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wmj5<\/a><\/p>\n

WorldMMeeddiiccaall JJoouurrnnaall
\nVol. No.1,March200551
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEEddiittoorriiaall
\nMedical Professionalism 1
\nTracing The Aetiology Of
\nGenetic Disorders In Children 1
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nUnesco\u2019s proposed Declaration
\non Bioethics and human rights 4
\nMedical Information and
\nPrivacy in the Information Society 6
\nAdvanced Medical Technology and Medical Ethics 14
\nStatement on healthcare in prisons
\nand other forms of detention 10
\nWWMMAA SSeeccrreettaarryy GGeenneerraall
\nFrom the Secretary General\u2019s Desk 11
\nWWMMAA
\nThe WMA Medical Ethics Manual 12
\nMMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
\naanndd EEdduuccaattiioonn
\nMedical Implants For Higher
\nPerformance And Longer Life 13
\nModern Demands in Health Care 17
\nCoordination of Progress in Information
\nTechnology with Health Care in the 21st Century 21
\nThe Medical Liability System
\nin Germany \u2013 An Accepted System 23
\nOut Of Africa 25
\nWWHHOO
\nWHO Supports Global
\nEffort To Relieve Chronic Pain 25
\nFight Childhood Obesity To Help
\nPrevent Diabetes, Say WHO & IDF 26
\nWHO Director-General Travels
\nTo Indonesia And Sri Lanka 27
\nRReeggiioonnaall aanndd NNMMAA NNeewwss
\nFiji Medical Association 27
\nEuropean NMAs meet in Oslo 28
\n\u201cUniversityHospitalCologne\u201dPhoto:EberhardHahne
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers and Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\ni see page ii
\nPresident-elect President Immediate Past-President
\nDr K. Letlape Dr Y.D. Coble Dr J. Appleyard
\nSouth African Med. Assn. 102 Magnolia Street Thimble Hall
\nP.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
\nLynnwood Ridge 0040 USA Blean, Nr Canterbury
\nPretoria 0153 Kent, CT2 9JJ
\nSouth Africa Great Britain
\nTreasurer Chairman of Council Vice-Chairman of Council
\nProf. Dr. J.D. Hoppe Dr. Y Blachar Dr. T.J. Moon
\nBundes\u00e4rztekammer Israel Medical Association Korean Medical Association
\nHerbert-Lewin-Platz 1 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
\nGermany P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721
\nSecretary General
\nDr. Otmar Kloiber
\nWorld Medical Association
\nBP63, 01212 Ferney-Voltaire Cedex
\nFrance
\nTel (33) 4 50 40 75 75
\nFax (33) 4 50 40 59 37
\nE-mail: otmar.kloiber@wma.net
\nANDORRA S
\nCol\u2019legi Oficial de Metges
\nEdifici Plaza esc. B
\nVerge del Pilar 5,
\n4art. Despatx 11, Andorra La Vella
\nTel: (376) 823 525\/Fax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nARGENTINA S
\nConfederaci\u00f3n M\u00e9dica Argentina
\nAv. Belgrano 1235
\nBuenos Aires 1093
\nTel\/Fax: (54-114) 383-8414\/5511
\nE-mail: comra@sinectis.com.ar
\nWebsite: www.comra.health.org.ar
\nAUSTRALIA E
\nAustralian Medical Association
\nP.O. Box 6090
\nKingston, ACT 2604
\nTel: (61-2) 6270-5460\/Fax: -5499
\nWebsite: www.ama.com.au
\nE-mail: ama@ama.com.au
\nAUSTRIA E
\n\u00d6sterreichische \u00c4rztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213
\n1010 Wien
\nTel: (43-1) 51406-931
\nFax: (43-1) 51406-933
\nE-mail: international@aek.or.at
\nREPUBLIC OF ARMENIA E
\nArmenian Medical Association
\nP.O. Box 143, Yerevan 375 010
\nTel: (3741) 53 58-63
\nFax: (3741) 53 48 79
\nE-mail:info@armeda.am
\nWebsite: www.armeda.am
\nAZERBAIJAN E
\nAzerbaijan Medical Association
\n5 Sona Velikham Str.
\nAZE 370001, Baku
\nTel: (994 50) 328 1888
\nFax: (994 12) 315 136
\nE-mail: Mahirs@lycos.com \/
\nazerma@hotmail.com
\nBAHAMAS E
\nMedical Association of the Bahamas
\nJavon Medical Center
\nP.O. Box N999
\nNassau
\nTel: (1-242) 328 6802
\nFax: (1-242) 323 2980
\nE-mail: mabnassau@yahoo.com
\nBANGLADESH E
\nBangladesh Medical Association
\nB.M.A House
\n15\/2 Topkhana Road,
\nDhaka 1000
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2-9566060\/9568714
\nE-mail: bma@aitlbd.net
\nBELGIUM F
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nTel: (32-2) 644-12 88\/Fax: -1527
\nE-mail: absym.bras@euronet.be
\nWebsite: www.absym-bras.be
\nBOLIVIA S
\nColegio M\u00e9dico de Bolivia
\nCasilla 1088
\nCochabamba
\nTel\/Fax: (591-04) 523658
\nE-mail: colmedbo_oru@hotmail.com
\nWebsite: www.colmedbo.org
\nBRAZIL E
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bela Vista
\nSao Paulo SP \u2013 CEP 01333-903
\nTel: (55-11) 317868 00
\nFax: (55-11) 317868 31
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBULGARIA E
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov
\n1431 Sofia
\nTel: (359-2) 954 -11 69\/Fax:-1186
\nE-mail: usbls@inagency.com
\nWebsite: www.blsbg.com
\nCANADA E
\nCanadian Medical Association
\nP.O. Box 8650
\n1867 Alta Vista Drive
\nOttawa, Ontario K1G 3Y6
\nTel: (1-613) 731 9331\/Fax: -1779
\nE-mail: monique.laframboise@cma.ca
\nWebsite: www.cma.ca
\nCHILE S
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: sectecni@colegiomedico.c
\nWebsite: www.colegiomedico.cl
\nCHINA E
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nTel: (86-10) 6524 9989
\nFax: (86-10) 6512 3754
\nE-mail: suyumu@cma.org.cn
\nWebsite: www.chinamed.com.cn
\nCOLOMBIA S
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCalle 72 – N\u00b0 6-44, Piso 11
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nTel: (57-1) 211 0208
\nTel\/Fax: (57-1) 212 6082
\nE-mail: federacionmedicacol@
\nhotmail.com
\nDEMOCRATIC REP. OF CONGO F
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (242-12) 24589\/
\nFax (Pr\u00e9sidente): (242) 8846574
\nCOSTA RICA S
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000
\nSan Jos\u00e9
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: unmedica@sol.racsa.co.cr
\nCROATIA E
\nCroatian Medical Association
\nSubiceva 9
\n10000 Zagreb
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: orlic@mamef.mef.hr
\nCZECH REPUBLIC E
\nCzech Medical Association .
