken medical journals with new ones added likely to be cited than original research), the publishing world. But publishing high every week. As a front line clinician and and citations do not equal impact in terms volumes negatively affects the rankings active medical researcher, I rely on the of promoting a paradigm shift in thinking based on impact factor as for example the published literature to guide my practice, or practice change. journal PLoS One has found out; their update me on the latest developments and huge submission rates are now falling as hopefully inspire me. And I rely on the When I began my first Co-Editor-in- their impact factor, once quite high, steadily Journals I publish in to disseminate the Chief role in 2003 at the American Jour- declines. More and more open access Jour- research findings with the hope that the nal of Gastroenterology (AJG), open access nals are opening; I now receive every single
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week multiple requests sometimes begging ally, Australia’s leading Journal, the Medical testing the evidence, and Journal Editors me to submit to a new open access Journal. Journal of Australia (MJA), a Journal that play a key gatekeeper role in the process. Publishing in open access journals with du- publishes 22 issuers per year in print and Any study can be wrong despite the best bious business models that may not exist to- on-line. While already an excellent journal possible peer review, but it is the accumula- morrow in an era of intense Darwinian style admired by the community and government, tion and synthesis of new knowledge that competition is a risk for emerging research- the challenge I face is how to maximise the we as editors proudly contribute to dissemi- ers. Predator journals have also been a seri- relevance of the Journal, better educate nating. General medical journals like the ous contaminating influence; these are jour- clinicians, disseminate and showcase clini- Medical Journal of Australia play a special nals that charge a fee for publishing yet fail cally impactful research, accelerate change role in presenting and explaining research, to carry out any or adequate peer review or in practice and positively influence health making research and data accessible, edu- careful editorial oversight, which is likely to policy. I relish the challenge. In my Jour- cating, translating, engaging the public and promote the publication of false or mislead- nal now, for example, all original research shaping health policy. Finally, I would argue ing data. I predict many of the open access is published in full and is available for free we are all still failing to help translate new Journals will disappear and I fear it will take to all with no author charges, a challenge medical knowledge quickly enough, and it decades to undo the damage of publishing to the open access user pays model. This is is here as a profession we can and must aim poor quality research. consistent with the European Competitive to do better. Council recommendation that all publicly The counter argument has been that jour- funded research be made freely available by nal peer review is inadequate anyway and 2020. We also conduct blinded peer review References just openly publishing all available research and routine statistical review as part of our 1. Ware M, Mabe M. The STM report. An over- undertaken is a better model. I know the quality processes. view of scientific and scholarly journal publish- ing. 2012; 3rd ed. research into journal peer review has not 2. Kassirer JP. Editorial independence: painful les- provided convincing evidence flaws are all One of my goals is to measure the impact sons. Lancet 2016; 387(10026): 1358-9. or even mostly detected although this needs of the Medical Journal of Australia in terms 3. Jefferson T, Alderson P, Wager E, Davidoff F. looking at across a range of journals [3, 4]. of changing practice or policy. It is generally Effects of editorial peer review: a systematic re- Many published articles with positive find- stated it takes 17 years to translate research view. JAMA 2002; 287(21):2784-6. 4. Smith R. Peer review: a flawed process at the ings are later shown to be incorrect [5]. into practice but this is highly variable and heart of science and journals. J R Soc Med. 2006; However, I am still convinced strong review excellent data are unavailable, plus our in- 99(4):178-82. and editorial processes minimise obvious terest is post publication impact [6]. For ex- 5. Ioannidis JP. Why most published research find- mistakes and improve articles, and I am ample, most guidelines are simply ignored ings are false. PLoS Med. 2005; 2(8):e124. committed to research into strengthening in practice in Australia and everywhere [7]. 6. Morris ZS, Wooding S, Grant J. The answer is the model. Rather than focussing on an artificial metric 17 years, what is the question: understanding time lags in translational research. J R Soc Med. like the impact factor, instead our interest 2011;104(12): 510-20. No one can now read everything published should be in knowing is our Journal pro- 7. NHMRC. NHMRC Annual Report on Aus- in their field today even if it is a very highly moting translation (because funders, gov- tralian Clinical Practice Guidelines. 2014. specialized one; how generalists can be ex- ernments and the public do now want to pected to maintain very broad expertise is know about this today). In my view transla- Nicholas J. Talley, MD, PhD becoming more and more troublesome even tion should be the true Journal value added Editor-in-Chief, though the generalist represents a key player metric. Medical Journal of Australia in the delivery of best medical care. In 2015 Pro Vice-Chancellor and Laureate Professor, I was appointed to be the Editor-in-Chief In conclusion, I would suggest that science University of Newcastle, Australia of a major general medical Journal glob- is permanently about self-correction and E-mail: [email protected]
