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December 2006 - HIV/AIDS
The emergence of HIV/AIDS in the 1980s provoked an enormous
amount of ethical reflection and policy development in addition
to the clinical and research responses that the epidemic required.
In the absence of any effective treatment, the early ethical focus
was on the responsibility of health professionals to care for
patients regardless of their condition or its source. This required
combating prejudices against homosexuality and drug dependency
and dealing with uncertainty regarding the risk of transmission
of the virus. Despite some opposition from their members, many
if not most medical associations reiterated the traditional responsibility
of physicians to treat patients in need even if this involved
some risk to the physician's own health (cf. for example the 1988
WMA Statement on the Professional
Responsibility of Physicians in Treating Aids Patients). Medical
association policies also resisted calls for the public identification
of HIV-infected individuals on the grounds that the need to protect
them from the social stigma attached to this condition outweighed
the interests of public health officials and health care providers.
During the 1990s and subsequently the controversy about the
responsibility of physicians and other health providers to treat
HIV/AIDS patients has subsided as the risk of transmission has
proved to be very low. Conversely, the debate about whether the
HIV-status of a patient should be kept confidential has heated
up. On the one hand, it is felt that the availability of prophylaxis
and treatment for HIV should entail the routine testing of at-risk
populations and expectant mothers and reporting the results both
to caregivers and to public health authorities, thus 'normalizing'
the condition. On the other hand, in many parts of the world the
acute social stigma attached to HIV persists and the routine disclosure
of positive test results would lead many to forego such tests.
It would seem difficult, if not impossible, to develop a policy
on this issue that would be acceptable everywhere.
The development of treatments for HIV has raised additional
ethical issues, especially in relation to access to such treatments.
Despite the initial high cost of such treatments, many wealthy
countries have made them available to all their citizens. However,
the vast majority of HIV-infected individuals live in poor countries
with neither the resources nor the infrastructure to provide treatment
to all those in need. WHO, UNAIDS and several NGOs have developed
programs to address this need (cf. February
2005 Issue of the Month) but it is a long way from being met.
One major obstacle is the patent protection given to pharmaceutical
products that makes the production and distribution of more affordable
generic copies either difficult or impossible.
Still other ethical issues arise in the search for an effective
HIV vaccine. Among those considered in the 2000 UNAIDS guidance
document, Ethical
considerations in HIV preventive vaccine research, are the
following: community participation in the design of trials, appropriate
ethics review of proposed trials, protection of vulnerable populations,
appropriate use of placebo, informed consent, concurrent and continuing
care of trial participants, and the inclusion of women and children.
In October 2006 the WMA General Assembly adopted a new policy
statement on HIV/AIDS and the Medical
Profession. The statement deals with the following issues:
discrimination, appropriate/competent medical care, testing, protection
from HIV in the health care environment, protecting patient privacy
and issues related to notification, and medical education.
Among National Medical Association policy statements on this
topic are the following:
November 2006 - End of Life Care
With the rapid development of life-extending medical technologies
from the 1960s onwards, physicians, patients and their family
members often felt compelled to make use of these technologies
in all circumstances. Death came to be regarded as a medical failure
rather than a natural event. When it would become clear that death
was about to occur in spite of all attempts to prolong life, physicians
sometimes considered that patients no longer needed their services
and went to care for other patients with better prognoses. End
of life care was left to nurses and social workers.
The medical profession, led by Elizabeth Kubler-Ross, Cicely
Saunders and Balfour Mount, among others, eventually recognized
the shortcomings of this approach. These pioneers were instrumental
in the development of palliative care as a more humane approach
to patients approaching the end of their lives and palliative
medicine as a special area of medical expertise. Although somewhat
marginalized from mainstream medicine at the beginning, palliative
medicine has slowly become recognized as essential for providing
quality care to patients at the end of their lives.
The WMA dealt with the needs of dying patients as early as 1983
in its Declaration of Venice on Terminal
Illness, which was revised and expanded at the 2006 WMA General
Assembly. Then, as now, the Declaration calls on physicians to
relieve suffering and act to protect the best interests of their
patients even in the case of incurable disease. The 2006 version
encourages governments and research institutions to invest additional
resources in developing treatments to improve end-of-life care
and medical schools to include the teaching of palliative medical
care in their curricula.
Policies of the WMA that deal with other end of life issues
are the Declaration on Euthanasia,
the Statement on Physician Assisted
Suicide and the Statement on Advance
Directives.
Several National Medical Associations have developed policies
and programs on end of life issues, including the American
Medical Association and the British
Medical Association. Other major sources of information on
the topic include the following:
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