\nJ.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nTel: (420-2) 242 66 201\/202\/203\/204
\nFax: (420-2) 242 66 212 \/ 96 18 18 69
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nUNITED STATES S
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\n717 Ponce de Leon Boulevard
\nCoral Gables, FL 33114-1016
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDENMARK E
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nTel: (45) 35 44 -82 29\/Fax:-8505
\nE-mail: er@dadl.dk
\nWebsite: www.laegeforeningen.dk
\nDOMINICAN REPUBLIC S
\nAsociaci\u00f3n M\u00e9dica Dominicana
\nCalle Paseo de los Medicos
\nEsquina Modesto Diaz Zona
\nUniversitaria
\nSanto Domingo
\nTel: (1809) 533-4602\/533-4686\/
\n533-8700
\nFax: (1809) 535 7337
\nE-mail: asoc.medica@codetel.net.do
\nECUADOR S
\nFederaci\u00f3n M\u00e9dica Ecuatoriana
\nV.M. Rend\u00f3n 923 \u2013 2 do.Piso Of. 201
\nP.O. Box 09-01-9848
\nGuayaquil
\nTel\/Fax: (593) 4 562569
\nE-mail: fdmedec@andinanet.net
\nEGYPT E
\nEgyptian Medical Association
\n\u201eDar El Hekmah\u201c
\n42, Kasr El-Eini Street
\nCairo
\nTel: (20-2) 3543406
\nEL SALVADOR, C.A S
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10
\nColonia Miramonte
\nSan Salvador
\nTel: (503) 260-1111, 260-1112
\nFax: -0324
\nE-mail: comcolmed@telesal.net
\nmarnuca@hotmail.com
\nESTONIA E
\nEstonian Medical Association (EsMA)
\nPepleri 32
\n51010 Tartu
\nTel\/Fax (372) 7420429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nETHIOPIA E
\nEthiopian Medical Association
\nP.O. Box 2179
\nAddis Ababa
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@telecom.net.et \/
\nema@eth.healthnet.org
\nFIJI ISLANDS E
\nFiji Medical Association
\n2nd Fl. Narsey\u2019s Bldg, Renwick Road
\nG.P.O. Box 1116
\nSuva
\nTel: (679) 315388
\nFax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fj
\nFINLAND E
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nTel: (358-9) 3930 826\/Fax-794
\nTelex: 125336 sll sf
\nE-mail: fma@fimnet.fi
\nWebsite: www.medassoc.fi
\nFRANCE F
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nTel: (33) 1 53 89 32 41
\nFax: (33) 1 53 89 33 44
\nE-mail: cnom-international@
\ncn.medecin.fr
\nGEORGIA E
\nGeorgian Medical Association
\n7 Asatiani Street
\n380077 Tbilisi
\nTel: (995 32) 398686 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY E
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nTel: (49-30) 400-456 363\/Fax: -384
\nE-mail: renate.vonhoff-winter@baek.de
\nWebsite: www.bundesaerztekammer.de
\nGHANA E
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nTel: (233-21) 670-510\/Fax: -511
\nE-mail: gma@ghana.com
\nHAITI, W.I. F
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nTel: (509) 245-2060
\nFax: (509) 245-6323
\nE-mail: amh@amhhaiti.net
\nWebsite: www.amhhaiti.net
\nHONG KONG E
\nHong Kong Medical Association, China
\nDuke of Windsor Building, 5th Floor
\n15 Hennessy Road
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.org
\nWebsite: www.hkma.org
\nHUNGARY E
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36
\n1443 Budapest, PO.Box 145
\nTel: (36-1) 312 3807 \u2013 311 6687
\nFax: (36-1) 383-7918
\nE-mail: motesz@motesz.hu
\nWebsite: www.motesz.hu
\nICELAND E
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nTel: (354) 8640478
\nFax: (354) 5644106
\nE-mail: icemed@icemed.is
\nINDIA E
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nTel: (91-11) 337009\/3378819\/3378680
\nFax: (91-11) 3379178\/3379470
\nE-mail: inmedici@vsnl.com \/
\ninmedici@ndb.vsnl.com
\nINDONESIA E
\nIndonesian Medical Association
\nJalan Dr Sam Ratulangie N\u00b0 29
\nJakarta 10350
\nTel: (62-21) 3150679
\nFax: (62-21) 390 0473\/3154 091
\nE-mail: pbidi@idola.net.id
\nIRELAND E
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nTel: (353-1) 676-7273
\nFax: (353-1) 6612758\/6682168
\nWebsite: www.imo.ie
\nISRAEL E
\nIsrael Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nTel: (972-3) 6100444 \/ 424
\nFax: (972-3) 5751616 \/ 5753303
\nE-mail: estish@ima.org.il
\nWebsite: www.ima.org.il
\nJAPAN E
\nJapan Medical Association
\n2-28-16 Honkomagome, Bunkyo-ku
\nTokyo 113-8621
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nKAZAKHSTAN F
\nAssociation of Medical Doctors
\nof Kazakhstan
\n117\/1 Kazybek bi St.,
\nAlmaty
\nTel: (3272) 62 -43 01 \/ -92 92
\nFax: -3606
\nE-mail: sadykova-aizhan@yahoo.com
\nREP. OF KOREA E
\nKorean Medical Association
\n302-75 Ichon 1-dong, Yongsan-gu
\nSeoul 140-721
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKUWAIT E
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nTel: (965) 5333278, 5317971
\nFax: (965) 5333276
\nE-mail: aks.shatti@kma.org.kw
\nLATVIA E
\nLatvian Physicians Association
\nSkolas Str. 3
\nRiga
\n1010 Latvia
\nTel: (371-7) 22 06 61; 22 06 57
\nFax: (371-7) 22 06 57
\nE-mail: lab@parks.lv
\nLIECHTENSTEIN E
\nLiechtensteinischer \u00c4rztekammer
\nPostfach 52
\n9490 Vaduz
\nTel: (423) 231-1690
\nFax: (423) 231-1691
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerzte-net.li
\nLITHUANIA E
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nLUXEMBOURG F
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\nDuch\u00e9 de Luxembourg
\n29, rue de Vianden
\n2680 Luxembourg
\nTel: (352) 44 40 331
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nAssociation and address\/Officers
\nii
\nAssociation and address\/Officers
\niii
\nMACEDONIA E
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nMALAYSIA E
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nTel: (60-3) 40418972\/40411375
\nFax: (60-3) 40418187\/40434444
\nE-mail: mma@tm.net.my
\nWebsite: http:\/\/www.mma.org.my
\nMALTA E
\nMedical Association of Malta
\nThe Professional Centre
\nSliema Road, Gzira GZR 06
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: mfpb@maltanet.net
\nWebsite: www.mam.org.mt
\nMEXICO S
\nColegio Medico de Mexico
\nFenacome
\nHidalgo 1828 Pte. Cons. 410
\nColonia Obispado C.P. 64060
\nMonterrey, Nuevo L\u00e9on
\nTel\/Fax: (52-8) 348-41-55
\nE-mail: fenacomemexico@usa.net
\nWebsite: www.fenacome.org
\nNEPAL E
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nTel: (977 1) 225860, 231825
\nFax: (977 1) 225300
\nE-mail: nma@healthnet.org.np
\nNETHERLANDS E
\nRoyal Dutch Medical Association
\nP.O. Box 20051
\n3502 LB Utrecht
\nTel: (31-30) 28 23-267\/Fax-318
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: www.knmg.nl
\nNEW ZEALAND E
\nNew Zealand Medical Association
\nP.O. Box 156
\nWellington 1
\nTel: (64-4) 472-4741
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNIGERIA E
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nTel: (234-1) 480 1569,
\nFax: (234-1) 493 6854
\nE-mail: info@nigeriannma.org
\nWebsite: www.nigeriannma.org
\nNORWAY E
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nTel: (47) 23 10 -90 00\/Fax: -9010
\nE-mail: ellen.pettersen@
\nlegeforeningen.no
\nWebsite: www.legeforeningen.no
\nPANAMA S
\nAsociaci\u00f3n M\u00e9dica Nacional
\nde la Rep\u00fablica de Panam\u00e1
\nApartado Postal 2020
\nPanam\u00e1 1
\nTel: (507) 263 7622 \/263-7758
\nFax: (507) 223 1462
\nFax modem: (507) 223-5555
\nE-mail: amenalpa@sinfo.net
\nPERU S
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores
\nLima
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@colmedi.org.pe
\nWebsite: www.colmed.org.pe
\nPHILIPPINES E
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: pmasec1@edsamail.com.ph
\nPOLAND E
\nPolish Medical Association
\nAl. Ujazdowskie 24
\n00-478 Warszawa
\nTel\/Fax: (48-22) 628 86 99
\nPORTUGAL E
\nOrdem dos M\u00e9dicos
\nAv. Almirante Gago Coutinho, 151
\n1749-084 Lisbon
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: ordemmedicos@mail.telepac.pt
\n\/ intl.omcne@omsul.com
\nWebsite: www.ordemdosmedicos.pt
\nROMANIA F
\nRomanian Medical Association
\nStr. Progresului 10
\nSect. 1, Bucarest, cod 70754
\nTel: (40-1) 6141071
\nFax: (40-1) 3121357
\nE-mail: amr@amr.sfos.ro
\nWebsite: www.cdi.pub.ro\/CDI\/
\nParteneri\/AMR_main.htm
\nRUSSIA E
\nRussian Medical Society
\nUdaltsova Street 85
\n121099 Moscow
\nTel: (7-095)932-83-02
\nE-mail: rusmed@rusmed.rmt.ru
\ninfo@russmed.com
\nSLOVAK REPUBLIC E
\nSlovak Medical Association
\nLegionarska 4
\n81322 Bratislava
\nTel: (421-2) 554 24 015
\nFax: (421-2) 554 223 63
\nE-mail: secretarysma@ba.telecom.sk
\nSLOVENIA E
\nSlovenian Medical Association
\nKomenskega 4
\n61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOUTH AFRICA E
\nThe South African Medical Association
\nP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nTel: (27-12) 481 2036\/7
\nFax: (27-12) 481 2058
\nE-mail: liliang@samedical.org
\nWebsite: www.samedical.org
\nSPAIN S
\nConsejo General de Colegios M\u00e9dicos
\nPlaza de las Cortes 11
\nMadrid 28014
\nTel: (34-91) 431 7780
\nFax: (34-91) 431 9620
\nE-mail: internacional1@cgcom.es
\nSWEDEN E
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610
\nSE – 114 86 Stockholm
\nTel: (46-8) 790 33 00
\nFax: (46-8) 20 57 18
\nE-mail: info@slf.se
\nWebsite: www.lakarforbundet.se
\nSWITZERLAND F
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses
\nElfenstrasse 18 \u2013 POB 293
\n3000 Berne 16
\nTel: (41-31) 359 \u20131111\/Fax: -1112
\nE-mail: fmh@hin.ch
\nWebsite: www.fmh.ch
\nTAIWAN E
\nMedical Association
\n201, Shih-pai Rd., Sec. 2
\nP.O. Box 3043
\nTaipei 11217
\nTel: (886-2) 2871-2121, ext 7358
\nFax: (886-2) 28741097
\nE-mail: cma@vghtpe.gov.tw
\nTHAILAND E
\nMedical Association of Thailand
\n2 Soi Soonvijai
\nNew Petchburi Road
\nBangkok 10320
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: http:\/\/www.medassocthai.org\/
\nindex.htm.