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that governmental bodies, including Health Southeast European Medical Forum Ministries, should respect the independence of such organizations and develop partner- ship with them. and innovations and shared experience and views in different medical fields such as The VII Congress of SEEMF in Batumi surgery, oncology, neurology, pediatrics and proved the strength and meaningfulness endocrinology among others. The scientific of cooperation between doctors and medi- program of the VII Congress of SEEMF cal scientists from different countries with was dominated by lectures, reports and different specialties for the achievement presentations, striving to outline the nov- of common goals – better health systems, elties, to discuss achievements, to track the progress in medical science, faster imple- prospects of application in practice of the mentation of medical achievements in conclusions of fundamental discoveries and practice. Once again the SEEMF Congress clinical trials. Impressive was the presenta- reaffirmed its unique role and proved that tion of Georgian researchers from medical such an international organization can sig- schools in Tbilisi, Batumi, medical centers nificantly contribute to the health and wel- and research institutes. fare of millions of people in the region.
During the event a meeting of the SEEMF Today in the process of global changes in Board was held. The Board voted on the state structures and policies, more than ever Andrey Kehayov traditional award nominations in the field SEEMF proves its constructive role and of medicine. Prof. Giya Lobzhanidze, Presi- influence in the medical community – to During the last seven years the South- dent of the Georgian Medical Association, bring together physicians and scientists and east European Medical Forum (SEEMF) was honored with the award Outstanding commit to the mission of being a peace- holds large scientific medical multidisci- Physician of Southeast Europe. The Presi- maker of the future. This is an achievement plinary meetings every year. Georgia hold dent of the Latvian Medical Association that demonstrate that the efforts of Dr. An- the 7th International Medical Congress of Dr. Peteris Apinis and Assoc. Prof. Tatiana drey Kehayov and the SEEMF Board for the SEEMF from the 7-10 of September. Tserekhovich, Belarus, were awarded for 11 years now lead to success, to good results. The Congress was organized jointly with their contribution to the development of the Georgian Medical Association and the public health, Prof. Alexander Tsiskaradze, University of Tbilisi and was attended by Georgia, and Prof. Daniela Miladinova, With the mission of peacekeepers numerous medical professionals from over Macedonia, were awarded for outstanding 20 countries: Georgia, Bulgaria, Belarus, contribution in the field of medical science, The VII Congress of SEEMF is further evi- Macedonia, Slovenia, Kazakhstan, Serbia, the Medical Faculty of the Ss Cyril and dence of the progress of our organization, of Latvia, Spain, Greece, etc. Methodius University in Skopje, Macedo- proven benefits of the unification of medi- nia, and the State University of Tbilisi were cal professionals from different countries Distinguished specialists and experts, such awarded for contribution to the develop- united by core values of the profession. Be- as Acad. Vladimir Ovcharov, Bulgaria, Prof. ment of medical science and SEEMF. Two cause only the medical profession uniquely Ognyan Hadjiiski, Deputy Chairman of the new members were elected to the Board of brings together science, law, ethics. The of- Bulgarian Medical Association, Prof. Pavel the Organization – Acad. Vladimir Ovcha- ficial opening, the respect witnessed by the Poredos, President of the Slovenian Medi- rov and Assoc. Prof. Todor Cherkezov. The authorities in the autonomous Adjara with cal Association, Prof. Giya Lobzhanidze, Board of SEEMF approved an open letter the main city of Batumi, the participation President of the Georgian Medical Associ- to the Albanian Order of Physicians declar- of representatives from over 20 countries – ation, Dr. Goran Dimitrov, President of the ing that SEEMF firmly supports the pro- these are real facts which measure the au- Macedonian Medical Association, Assoc. fessional independence and self-governance thority of SEEMF. Prof. Gligor Tofoski of the Medical Faculty of the medical profession and considers any of the University of Skopje, Macedonia, and kind of administrative interference in the Once again the variety and richness of the over a hundred of medical specialists pre- work of professional organizations of phy- scientific program determine the appear- sented reports on the latest achievements sicians unacceptable and inappropriate and ance of the event. The massive presence of