\nTUNISIA F
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1082 Tunis Cit\u00e9 Jardins
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: ordremed.na@planet.tn
\nTURKEY E
\nTurkish Medical Association
\nGMK Bulvary,.
\nPehit Danip Tunalygil Sok. N\u00b0 2 Kat 4
\nMaltepe
\nAnkara
\nTel: (90-312) 231 \u20133179\/Fax: -1952
\nE-mail: Ttb@ttb.org.tr
\nUGANDA E
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874
\nKampala
\nTel: (256) 41 32 1795
\nFax: (256) 41 34 5597
\nE-mail: myers28@hotmail.com
\nUNITED KINGDOM E
\nBritish Medical Association
\nBMA House, Tavistock Square
\nLondon WC1H 9JP
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6710
\nE-mail: vivn@bma.org.uk
\nWebsite: www.bma.org.uk
\nUNITED STATES OF AMERICA E
\nAmerican Medical Association
\n515 North State Street
\nChicago, Illinois 60610
\nTel: (1-312) 464 5040
\nFax: (1-312) 464 5973
\nWebsite: http:\/\/www.ama-assn.org
\nURUGUAY S
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515
\nCP 11200 Montevideo
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nVATICAN STATE F
\nAssociazione Medica del Vaticano
\nStato della Citta del Vaticano 00120
\nTel: (39-06) 6983552
\nFax: (39-06) 69885364
\nE-mail: servizi.sanitari@scv.va
\nVENEZUELA S
\nFederacion M\u00e9dica Venezolana
\nAvenida Orinoco
\nTorre Federacion M\u00e9dica Venezolana
\nUrbanizacion Las Mercedes
\nCaracas
\nTel: (58-2) 9934547
\nFax: (58-2) 9932890
\nWebsite: www.saludfmv.org
\nE-mail: info@saludgmv.org
\nVIETNAM E
\nVietnam General Association
\nof Medicine and Pharmacy (VGAMP)
\n68A Ba Trieu-Street
\nHoau Kiem district
\nHanoi
\nTel: (84) 4 943 9323
\nFax: (84) 4 943 9323
\nZIMBABWE E
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791\/553
\nFax: (263-4) 791561
\nE-mail: zima@healthnet.zw
\nEditorial
\nMedical Professionalism
\nThe problems facing the medical profession appear to be ever increasing. Some of the arti-
\ncles in the current issue of the World Medical Journal reflect this trend. The overview of
\nbioethical and other aspects of medical technological advances presented in Tokyo during
\nthe scientific session of the WMA Assembly in Tokyo, analyse both the benefits and the
\nproblems related to technological advance (see also Haddad’s article in WMJ50(4).
\nIt even possible to detect the relegation of clinical skills in some clinical protocols to a
\nlower priority in the management of presenting disease ,which place the carrying out of
\ntechnological tests before clinical examination in the list of priorities.
\nThe concerns of the European Forum of Medical Associations and WHO about the
\nBologna Process, which proposes radical changes affecting the nature of basic medical
\ntraining, at a time when there has already been general agreement about the reform of the
\nbasic medical curriculum, also express some feelings of serious disquiet. While welcom-
\ning some aspects of the proposals, there is grave concern at the suggestion that the funda-
\nmental proposals for Bachelor \/ Master degrees for recognising academic studies should be
\napplied to medical basic studies. The apprehensions relate to the additional problems of
\nrecognition which these will raise in an increasingly globalised world, where the problems
\nof recognition and increasing medical migration are significant problems already. It found
\nno evidence that the proposed two cycle Bachelor \/ Master process will improve anything
\nin the medical training process justifying the application of the Bologna proposals to med-
\nical studies which are a specific training for a profession. Finally it expressed deep con-
\ncern, that such a move might undermine the positive integration of the theoretical and clin-
\nical parts of medical education and then be harmful for the quality of patient care.\u201d
\nBehind all of these problems is the increasing questioning of what constitutes profession-
\nalism in medicine. Dr. Mary Schramm ,President of the Fiji Medical Association, extracts
\nof whose address appear in the NMA news section, reinforces the importance of some of
\nthe principles on which medical practice had been based for millenia. In the extracts from
\nher speech which appear in the NMA News section ,and she calls for their reinforcement.
\nFaced with the number of problems which individual doctors in their ordinary daily prac-
\ntice have to address, it is essential that, in a time of changing values and expectations, the
\nprofession collectively also addresses the question of the professions\u2019 role in today’s soci-
\nety and whether or not this has any implications for the fundamental principles on which
\nthe practice of medicine have been hitherto based.
\nAlan J. Rowe
\nEditorial
\n1
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
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\nHon. Editor in Chief
\nDr. Alan J. Rowe, OBE, FRCGP
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\n19 Wimblehurst Court
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\nISSN: 0049-8122
\nAt the Great Ormond Street Hospital for Children (GOSH) NHS Trust and the Institute
\nof Child Health (ICH), the new Dean, Professor Andrew Copp(i)
\n, reports that research
\ncovers many aspects of child and developmental health, ranging from clinical genetics
\nto mental health. The goal is to make discoveries that can improve clinical practice for
\nthe benefit of children locally, nationally and indeed internationally throughout the
\nworld. Research and teaching opportunities are provided for ever broader clinical ques-
\ntions in child health \u2013 evidence-based disgnosis and cures for many common childhood
\nillnesses.
\nTracing The Aetiology Of Genetic Disorders
\nIn Children
\nThe \u2018Jeans for Genes\u2019Appeal
\nFollowing the complete sequences of the
\nhuman genom, new ideas on genetic disor-
\nders, the relation between structure and
\nfunction in the chromosomes, and the spon-
\ntaneous occurrence of mutations, are being
\ninvestigated. An innovative piece of equip-
\nment known as a pyrosequencer is at the
\nheart of numerous collaborations between
\nuniversities on the genes, development and
\ndisease theme. For example, Dr James
\nTurton is researching the genetics of the
\nforebrain and pituitary gland development,
\nlooking for mutations as transcription fac-
\ntor candidate genes in children with
\nendocrine growth disorders. The DNA
\nsequences in the genes will determine the
\nfunction and developmental processes of
\neach transcription factor, thus aiding disg-
\nnosis and treatment.
\nPyrosequencing, using differential heat
\nprocesses to \u2018melt\u2019DNA chains, enables sci-
\nentists to study genes much more quickly
\nthan was previously possible. Changes can
\nthus be detected in the genes that might be
\nrelevant to disease causation. The system
\nidentifies genetic mutations or variations in
\na person\u2019s DNA sequence known as \u2018single
\nnucleotide polymorphisms\u2019. Such SNPs act
\nlike disease markers which identify people
\nwho may be prone to a certain disease.