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scientific speakers from Georgia, young Factor on the European map influence public health of millions of people scientists, post-graduates turned the Con- in a vast area of the world. I would like to gress into a bright event for the country. Now we can say with pleasure that our remind that SEEMF made important pro- The presence of outstanding speakers from Southeast European Medical Forum is posals to the World Medical Association – other countries and the latest developments among the fastest growing organizations related to climate change, to reduction of in the field of socially significant diseases and is a factor in the scientific medical harmful emissions in the Mediterranean represent impetus to improve practice. It is community in Europe because it is a multi- region, to closing of nuclear reactors. not by chance that the Congress has been disciplinary structure that deals with vari- accredited by EACCME with 15 credits. ous fields of medicine, and also discusses Today we face a new challenge – the crisis organizational aspects of health systems in of migrants and on the one hand its impact I am very glad that young physicians and different countries, seeking ever better solu- on health activities, health budgets of re- researchers attended this year. Yet we intend tions for millions of patients. The Seventh ceiving countries, and on the other hand – to work hard in this direction. Even at the Congress of our forum can be described the existing centers, changes in the struc- meeting of the SEEMF Board we discussed as highly successful since it confirmed its ture and composition of the settlements the idea each year to organize a seminar or specificity by combining science, profes- represent a danger and challenge to public a conference for young doctors in Greece at sionalism and friendship in a joint effort to health throughout the region. This global Kos – the island of Hippocrates – and there is better health. It is important to emphasize change poses new conditions and requires hardly a better place to express support for fu- that SEEMF is continuously evolving – unconventional approaches by doctors, by ture representatives of the medical profession. I did not even expect that so many coun- health politicians, by the governments of all tries will join in for achieving our goals and countries. During the traditional board meeting im- mission. I think it is time to promote new portant decisions were taken about the activities to organize seminars, workshops, I am glad that what we have achieved today special SEEMF awards. The new board conferences on specific topics. is far beyond the wildest expectations of the members – Acad. Vl. Ovcharov and Assoc. time when we created SEEMF. Prof. T. Cherkezov from Bulgaria – were The rapid development of our forum is a unanimously welcomed. The award voting is prerequisite to establish more intense con- Prof. Stylianos Antipas, Secretary extremely enjoyable because the number of nections with European scientific and med- General of SEEMF, Greece nominees from different organizations and ical societies and organizations to show that countries is growing and scientific reports we live actively and physicians of Southeast are becoming more profound. And partici- Europe are working hard to get evaluation Interviews by Dr . Andrey pants in the general discussion on the cur- and support from European centers and Kehayev, September 2016 rent problems in health systems express very networks. wise and bold ideas. Part of the mission of Prof. Paul Poredos, SEEMF is to make these ideas available to Vice President of SEEMF, Prof . Giya LobzhanidzePresident governments and health politicians, to insist Slovenia of the Association of Physicians and work for their implementation in the in Georgia, professor at Tbilisi member-countries of our organization. State University, co-chairman of Times of Hardship the Organizing Committee of In the complex global environment in the VII Congress of SEEMF terms of the ever-changing governmental We are all satisfied because we put a lot of structures and policies in SEEMF member effort in each subsequent year to watch our – Dear Professor, please provide some in- countries, our organization proves its con- forum grow and develop, including more formation about the association of doctors in structive role. SEEMF doctors and scien- countries, not only from Southeast Europe Georgia. tists confirm daily their mission of peace- but also from Asia, Central Europe, the keepers in the region and the world. Nordic countries. So SEEMF provides a – Our association was founded in 1989 unique opportunity to share new and best and is the first organization of this type. I dream of a better world! medical knowledge. The congresses of the 23 thousand doctors work in Georgia, of organization fulfill the mission to contrib- which 8 thousand are our members – we Dr. Andrey Kehayov, SEEMF ute to the development of medical science are the largest organization in the country. President, Bulgaria and the organization of health systems, to We have regional structures. Now we are in
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Adjara, where our organization is good and universal health care to provide for all peo- center of Tbilisi. The hospital will be a uni- strong. ple who have no private insurance. There are versity hospital and of the Association, it is changes in store, but the government has a joint project of achieving European stan- The objectives of the Association are: as- not yet decided what is to be done. dards, combining treatment, teaching and sistance to doctors, post-graduate educa- research. My dream is that undergraduate tion, work with patients, social protection of – How would you define the role of SEEMF and graduate students work there. My oth- doctors. We help our members to improve Congress in Batumi for the development of er dream is to see that my students com- their skills abroad, assist post- and under- Georgian Medical Association? plete their studies successfully and become graduate students. We regularly organize medical doctors. And the greatest dream – scientific conferences and publish a journal. – This SEEMF Congress reached in my to see that the world becomes a better place opinion two goals. First, we heard a lot of to live. – These are scientific and educational activities. good lecturers from abroad; it had an ex- And do you participate in making the health- tremely strong scientific program with Moreover, I have three granddaughters – care policy of Georgia? renowned lecturers. The Congress is an I dream that they will grow up healthy and incredible platform for exchange of expe- happy. – We work as consultants, as experts. In our rience. We showed all participants the sci- country we have the opportunity to interact entific potential of Georgia; showed it to with the government and parliament repre- Europe and the world. Assoc . Prof . Goran Dimitrov sentatives. There are parliamentary commit- tees on health and social security, we offer Moreover, there was the young doctors specific amendments, bills. section at the Congress and their meetings Chairman of the Macedonian were successful, interesting discussions Medical Association: – What is your assessment of the state of health were held. We will publish the most inter- care in Georgia today? esting presentations in the international We safeguard the honor of doctors Georgian Medical Journal, which becomes – There are some good changes now in the official journal of SEEMF. I must un- – What is your assessment of the past Congress? Georgian health care. Indeed, a few years derline that almost no international orga- ago all hospitals were sold – 99% of them nization of this type has got its own jour- – The SEEMF Congress held in Batumi, are now in private hands, and only 3-4 nal. Georgia, was an impressive meeting at hospitals remained state-owned. Therefore which scientific ideas were shared, and there is a need for the State University to – What impressed you personally apart from also friendships developed. Representa- build a new hospital. Today the Ministry of Professor Padilla from Seville? tives of SEEMF member associations from Health faces difficulties because little has 17 countries were present. The hosts from remained under their control as everything – A very serious and impressive was the the Georgian Medical Association provided has been sold. report of Academician Vl. Ovcharov – im- a wonderful and diverse scientific and cul- munology is the future, which he outlined. tural program. Of course, in private hands hospitals thrive. In fact Acad. Ovcharov spoke about tomor- But they have no interest in education and row’s medicine. – In general, how do you assess the scientific training; they do not accept undergraduate events organized by SEEMF? or graduate students for training. So the Extremely serious was the report of Prof. goal is to create university clinics – district, Pavel Poredos from Slovenia – a practical – Each subsequent Congress is becoming municipal, to build hospitals where the poor dimension to the program for prevention. better and better. I hope that the next one can be treated. I think that after the Oc- I think in each section there were very good will be rich in scientific activities and new tober elections it will be decided to create presenters. friendships. This year a large number of such public hospitals in large cities. participants presented for discussion many – What are your personal dreams? novelties, especially in the field of surgery. – Is there health insurance in Georgia? For example, I listened with interest to the – I’m a surgeon. As I said, we are build- report of Prof. Padilla of the University of – We have private companies. Four years ing a university hospital and I expect it to Seville on liver transplants. The number of ago the government adopted a program of open in two years time – it is located in the Bulgarian participants was also big. The
116 FRANCE WMA History