\nThe problem lies in identifying the genes
\nthat underlie childhood growth. Children
\ncome into GOSH with all kinds of growth
\nproblems, from relatively straightforward,
\neasily measurable hormone deficiencies that
\ncan be treated by giving hormone replace-
\nment, right through to those who have life-
\nthreatening conditions in which their devel-
\nopment is severely restricted or abnormal.
\nSince the development of the pituitary gland
\nis closely linked to that of the forebrain,
\nsome children may, for example, have very
\nserious central nervous system problems
\nsuch as blindness, autism and development
\ndelay. Severely affected children may never
\ngo on to develop normal brains, or in the
\ncase of Duchenne muscular dystrophy boys
\nmay become progressively weaker, result-
\ning in death at a tragically young age.
\nThe DNA pyrosequencer is used to screen
\ncandidate genes \u2013 those which have already
\nbeen identified as playing a role in growth
\nproblems. The pituitary development group
\nhas identified many changes in both known
\nand novel genes implicated in normal devel-
\nopment of the pituitary and in control of
\nhuman growth. The skill of the biochemist
\nlies in being able to pick out genuine, dis-
\nease-causing mutations from natural varia-
\ntions or polymorphisms found across the
\nnormal population. Nevertheless, even these
\nvariations may in time provide clues about
\ntranscription factors that modify growth,
\nfrom DNA sequence to RNA (messenger,
\ntransfer and ribosomal) to functional pro-
\nteins. Human growth hormone (HGH), via
\nadenyl cyclase, can stimulate normal devel-
\nopment and injections can be given to com-
\nbat pituitary dwarfism. Local hormones, the
\ncytokines, play their part in the growth and
\ndevelopment of specialised tissues in terms
\nof gene expression. Teams at GOSH are
\nworking on the genes involved in asthma
\nconnected with cystic fibrosis \u2013 where over
\n230 mutations have been found \u2013 juvenile
\narthritis disorders and various genetic der-
\nmatological diseases.
\nGene therapy for cystic
\nfibrosis
\nIt is 17 years since scientists first discovered
\nthe gene responsible for cystic fibrosis, rais-
\ning the prospect of a cure for a commonly
\ninherited life-threatening disease.
\nIn a recent breakthrough, Dr Adam Jaffe and
\nhis team at GOSH have discovered that,
\ngiven the correct conditions, children can
\ngrow new and healthy lung tissue from stem
\ncells. The first trials of gene therapy for
\npatients with CF aimed to replace the abnor-
\nmal gene with a healthy copy administered
\nby a nasal spray. Despite initial optimism,
\nand even a temporary cure in some patients
\nwho nevertheless reverted back to their
\noriginal condition, treatment has proved to
\nbe elusive. This is partly because of the
\nnature of CF: the disease causes the lungs\u2019
\nsecretions to become thick and sticky. In the
\nabsence of treatment death can follow at an
\nearly age as these secretions clog up the
\nlungs, making breathing difficult, causing
\nrecurrent infections and leading eventually
\nto respiratory failure.
\nIn order to replace the abnormal gene in CF
\nsufferers, the healthy gene must be attached
\nto a \u2018transfer agent\u2019that will carry it into the
\ntarget cell. Although this has been achieved
\nusing either a virus or a liposome (a fatty
\nsubstance that sticks naturally to cell sur-
\nfaces), the presence of so much mucus
\nmakes for great difficulty in penetrating the
\ncell. An additional problem is uncertainly
\nabout exactly which cells within the air-
\nways should act as a focus for the vector.
\nIt has long been known that bone marrow
\nproduces the cells that become blood cells.
\nMore recently, scientists have proved that
\nbone marrow also produces stem cells with
\nthe property of \u2018plasticity\u2019 ? that is, they are
\ncapable of becoming other types of cell
\nentirely. Indeed, stem cells in the blood
\ncould become lung cells, and so they could
\noffer an effective means of replacing dis-
\neased lung cells affected by cystic fibrosis.
\nDr Jaffe suggests that in the near future it
\nmight be possible to cure babies of CF in
\nthe womb. Treatment here may be less
\nproblematic because unborn babies have
\nnot yet developed their own independent
\nimmune systems, and would therefore put
\nup less resistance to an incoming agent.
\nGene therapy to tackle
\nblindness
\nThe eye represents a fruitful area for gene
\ntherapy according to Professor Robin Ali.
\nClinical trials are being set up for a rare
\ninherited condition in the eye caused by a
\nsingle defect that causes blindness in chil-
\ndren, and age-related macular degeneration
\n(AMD) in the over 65s, a relatively com-
\nmon cause of blindness in the elderly that
\nhas a complex mix of causes including dia-
\nbetes. In both cases, a virus-derived vector
\nwould be used to insert a gene into the cells
\nof the retina. For the inherited disorder, this
\nwould involve replacing the missing or
\ndefective gene. For AMD, genes would be
\nemployed to treat major symptoms of the
\ncondition, for example inhibiting the
\ngrowth of destructive, invasive blood ves-
\nsels into the retina.
\nEditorial
\n2
\nGenetics, development
\nand disease
\nAccording to Professor Peter Scambler, treat-
\ning children with birth defects and inherited
\nconditions constitutes a major part of medical
\npractice in the West, America and Japan.
\nAlthough individually rare (the commonest,
\nCF, has a prevalence of carriers around 1 in
\nevery 25 people), the 4,000 or so known
\ngenetic disorders cause immense suffering
\nfor affected children and their families.
\nClinical management and genetic coun-
\nselling for these conditions depend on pre-
\ncise diagnoses, which are considerably
\nhelped by having sophisticated computer
\ndatabases. The aim is to pick out the genes
\nthat have been mutated causing malforma-
\ntions and cancers, using the new techniques
\nfrom biochemistry and molecular biology.
\nOnce a gene involved in a disease syn-
\ndrome is identified, the function of the pro-
\ntein it encodes for is elucidated. In order to
\nfurther our understanding of the fundamen-
\ntal mechanisms operating in embryology, it
\nis important to establish an axis in the inter-
\nnal architecture of the cell. In the develop-
\nment of children\u2019s diseases, and in the
\nexpression of genetic mechanisms, rare dis-
\norders may present at the same time as
\ncommon problems, for example in heart
\nconditions, diabetes and mental illness.
\nAt GOSH\/ICH, in addition to studying sin-
\ngle gene disorders, work is underway which
\nattempts to unravel more complex gene and
\ngene-environment interactions that may
\nunderlie common conditions such as deaf-
\nness, cleft lip and palate, obesity and aller-
\ngies in atopy. At the whole organ and cellu-
\nlar level, doctors are interested in disease
\nprocesses and how they might be modelled
\neffectively in the laboratory and on comput-
\ner. For instance, significant progress has
\nbeen made in understanding how malformed
\nduplex kidneys occur, and in bringing back
\nto life cells involved in ischaemic heart dis-
\nease, the penumbra where they lack oxygen,
\nand in spinal and neuronal injuries which can
\nbe treated with stem cells. Novel routes to
\ntreatment are being discovered which impact
\ndirectly upon disease processes. Surgical
\ntreatments at the micro-level, such as heart
\nvalves delivered by catheter inside the heart,
\nor relief of kidney and bladder malfunctions,
\nare constantly being improved.
\nMaking sense of Usher
\nsyndrome
\nDr Maria Bitner-Glindzicz reports that
\nUsher syndrome is a form of inherited deaf-
\nness in which children also progressively
\nlose their sight. Restricted vision or night
\nblindness in Usher syndrome may first
\nbecome apparent around the age of 7 years ?
\nand this often progresses to severe visual
\nimpairment in the teens. During the year
\n2000, her medical team saw two very unusu-
\nal families at GOSH and succeeded in iden-
\ntifying the gene responsible for their condi-
\ntion. Within these families, siblings or other
\nrelatives such as cousins had not only devel-
\noped deafness, but they also had hyperinsuli-
\nnaemia problems with blood glucose con-
\ntrol, which had not been previously linked to
\nUsher syndrome. It was established that the
\ngenes causing these conditions were located
\nnext to each other and that a stretch of DNA
\nwas missing from the tip of chromosome 11.