topic on a heart transplant impressed me Currently 5,500 doctors are our members. all cases in which the life of our doctors is particularly. When the Association was established it endangered, we support them before insti- included also dentists and pharmacists, but tutions. I would add that a Medical Cham- – What do you think should be the future of today they are already in separate structures, ber operates in our country, which deals such a specific organization as SEEMF? associations. The Association brings to- with legal aspects of the profession and the gether 73 associations of different medical trade unions fight for better pay and better – I believe that in the future SEEMF will specialties that annually organize between working conditions. expand even more, attracting more mem- 120 and 170 scientific events – congresses, bers from Eastern and Southern Europe to symposia, conferences, many of which are – What should be the role of the Macedonian share their problems and successes in medi- international. Medical Association after 10 years? cine. The first and main task of the Association – Such a union must continue in the future – Tell us please about the Macedonian Medical is to retain the honor and reputation of to protect the reputation and honor of doc- Association. doctors in Macedonia. We daily monitor tors and take care of their education, con- everything that is related to the health and tinuing medical education and welfare. – Last year, the Macedonian Medical As- status of doctors in the country. We manage sociation celebrated its 70th anniversary. to keep the authority of doctors. We react in E-mail: [email protected]
Paul Cibrie: Defending the Medical Profession in the Age of Internationalization
The history and memory of the professional the French Medical Trade Union Confed- reorganization of medicine after WWII re- eration (CSMF: Confédération des Syndi- mains understudied today and we still know cats Médicaux Français). He participated little about detailed events and individuals ac- in essential debates about the creation of a tors including the early history of the WMA. public healthcare system in France in the This contribution intends to present the life 1920s and 1930s. In this context Paul Cib- and work of the French physician Paul Cibrie rie drafted and promoted a Medical Char- (1881–1965) who played an active role in the ter that laid the foundations for medical foundation of the WMA. This summary ac- practice in France during the rest of the 20th count is based on my MD thesis investigat- century based on the following principles: ing the life and work of Paul Cibrie, poorly patient’s freedom to choose their physi- studied by historians and the medical com- cian, professional confidentiality, liberty to munity [1]. Cibrie’s work was of prime im- set fees and direct payment by the patient Paul Cibrie portance first for reforming French medicine without intervention of a third party for fee during the interwar period and second for the setting and payment, therapeutic liberty for interests of French physicians. In order formulation and promotion of professional the physician and finally control over the to keep control over professional affairs medical ethics by the WMA after WWII. profession exclusively done by the profes- among members of the profession, he took sion itself. part in the creation of the French Medi- Paul Cibrie was born in 1881 in Dordogne. cal Council/College (Ordre des Médecins) He studied medicine in Toulouse and com- In 1928, Paul Cibrie was designated sec- under the French Vichy regime and there- pleted his medical training in Paris. By the retary-general of the CSMF and editor- by became entangled and compromised age of 30 he started to work for the Alliance in-chief of the physicians association and himself expressing controversial opinions of the French Medical Unions (USMF: labour union journal. His engagement for supporting xenophobic and anti-Semitic Union des Syndicats Médicaux Français) a social medicine went along with a stout ideas common within the French medical and continued to do so with its successor, defense of the professional and economic community of the time.
BACK TO CONTENTS 117 WMA History FRANCE
Immediately after WWII, the interna- cratic Oath and proposed to make pledg- tional medical community reacted strongly ing it compulsory before getting a medical to the shocking revelations about medical degree. WMA member countries agreed to war crimes and Nazis atrocities, physi- adopt the revised version of the oath, which cians from several allied countries joined became known under the name of Geneva to discuss the need of professional and Declaration. Then, the committee obliged international medical relations and pro- the German Medical Association to pres- ceeded with the creation of an Organiz- ent an official statement and apology and a ing Committee for what would become public declaration about crimes committed the WMA. Paul Cibrie represented France by Nazis doctors since 1933. at these meetings. He pledged for the re- establishment of the Professional Interna- Second, as president of the Ethics Com- tional Association of Physicians (APIM: mittee of WMA, Paul Cibrie was a leading Association Professionnelle Internationale force in the formulation of the Interna- des Médecins) founded in July 1926 under tional Code of Medical Ethics stipulating French leadership. French preeminence in the duties of physicians in general, their international medical decisions supported duties to patients and colleagues. Along by the