\nOn-going research has revealed that abnor-
\nmalities associated with at least 13 genes can
\nunderlie Usher syndrome. In most cases the
\nnormal role of the gene is to control the
\ndevelopment of sensory hair cells of the
\ninner ear. In relation to the eye, their function
\nis less clear \u2013 young children with the condi-
\ntion develop normally until around 7\u20138 years
\nof age. Visual problems controlled by these
\ngenes appear to be associated with maintain-
\ning photoreceptor cells required for sight.
\nThe severity of Usher syndrome together
\nwith increasing knowledge of its genetic
\nbasis means that more sensitive detection
\nand earlier treatment may become possible.
\nThe responsible genes identified to date are
\nall recessive; hence a couple who are both
\ncarriers of the abnormal gene have a 1 in 4
\nchance of their child being affected. The
\ncondition is quite often diagnosed in a child
\nbefore the couple have completed their fam-
\nily, and so this has very significant implica-
\ntions in terms of counselling. However, as
\nwe don\u2019t yet know all the genes that can
\ncause Usher syndrome, and those that we do
\nknow are very large, accurate genetic testing
\nduring pregnacy is not yet possible.
\nTo date there are three types of Usher syn-
\ndrome which differ in severety and age at
\nonset. The severest form, type 1, presents
\nwith profound deafness, balance problems,
\nfailure to develop speech and the need to
\nlearn sign language for communication
\nunless there is a cochlear implant. Children
\nwith type 2 have moderate to severe deaf-
\nness, normal balance, and they can learn to
\nspeak if they have a hearing aid. Type 3 is a
\nrecent category in which hearing is normal
\nat birth but progressively deteriorates. All
\nchildren suffering with Usher syndrome will
\nultimately develop severe visual problems.
\nThe relative rarity of the syndrome, as with
\nso many genetic diseases in children (1 in
\n1000 children are born deaf and about 5%
\nof these are thought to have Usher syn-
\ndrome), does not make it an obvious candi-
\ndate for the development of genetic tests.
\nFurther knowledge about the genes
\ninvolved in disease causation would not
\nonly allow pre-natal testing, but would also
\nbring closer the possibility of gene therapy
\nfor the visual problems in affected children.
\nGenetic abnormalities under-
\nlying Bardet-Biedl syndrome
\nInfants with Bardet-Biedl syndrome (BBS)
\nare often born with extra fingers or toes, have
\nlearning difficulties, and gradually develop
\nprogressive blindness and obesity. In some
\ncases the latter can lead on to diabetes, heart
\ndisease or kidney failure, causing early death
\nin about a third of those with BBS.
\nDr Philip Beales, a Wellcome Trust Senior
\nResearch Fellow, explains that his interest
\nin BBS started when he was working on
\ndiabetes in children, which involves many
\ngenes and gene interactions. When he saw
\nhis first case of BBS (1 in 70,000 children
\nare affected), which has diabetes and obesi-
\nty at its core, he realised that this condition
\nmight help doctors understand more com-
\nmon problems in the population.
\nWith access to genetic information for about
\n500 families, much of Dr Beales\u2019 research
\nfocusses on the genetic abnormalities that
\nEditorial
\n3
\nOn January 28, 2005 the International
\nBioethics Committee (IBC) of UNESCO
\n(United Nations Educational, Scientific and
\nCultural Organization) finalized its pro-
\nposed Universal Declaration on Bioethics
\nand Human Rights2
\nAccording to the
\ntimetable approved in April 2004 by
\nUNESCO\u2019s Executive Board, the Decla-
\nration will be presented to UNESCO\u2019s
\nGeneral Conference in October 2005 for
\nadoption. Before going to the General
\nConference, the IBC final draft will be
\nexamined, and is likely to be amended, by a
\ncommittee of government experts meeting
\nin April and June 2005.
\nDespite two major consultations on earlier
\ndrafts of the Declaration and subsequent
\nrevisions, the IBC\u2019s final draft is seriously
\nflawed. At a conference held on 25\u201326
\nFebruary 2005 in Paris to review this draft,
\nspeaker after speaker pointed out ambigui-
\nties, inconsistencies and omissions and
\nexpressed major differences of opinion
\nregarding the aims and contents of the doc-
\nument. Since no further consultation is
\nscheduled, it will be up to the government
\nexperts and ultimately the government rep-
\nresentatives to the UNESCO General
\nConference to determine the final form of
\nthe document and to decide whether it
\nshould be adopted.
\nPhysicians and other health care profes-
\nsionals have good reason to be concerned
\nabout the deficiencies of the draft
\nDeclaration. Although it would not have
\nthe binding legal status of a Convention, it
\nencourages nation states to \u201ctake all appro-
\npriate measures, whether of a legislative,
\nadministrative or other character, to give
\neffect to the principles set out in this
\nDeclaration3
\n\u201d, and it contains provisions
\nfor monitoring and evaluating its imple-
\nmentation by states. It would be far better
\nto correct the deficiencies of the document
\nbefore it is adopted rather than having to
\ndeal with them afterwards.
\nMajor Defects
\nAlthough the draft Declaration contains
\nmuch that is worthy of support, its scope
\nand aims are inappropriate and many of its
\nprinciples present problems in their inter-
\npretation and application. In what follows,
\nonly the most important shortcomings of
\nthe Declaration will be discussed.
\nScope \u2013 Contrary to the advice of the WMA
\nEthics Unit4
\nand the World Health Orga-
\nnization (WHO)5
\namong others, the
\nDeclaration defines \u2018bioethics\u2019 very broad-
\nly as \u201cthe systematic, pluralistic and inter-
\ndisciplinary study and resolution of ethical
\nunderlie BBS. The condition is unusual in that
\nsome of those affected have mutation not only
\nin both copies of the same gene (one paternal,
\none maternal, the usual pattern in recessively
\ninherited conditions), but they may also have
\na third mutation in another gene.
\nEight genes involved in causing BBS have
\nbeen found and, with colleagues from the
\nUSA and Canada, Dr Beales\u2019 group is
\ninvestigating their function. Of particular
\ninterest is the role that some or all of these
\ngenes play in the motility of cilia. Ciliated
\ncells with motile, flexible tails based on
\nATPase activity are widespread throughout
\nthe human body.
\nMuch work has involved a Birmingham-
\nbased, Pakistani family in which all three
\nsons (but not the one daugther) are severely
\naffected by BBS. The protein encoded by the
\nBBS-8 gene is missing in all three boys in
\nthis family. The researchers hope that these
\nstudies will reveal more about the link
\nbetween ciliary and cellular function, and in
\nturn further elucidate the developmental and
\ncognitive patterns which occur in BBS.
\nGenes, sex, facial expression
\nand autism
\nTwo striking features in studying childhood
\nto adult autism have been linked: the fre-
\nquent problems of those affected in under-
\nstanding the meaning of expressions on
\npeople\u2019s faces, and records which show that
\nmen are much more likely to have autism
\nthan women.
\nProfessor David Skuse has reported
\nprogress in tracking these conditions. His
\nteam have looked at the sex chromosomes,
\nXX for women and XY for men, and they
\nfound that one of the clearest risk factors
\nfor autism lies in possessing only one X
\nchromosome. Women suffering from
\nTurner\u2019s syndrome (one X instead of two)
\nand men (XY) both have a much higher risk
\nof autism than women with two X chromo-
\nsomes. Indeed, women with a specific dele-
\ntion of a particular section of the X chromo-
\nsome cannot accurately process some facial
\nexpressions. They behave in this respect
\nlike autistic people.
\nThis key section of the X chromosome is
\nlinked to the amygdala part of the brain
\ninvolved in processing emotional expres-
\nsions on people\u2019s faces. The data suggest
\nthat having two fully functioning X chro-
\nmosomes definitely protects agains autism
\n\u2014 and would account for the traditional,
\ncooperative care so well developed
\namongst women as compared to the com-
\npetitive, combative streak so often found in
\nmen.
\nIvan M. Gillibrand
\n(i)
\nReference
\nLeading the way
\nResearch Review 2003
\nInstitute of Child Health and Great
\nOrmond Street Hospital for Children
\nNHS Trust
\nMedical Ethics and Human Rights
\n4
\nMedical Ethics and Human Rights
\nUnesco\u2019s proposed Declaration on Bioethics and human rights1
\nissues raised by medicine, life and social
\nsciences as applied to human beings and
\ntheir relationship with the biosphere,
\nincluding issues related to the availability
\nand accessibility of scientific and techno-
\nlogical developments and their application\u201d
\n(article 1). By including ethical issues in
\nmedicine in the scope of the document,
\nUNESCO is clearly overstepping its man-
\ndate and encroaching on that of WHO.
\nMore seriously, many of the document\u2019s
\nprinciples are inappropriately applied to
\nclinical medical practice, as will be shown
\nbelow.
\nAims \u2013 Article 3 of the draft Declaration lists
\nno less than seven aims. The first is the most
\nproblematic because it includes two incom-
\npatible proposals: (1) \u201cto provide a universal
\nframework of fundamental principles and
\nprocedures to guide States in the formulation
\nof their legislation and policies in the field of
\nbioethics,\u201d and (2) \u201cto form the basis for
\nguidelines concerning bioethical issues for
\nthe individuals, groups and institutions con-
\ncerned.\u201d These statements demonstrate clear-
\nly the confusion of law and ethics that perme-
\nates the document. Given the definition of
\nbioethics as \u201cthe study and resolution of eth-
\nical issues\u2026,\u201d how can bioethics be incorpo-
\nrated into laws? There can be laws regulating
\nthe practice of medicine, medical research
\nand the organization and delivery of medical
\ncare, but these should not be confused with
\nbioethics. The second part of this article is
\nappropriate for bioethics, insofar as it speaks
\nof guidelines for individuals, groups and
\ninstitutions. But these have a different status
\nto that of laws. They speak to how people
\nshould act rather than how they must act.
\nPrinciples \u2013 The heart of the Declaration is a
\nset of 12 principles that, according to article
\n2, \u201capply as appropriate and relevant: (i) to
\ndecisions or practices made or carried out in
\nthe application of medicine, life and social
\nsciences to individuals, families, groups and
\ncommunities; and (ii) to those who make
\nsuch decisions or carry out such practices,
\nwhether they are individuals, professional
\ngroups, public or private institutions, corpo-
\nrations or States.\u201d Whether a principle is
\nappropriate and relevant to a particular deci-
\nsion or practice will often be a matter of dis-
\nagreement, particularly between the two
\nmain audiences to which the Declaration is
\naddressed, namely, States and individuals\/
\ngroups\/institutions. Here again, the Docu-
\nment confuses law and ethics.
\nThe following principles are particularly
\nquestionable for their application to med-
\nical practice:
\nArticle 5 \u2013 Equality, Justice and Equity:
\n\u201cAny decision or practice shall respect the
\nfundamental equality of all human beings
\nin dignity and rights and ensure that they
\nare treated justly and equitably.\u201d This prin-
\nciple fails to take into account the multiple,
\nand incompatible, concepts of justice and
\nequity in health care6
\n. According to their
\ncodes of ethics, physicians are not being
\nunjust when they give priority to their own
\npatients over others, but a State could inter-
\npret this article in such a way as to require
\nphysicians to practise in public facilities
\nopen to all patients.
\nArticle 7 \u2013 Respect for Cultural Diversity and
\nPluralism: \u201cAny decision or practice shall
\ntake into account the cultural backgrounds,
\nschools of thought, value systems, traditions,
\nreligious and spiritual beliefs and other rele-
\nvant features of society.\u201d This is clearly
\nimpractical, if not impossible, in most clinical
\nencounters between physicians and patients.
\nArticle 10 \u2013 Informed Consent. This article is
\ndivided into three parts, the first dealing with
\nresearch, the second with medical diagnosis
\nand treatment, and the third with persons lack-
\ning the capacity to consent. Apart from the
\nfact that it is clearly impossible to summarize
\nthe ethical principles relating to informed
\nconsent in five sentences, the article makes no
\nprovision for emergency treatment in situa-
\ntions where consent cannot be obtained.
\nMoreover, although the Declaration is sup-
\nposed to provide a universal framework of
\nfundamental principles and basic procedures
\ndesigned to guide States in the formulation of
\ntheir legislation and their policies in the field
\nof bioethics, the principle for consent to med-
\nical diagnosis and treatment for incompetent
\npatients in this article is simply that existing
\ndomestic law should be followed.
\nArticle 11 \u2013 Privacy and Confidentiality:
\n\u201cAny decision or practice shall be made or
\ncarried out with respect for the privacy of
\nthe persons concerned and the confidential-
\nity of their personal information. Unless
\nirretrievably unlinked to an identifiable per-
\nson, such information shall not be used or
\ndisclosed for purposes other than those for
\nwhich it was collected.\u201d The second sen-
\ntence of this article is considerably more
\nrestrictive than the WMA Declaration on
\nEthical Considerations Regarding Health
\nDatabases7
\n, as well as existing legislation in
\nmany countries. If adopted, it could serious-
\nly inhibit epidemiological research.
\nArticle 12 \u2013 Solidarity and Cooperation:
\n\u201cAny decision or practice shall pay due
\nregard to solidarity among human beings
\nand encourage international cooperation to
\nthat end.\u201d Depending on how \u201cdue regard\u201d
\nis interpreted, this principle is inapplicable
\nto patient-physician encounters.
\nArticle 13 \u2013 Social Responsibility: \u201cAny
\ndecision or practice shall ensure that progress
\nin science and technology contributes, wher-
\never possible, to the common good.\u201d The
\ncomment on article 12 applies equally here.
\nArticle 15 \u2013 Responsibility towards the
\nBiosphere: \u201cAny decision or practice shall
\nhave regard to its impact on all forms of life
\nand their interconnections and to the special
\nresponsibility of human beings for the pro-
\ntection of the environment, biodiversity and
\nthe biosphere.\u201d Here again, the Declaration
\nis far removed from the realities of clinical
\nmedicine.
\nThe next section of the Declaration is enti-
\ntled, \u201cConditions for Implementation.\u201d
\nThe eight articles here are just as problem-
\natic as the above-mentioned principles.
\nFor example:
\nArticle 16 \u2013 Decision-Making. This article
\nrequires that any decision or practice
\nshould \u201cbe made following full and free
\ndiscussion and in accordance with fair pro-
\ncedures.\u201d This may be appropriate for law
\nmaking but certainly cannot apply to emer-
\ngency medical procedures.
\nArticle 17 \u2013 Honesty and Integrity: \u201cAny
\ndecision or practice should be made or car-
\nried out with: (i) professionalism, honesty
\nand integrity; (ii) declaration of all conflicts
\nof interest; and (iii) due regard to the need
\nto share knowledge about such decisions
\nand practices with the persons affected, the
\nscientific community, relevant bodies and
\ncivil society.\u201d Since the Declaration is
\nMedical Ethics and Human Rights
\n5
\naddressed to every individual, the require-
\nments of professionalism and of a declara-
\ntion of conflicts of interest are inappropri-
\nate. The \u201cdue regard\u201d of the last sentence is
\nopen to multiple interpretations.
\nConclusion
\nDespite its best efforts, the IBC was unable
\nto produce an adequate Declaration on
\nBioethics and Human Rights in the nine
\nmonths allotted to it by the UNESCO
\nExecutive Board. It is highly unlikely that
\nthe committee of government experts in
\ntwo meetings will be able to succeed where
\nthe IBC failed. This is not at all surprising,
\ngiven the nature of bioethics, its relatively
\nrecent rapprochement with human rights,
\nand UNESCO\u2019s desire to respect cultural
\ndiversity and national sovereignty. The
\nWorld Medical Association, which deals
\nwith similar challenges, took three years
\n(1997-2000) to revise the Declaration of
\nHelsinki. One reason for this delay that
\ncould be a lesson for the UNESCO project
\nwas the willingness of the WMA Council
\nto recognize that the process followed dur-
\ning the first 18 months of the revision was
\nnot the right one and that a different
\napproach was needed8.
\nThe new approach
\nproved successful, despite many difficult
\nchallenges. We can only hope that the
\nUNESCO Executive Board or General
\nAssembly will likewise realise that the
\nprocess followed to date to develop a
\nDeclaration on Bioethics and Human
\nRights has not been successful and will
\nauthorize a new approach, one that will
\ninclude sufficient time for further consulta-
\ntion and consensus-building.
\nJohn R. Williams, Ph.D.
\nDirector of Ethics
\nWorld Medical Association
\n1
\nThe views expressed in this article are those
\nof the author, not necessarily of the World
\nMedical Association.