country’s role in APIM was chal- with the Geneva Declaration, this Code Fabrice Noyer lenged by the rising English and Ameri- of Ethics was the basis and became the can influence in international affairs after introduction of the Helsinki Declaration, receptive, loyal and compromising, coura- WWII. Debates ended with the official a major achievement of the WMA, voted geous and opportunistic. The height of his creation of the WMA in September 1947 in 1964, and establishing ethical principles paradoxical personality probably is that at and Paul Cibrie became one of the two for medical research involving human sub- the same time he was a driving force and French delegates a member of the WMA jects. main author of the International Code of Council. The initially declared main objec- Medical Ethics and a personal friend of tive of the WMA was: to promote closer ties Third, Paul Cibrie brought his prewar ex- Pierre Laval, a notorious anti-Semitic and among the national medical and among the perience with state-run social and health influential member of the Vichy govern- doctors of the world […] to assist all people of insurance to the WMA Committee on ment, whom Paul Cibrie provided with a the world to attain the highest possible level Social Security Systems. After the reorga- cyanide capsule while in prosecution cus- of health. In concert with the British phy- nization of the French, the Vichy regime tody offering Laval the possibility of suicide sician Charles Hill, Paul Cibrie drafted initiated, Social Security System in 1945, in order to avoid his outstanding execution the constitution of the WMA, which was his engagement in the WMA committee in October 1945, an attempt that neverthe- ratified at the First General Assembly in gave Paul Cibrie the opportunity to con- less failed. September 1947. Continuously Paul Cib- tinue to battle for a defense and promotion rie sought to promote French interest and of the medical profession interests in face Despite his complex and compromising perceptions in the WMA’s positioning and of governmental organizations and private personality Paul Cibrie has to be considered attempted to resist a medical “Marshall healthcare providers and organisms at an as one of the building figures of the WMA. plan” for the WMA. Nevertheless, WMA international level. In a sense he continued A tenacious member of the medical pro- main offices were shared between Paris and within the WMA his engagement for his fession, he defended throughout his whole London and finally left these two cities for Medical Charter elaborated in the interwar life the honor and interests of the medical New-York in 1947. period in the French context. profession from his engagement in French medical professional unions and promoted Paul Cibrie contributed extensively to many Paul Cibrie left the WMA in 1957 and professional independence at an interna- committees of the WMA. First, he was in continued his activities in the CSMF’s tional level in the WMA. Despising party charge of the delicate question of Nazis Council as honorary president until one politics and the public sphere, Paul Cibrie medical war crimes. Acknowledging that month before his passing away on 7 March never campaigned for a party, but he has the Hippocratic Oath had been abandoned 1965. Throughout his career, he displayed a oriented and labored professional politics by medical education and its institutions, the complex and at times ambiguous position- of the medical profession in a lasting and members of the WMA War Crimes Com- ing that may be characterized possibly as a highly influential way in the age of post- mittee suggested a rewriting of the Hippo- “reactionary modernism”: authoritarian and WWII reorganization and internationaliza-
118 Climate Change
tion. His work at the WMA was pathbreak- Helsinki Declaration creating ethical rules Mondiale: vie et œuvre du docteur Paul Cibrie ing and influential for the way medicine has for research with human subjects. (1881–1965). Thèse de médecine, Faculté de mé- decine de Strasbourg, 22 septembre 2016. been practiced on a daily basis eversince and on a global scale by rendering the revised Fabrice Noyer, MD Hippocratic Oath mandatory to obtain a References General practitioner, graduate of the medical degree, and by preparing the Inter- 1. Noyer, Fabrice. Du syndicalisme médical de University of Strasbourg, France national Code of Medical Ethics and the l’entre-deux guerres à l’Association Médicale E-mail: [email protected]
Introduction to work at COP22 even with the most optimistic previsions which assume that all conditional pledges are respected; • while the COP21 surprisingly recognized loss and damage alongside mitigation and adaptation within the Paris Agree- ment, progress on defining how it will be addressed by the Warsaw International Mechanism has been slow, and many crucial pieces including financing and non-economic loss and damage (which includes health and loss of life) are still unclear; • health remains central to climate change adaptation discussions while also having an important place in mitigation action especially in the pre-2020 agenda defined with the adoption of the Paris Agree- ment; how those commitments will be Yassen Tcholakov Lujain Aloqdmani implemented still remains to be seen.