\n2
\nhttp:\/\/portal.unesco.org\/shs\/en\/file_down
\nload.php\/10d16a8d802caebf882673e
\n4443950fd Preliminary_Draft_EN.pdf
\n3
\nProposed Universal Declaration on Bioethics
\nand Human Rights, paragraph 24
\n4
\nhttps:\/\/www.wma.net\/e\/ethicsunit\/
\nunesco_project_bioethics.htm
\n5
\nhttp:\/\/portal.unesco.org\/shs\/en\/file_down
\nload.php\/e9d8dfce8497c221c4e620d11952
\ndde1Consultation_en.pdf
\n6
\nWMA Medical Ethics Manual
\n(https:\/\/www.wma.net\/e\/ethicsunit\/re
\nsources.htm), 72
\n7
\nhttps:\/\/www.wma.net\/e\/policy\/d1.htm
\n8
\nWilliams JR: The Promise and Limits of In
\nternational Bioethics: Lessons from the Re
\ncent Revision of the Declaration of Helsinki.
\nJournal international de bio\u00e9thique\/Interna
\ntional Journal of Bioethics 2004; 15: 36-37
\nMedical Ethics and Human Rights
\n6
\nMedical Information and Privacy in the Information Society
\nNorio Higuchi
\nProfessor of Law
\nUniversity of Tokyo, Japan
\nPresented at the WMA General Assembly in
\nTokyo 2004
\nIt is truly a great honor and joy for me to be
\nhere, given a chance to talk about one of the
\nmost important and interesting topics which
\nis medical information and privacy in con-
\ntemporary society. I have been teaching
\ncomparative law and medicine for more
\nthan ten years at the University of Tokyo
\nfrom the nnn in particular relating to the
\nU.S. and Japan and now I am chairing a
\ngovernment committee for making guide-
\nlines on this subject.
\nI. Introduction: Two
\nmetaphors to deal with
\nmedical information
\nThe importance of medical privacy in this
\nera
\n1) As all of you are aware, from the ancient
\nHippocratic Oath to the present day, the most
\nbasic duty of physicians is that of confiden-
\ntiality, or keeping the secrets of patients.
\nMedical information and privacy issues are
\nnot new. No one, physicians, patients, or
\ngeneral public, need or should worry about
\nit, since it has been a long established duty of
\nphysicians. Nevertheless, this particular
\nissue is a major concern in most countries
\nworldwide in this 21st century. Why? There
\nshould be some reason for it, and I believe
\nthere are at least three.
\nFirst, we have come to make more and
\nmore use of patients\u2019 information in a
\nbroader context. Medical information is
\noriginally acquired and accumulated for the
\ncare and cure of patients. It is nowadays,
\nhowever, used in a much broader context.
\nFor instance, it is used for a variety of aims,
\nsuch as the oversight of medical institu-
\ntions, educational uses for young physi-
\ncians, nurses, or paramedics. Also in some
\ncircumstances, physicians are legally oblig-
\ned to disclose medical information to out-
\nside authorities. It is easy to imagine such
\nsituations in public health area and also
\nchild protection matters. At any rate, the
\nmore use there is of medical information,
\nthe more concern we should feel about it.
\nSecond and related is the fact that we live in
\nthe so called \u201cinformation society\u201d. This
\nmedical information is not in a paper form,
\nbut an electronic file. It could be transferred
\ninstantly to the opposite side of the world.
\nAmazing it is, but it certainly increases fear
\namong us. Imagine that someone we do not
\nknow at all or have never seen, knows
\nabout my illness, diagnosis, family medical
\nhistory. it is really scary, isn\u2019t it?
\nThird, it has something to do with the
\nincreased distrust of physicians among the
\ngeneral public. It is well known that bioethics
\nin the United States has grown from the big
\nscandals about medical research in 1950s and
\n60s. Also informed consent doctrine and
\nemphasis upon patient autonomy in that
\ncountry is a sort of indication that we cannot
\nrely upon paternalistic protection by physi-
\ncians any more, \u201cin sum\u201d, we could not
\ndepent on medical professionals. In Japan,
\nduring the last ten years, we have seen many
\nmedical accidents in major hospitals,. Media
\nreport a lot and we see almost daily some
\nreports of medical mishaps. Patient safety has
\nbecome a major policy issue for the govern-
\nment, the Ministry of Health, Welfare and
\nLabor, who are planning to accumulate and
\nanalyze the reports of medical accidents and
\nincidents nationwide. Patient safety in this
\ncontext means, as we should be aware, that
\npatients should be safe from physicians!
\n2) Two metaphors to protect medical priva-
\ncy in Japan: the metaphor of ownership
\nThat is why we are now worrying about
\nmedical information issues. To deal with
\nour concern, two metaphors are quite popu-
\nlar in Japan. I will show you what they are
\nand, although they are popular and easy to
\nunderstand or believe, they are wrong or
\nuseless. I wonder if the same type of
\nmetaphors is used in other countries. If it is,
\nmy discussion will apply as well.
\nThe first metaphor is that of ownership of
\nproperty or a thing. We see a number of
\npublications, books and articles, which are
\ntitled \u201cWho owns medical charts or medical
\nrecords?\u201d This metaphor of ownership of
\nproperty is totally wrong.
\nIn the first place, information is not a thing
\nat all. For instance let us compare informa-
\ntion with your paper material in your hand.
\nThe paper is certainly a thing, but informa-
\ntion is not. Even though the paper includes
\ninformation, information is distinguishable
\nfrom the paper, which contains it.
\nInformation cannot be seen, or cannot be
\ntouched. It is intangible.
\nIn the second place, the claim of ownership
\nemphasizes monopolizing something. It
\nmeans that this particular something is
\nexclusively mine or yours or his or hers.
\nCertainly, if you say this paper document is
\nyours, then, when you read it, others cannot
\nread it. Others can be completely excluded.
\nInformation is, however, difficult to
\nmonopolize. Rather, information can be
\nshared at the same time. You can enjoy
\ninformation without disturbing others\u2019
\nenjoying it. That is the peculiar characteris-
\ntic of information.
\nIn the third place and most importantly, it is
\nhard to earmark so that this particular infor-
\nmation is yours. With regard to the paper
\ndocument in your hand, you can write your
\nname on it to show your ownership. In the
\ncase of information, it is really hard to do
\nso. Also, once information is disseminated
\nout of your control, it is extremely difficult
\nto recover and get back to the past. We
\nshould recognize that information is so spe-
\ncial. It cannot be contained. It is not a thing.
\nYou might say, however, that there is a legal
\ndevice for the ownership of information. It
\nis the scheme of intellectual property.
\nPatents and copyrights are famous exam-
\nples by which inventors or authors enjoy
\nownership over information they created,
\nand the law recognizes it.
\nProfessor Nobuhiro Nakayama, an authori-
\nty of intellectual property law in Japan, says
\nthat if information can be successfully con-
\ntained, then we could think of private prop-
\nerty in it. There are two means for it. One is
\nliterally to contain information, or to keep it
\nsecret from any others. If you know some-
\nthing valuable, and also if you would like to
\ntake advantage of it in financial terms, then
\nyou can make it secret rigidly and share
\nwith only few of those who would pay for
\nit. If you find someone who pays for it, the
\ninformation is your property, which would
\nbring money to you. However, this strategy
\nhas its own limitations. The more valuable
\nthe information is, then the more probable
\nthe information will be leaked. You cannot
\ntrace how it escapes and also it is hard to
\nget back to the past.
\nThat is how most society develops the intel-
\nlectual property scheme. Through this device
\nof legal imagination, the law grants a sort of
\nownership for a certain period to the inven-
\ntors, authors of other creators of information.
\nHowever, the important point is the fact that
\nthose inventors or authors could not keep it
\nsecret. Rather that the secrecy, the disclosure
\nis encouraged under the intellectual property
\nlaw. Well then, is there anything common
\nbetween the intellectual property idea and
\nour concern with medical information? Very
\nlittle, if any, is my answer.
\nWhen we talk about medical privacy, we
\nusually do not care about medical invention.
\nWhat we do discuss is patients\u2019 concern
\nabout their privacy. After all, the legal sys-
\ntem of intellectual property is a matter of
\nmoney. It is an artifical legal device to
\nencourage creative activities by giving
\nfinancial incentives. Most patients, however,
\ndo not wish to keep their information pro-
\ntected for financial reasons. In other words,
\nthe metaphor of ownership and property fits
\nvery well with monetary interest, which has
\nnothing to do with patients\u2019 concern.