In November 2016, the WMA will attend lot of work ahead to implement the Paris This year the WMA will be represented the 22nd Conference of the Parties to the Agreement through concrete and effective at COP22 by a delegation of 8 individuals United Nations Framework Convention on climate actions that will eventually decrease from a wide range of National Member or- Climate Change (COP22). and perhaps prevent the serious health im- ganisations. pacts of climate change. At this conference, the delegation will de- You may find their biographies below. fend the New Delhi Declaration and other Indeed, many elements of how the world WMA policies which have to deal with cli- will address climate change still remain un- mate change and environmental protection. certain: Week 1 • despite having pledged 100 billion dollars Following the very recent adoption of the to mitigation and adaptation, the coun- Lujain Aloqdmani Paris Agreement and its swift ratification tries of the world have not yet individu- by 81 parties which happened much sooner ally committed enough resources to meet Lujain Alqodmani is the International Of- than previously expected, the agreement will their common pledge; ficer and the Chair of Environment Com- come into force on 4 November 2016 This • despite having set an ambitious objective mittee of Kuwait Medical Association. She means that the first meeting of the Parties of reaching a maximal increase of 2 de- is currently also the National Health NGO to the Paris Agreement will take place dur- grees Celsius, and even striving to limit representative for climate change at Kuwait ing this upcoming COP22 in Marrakech, temperature rise to 1.5 degrees, the sum Environment Public Authority. Lujain is Morocco, something unexpected. There is of all contributions only reach 2.7 degrees currently an Emergency Physician at Amiri
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Hospital in Kuwait. She did an internship in her regional council. She is also an as- Nadim Nimeh with Climate Change Unit at the Depart- sociate member of the World Medical As- ment of Public Health and Environment sociation, and Communications Officer of Nadim Nimeh is a at the WHO HQ in Geneva and worked the Junior Doctors Network. medical oncologist greatly in the past years in climate change hematologist. He health policy in past UNFCCC meetings has been in practice including COP18 and COP21. Diogo Correia Martins for many years and he is involved in pa- Diogo Correia tient care and clini- Sofia Lindegren Martins is a Pub- cal trials. He has a lic Health medical Nadim Nimeh special interest in Sofia Lindegren resident in Portu- the effects of climate is a Medical Doc- gal, currently un- change on health, particularly as it relates to tor at Karolinska dertaking a Masters diseases of the blood and cancer. Dr. Nimeh University hospital. (MSc) degree in is a physician who has a keen interest in She is part of Swe- Diogo Correia Public Health at the global health issues, he is of the opinion that den’s Medical As- Martins London School of doctors need to know more on this subject, sociations working Hygiene & Tropi- not only because it affects us individually, group for Climate cal Medicine (LSHTM). Along with his but because it affects our communities, our Sofia Lindegren and Health where undergraduate and postgraduate studies, he children and our very existence. We need to she has been part of has gathered extensive experience in work- know enough details to impact the behavior creating their climate policy as well as been ing with student organisations in a leader- of all who we faithfully and diligently serve. lecturing for the public and healthcare pro- ship capacity, on national and international fessionals about health effects of climate levels, as well as interacting with the UN changes. She is a board member of Swedish system (WHO, UNESCO, UNFCCC, Gbujie Daniel Chidubem Doctors for the Environment and Swedish among others). Particular areas of interests Younger Medical Association and will start include global health and sustainable de- Gbujie Daniel a residency in Environmental and Occupa- velopment, with a special focus on health Chidubem is an tional Health. co-benefits resulting from climate change Associate Member mitigation and adaptation. of World Medical Association from Mardelangel Zapata Ponze de Leon Africa; he is practic- Week 2 ing as a general Oral Mardelangel Zapata surgeon in Nigeria. Ponze de Leon has Yassen Tcholakov Gbujie Daniel He is the Publication finished her Medi- Chidubem Director of the Junior cal Surgeon degree Yassen Tcholakov is a Public Health and Doctors’ Network at the Catolica de Preventative Medicine resident at McGill of the World Medical Association and also Santa María Univer- University in Canada. He is the Socio- the Regional Executive Director/ Coordina- sity in Peru. She now Medical Affairs Officer of the Junior Doc- tor of Junior Doctors’ of Africa. He has de- Mardelangel Zapata works at the San tors’ Network of the World Medical Asso- veloped a youth based program in an NGO Ponze de Leon Juan de Dios Home ciation. Yassen has extensive experience in in which he is the chief medical volunteer, Clinic as medical climate change: he has worked at the WHO this program communicates and collaborates and surgical assistant. She is also an associ- Department of Public Health and Environ- with rural residents on climate change giv- ate researcher of the Cardiological Institute ment, his master’s thesis was on the topic ing an African perspective and supporting Research Center PREVENCION. of climate change policy-making and he has the WMA policy on climate change. Gbujie contributed to NGO representation to the believes that mankind has a moral obligation She works actively within the Peruvian UN on climate change and sustainable de- to protect the earth and help ensure that ev- Medical Association, at the moment she is velopment including the proceedings which ery individual shares the benefits of a better President of the Junior Doctors Committee led to the drafting of the Paris Agreement. environment and a healthy climate.
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Mukti Ram Shrestha devotion and loyalty to the cause of human- cluding reproductive health and safe moth- ity. At present, he is the elected president of erhood, public health, and clinical medicine Mukti Ram Shrestha Nepal Medical Association. He has worked in remote districts of Nepal is an inspiration is a public health and 15 years as a public health officer in differ- and example for the whole medical fraternity. curative medicine ent parts of Nepal under the Ministry of expert at Tribhuvan Health. Dr. Shrestha served as the chairman Yassen Tcholakov, MD MIH, University Institute of Greenery Nepal, a non-governmental or- McGill University,Canada; of Medicine from ganization. This organization worked mainly E-mail: [email protected] where he received in the field of climate change and biodiver- most of his distin- sity sector. He has completed the Master’s Lujain Aloqdmani, International Officer Mukti Ram Shrestha guished medical de- Degree in Hospital Management and post and the Chair of Environment Committee grees in the field of graduate in obstetrics and gynaecology. His of Kuwait Medical Association medical education through his dedication, untiring, selfless effort in medical services -in E-mail: [email protected]
Obituary eradication of small- pox he became the D . A . Henderson, MD, MPH Dean of the Johns September 7, 1928 – August 19, 2016 Hopkins School of Public Health, then A great loss was felt by the public health community when physi- following the 2001 cian and epidemiologist D.A. Henderson, MD, MPH, who led United States an- the global smallpox eradication program, died on August 19th thrax attacks, an ad- at the age of 87 of complications of a hip fracture in Baltimore, visor and director of Maryland, USA. the Office of Public Health Emergency Smallpox a painful and often fatal disease killed over 300 million Preparedness in people in the 20th century alone. During a 10 year World Health Washington, D.C. Organization (WHO) campaign, Dr. Henderson led a historic In 1998 he founded global public health effort to officially eradicate smallpox, with the Johns Hopkins the last naturally acquired case occurring in 1977. The success of Center for Civilian the smallpox eradication program led to the Expanded Program Biodefense Strate- on Immunization (EPI), which has helped drastically to reduce gies, which is now many of the world’s preventable childhood diseases through im- the Center of Biosecurity, University of Pittsburg Medical Center munization. where he was the distinguished scholar.
Donald Ainslie Henderson, known as D.A. was born in 1928 in As an expert on bioterrorism, Dr. Henderson headed the scientific Lakewood, Ohio. He graduated from Oberlin College in 1950 and program at the World Medical Association General Assembly in received his MD from the University of Rochester in 1954. He was Washington, DC, in 2002, speaking about the past and future a resident physician at the Mary Imogene Bassett Hospital in Coo- realities of bioterrorism, and about the dangers of smallpox as a perstown, New York, and later was a Public Health Service Officer bioweapon. During that General Assembly, the WMA adopted in the Epidemic Intelligence Services (EIS) of the Communicable the Declaration of Washington on Biological Weapons. Disease Center (now the Centers for Disease Control and Preven- tion, CDC). He earned a Masters in Public Health in 1960 from Dr. Henderson was a firm and vocal advocate that the World the Johns Hopkins School of Hygiene and Public Health (now the Health Assembly destroy the remaining smallpox virus stockpiles Johns Hopkins Bloomberg School of Public Health). remaining in the United States and Russian Federation to reduce the risks associated with bioterrorism. Dr. Henderson served as an In the 1950s and 1960s, Dr. Henderson was at the CDC, where he expert advisor to the Junior Doctors Network in a proposed policy served as the chief of the EIS before being asked to head the WHO on the ‘destruction of the smallpox virus,’ which will be presented global smallpox eradication campaign in 1966. After the successful at the WMA General Assembly in Taiwan in October. IV