\n3) The second metaphor: balance of interest
\nThe second popular metaphor with regard
\nto medical privacy is balancing of interests.
\nSuppose there is a balance to judge what is
\njust. On the one side, we put medical priva-
\ncy and on the other, we put its uses for other
\nvalues than privacy. Let me quote one
\nexample from what happened recently in
\nJapan.
\nOur Parliament enacted the Individual
\nProtectionAct of 2003 which covers medical
\ninformation, and will take effect from April
\n2005. The first section of this important act
\nprescribes the main purpose of law, which is
\nto protect the privacy rights of individuals
\nwhile taking into consideration appropriate
\nuses of information. In sum, this Act orders
\nto make a good balance between protection
\nand use of information about citizens.
\nBut the problem is how to make good bal-
\nance. To tell the truth, the act itself is of lit-
\ntle help. Two points should be noted in par-
\nticular.
\nFirst, in the process of enactement, a sort of
\ninterim report was published in 1999 by an
\nadvisory committee, which clearly empha-
\nsized the basic idea the coming Act should
\nbe the right to control one\u2019s own informa-
\ntion. But, it is gone from the face of the Act.
\nThe idea of the right to control one\u2019s own
\ninformation is close to the ownership
\nmetaphor. It is now gone and has moved to
\nthe balancing metaphor.
\nSecond, Professor Yoshiharu Matsuura, a
\nlegal philosopher at Nagoya University,
\nexplains that the metaphor of balance
\nworks well only if there is already an estab-
\nlished rule in a comparable situation. This
\nis totally different from our situation, where
\nwe only say that both protection and use are
\nimportant to medical information. We can
\nsee no related or established rule, and this
\n7
\nMedical Ethics and Human Rights
\ncannot make a good argument from the
\ncomparison and analysis from it.
\n4) The failure of two metaphors
\nTo sum up so far, we love metaphors that
\nare easy to understand and also to apply in
\nappearance. The metaphor of ownership
\nand balance are exactly those types. Yet,
\nthey give us only dreams or illusions. They
\ndo not help us much.
\nII Construction from the
\nbasis: why we should pro-
\ntect medical information
\n1) Search for a way of solution
\nWhen we find that popular metaphors fail,
\nwe need to get back to the starting point of
\ndiscussion, as to why we should protect
\nmedical information.
\nThe answers may appear so various that it
\nmay sound a waste of time. An example of
\nbalance metaphor comes from patient safe-
\nty area in Japan. In April 2003, a govern-
\nment committee within the Ministry of
\nHealth, Welfare and Labour, issued a report
\nto make hospitals and medicine safer. The
\ncore idea is that we should learn from mis-
\ntakes. In order for us to do that, we need to
\ncollect accident and incident reports, and
\nsend back a proposal for deterrence and
\nprevention to each medical institution. To
\nrealize and organize the scheme, the report
\nargues for the establishement of a profes-
\nsional institution for patient safety.
\nOur interest in this report is that it tries to
\nmake uses of medical information of patient
\nsafety, while it emphasizes as well the impor-
\ntance of patient privacy. We can see the
\nmetaphor of balance.
\nFor instance, when our Parliament enacted
\nthe Information Protection Act, in 2003,
\neach House added a resolution requiring the
\ngovernment to consider within two years
\nwhether some additional special legislation
\nshould be enacted in three important evi-
\ndences, to prove that our representatives
\nregarded medical information protection as
\none of the highest policy issues.
\nBut, if it is so crystal clear, we need not use
\nthe metaphor of balance from the begin-
\nning. We should protect patient informa-
\ntion, and that is the end of discussion. The
\nproblem is, however, not so easy or not so
\nsimple. We need to return to the most basic
\nquestion: why we should protect medical
\ninformation.
\nConsider then an example from the credit
\nand finance area, which includes sensitive,
\ninformation in the medical field according
\nto our Parliament. Suppose that you are a
\ncreditor and that you lend money to some-
\none. Under Japanese law and maybe in other
\ncountries as well, you need not acquire con-
\nsent from your debtor when you transfer
\nyour claim (chose in action against the
\ndebtor) to a third party. After completing the
\ndeal between you and the third party, the
\ndebtor will have to pay the debt, not to you,
\nbut to the third party. Under the Civil Code
\nin Japan, you need not get consent from the
\ndebtor, but you have to give notice to the
\ndebtor. Otherwise, the debtor will be at a
\nloss as to whom he or she should pay.
\nThe Information Protection Act gave us an
\nopportunity to reconsider this rule. Suppose
\nthat you want your claim cashed now, and
\ndecide that you would transfer or sell your
\nclaim to a third party. During the transac-
\ntion, you would be required to explain
\nabout the debtor\u2019s financial situation. The
\npotential assignee would ask: Is the debtor
\nreliable? Does he have a stable job and
\nposition? Has he not made any defaults in
\nthe past deals? The information you would
\ngive to the third party is exactly credit
\ninformation of the debtor. If the new Act
\nprotects credit and financial information
\nand prescribes a consent rule to transfer it to
\nthe third party, you cannot enter a negotia-
\ntion without consent from the debtor.
\nIt is quite strange if you can transfer your
\nclaim without consent of the debtor under
\nlaw, but you cannot negotiate with the third
\nparty without permission from the debtor. In
\nmonetary transactions, debt transfer is much
\nmore important than the information related
\nto it. Still if the new act says, \u201cyou can do
\nthe principal part of transaction, but cannot
\ndo the incidental part and therefore cannot
\ndo the whole transaction,\u201d it is clearly a
\nlegal inconsistency. Also it would overthrow
\nthe credit transaction system altogether.
\n2) A couple of lessons from the example of
\ncredit area
\nLet us draw a few lessons from the example
\nabove mentioned.
\nFirst, the example reminds us that there are
\ntwo parts of transaction, though they are
\nclosely related with each other, which
\nshould be definitely distinguished: transfer
\nof debt, the principal part, and flow of Infor-
\nmation, the incidental part. In the case of
\nclaim transfer, the new act could not have
\nchanged the fundamental rule of it. Even
\nafter the passage of Information Protection
\nAct, therefore, any creditors could transfer
\ntheir claim freely without taking consent
\nfrom the debtor. It means that we should be
\ncautious about interpreting the new
\nInformation Protection Act. While it appears
\nto say that the transfer of information
\nincluding credit status would always require
\nconsent some exception should apply to this
\ncase. One possibility is to look to a section
\nin the Act that the information transfer to a
\nthird party is permissible without consent if
\nthe transfer has some legitimate basis under
\nthe law. Our Civil Code is exactly the law,
\none of the most basic laws in our country,
\nand the Code allows the transfer of claims
\nwithout consent, which transaction
\ninevitably accompanies with information
\ntransfer. Thus, creditors could discuss with a
\npotential buyer about debtor\u2019s credit status
\nwithout his consent under the new law.
\nAt any rate, the first lesson to learn from this
\ncredit example is this. We should keep in
\nmind that we may be dealing with informa-
\ntion matters side by side with the principle
\ntransaction, and the latter is more important
\nthan the former in most cases. In the medical
\ncontext, the principal part of transaction
\nbetween physician and patient is physicians\u2019
\ntreatment of patients\u2019 body and mind. In this
\naspect, the ownership metaphor applies
\nwithout question. Patients own their body
\nand mind. It is not a metaphor, but a reality.
\nThe bodily integrity or the right to decide on
\none\u2019s own body and mind should be most
\nhighly respected. We should stricly apply the
\ninformed consent rule to this principle part
\nof transaction, and that is for the better or
\nbest treatment for patients. We should, how-
\never, make a distinction with regard to infor-
\nmation matters. Suppose, for instance, that a
\n8
\nMedical Ethics and Human Rights
\nphysician hears that another physician has
\nmedical information about you, which is rel-
\nevant and necessary for your treatment.
\nShould he wait for your visit next time when
\nhe gets a consent from you authorizing the
\nrelease of information from that physician?
\nShould the same consent rule strictly apply?
\nMy answer is no. The rule would only delay
\nyour treatment, which is just a waste of time,
\nsince any of you would give your consent
\nand the delay would not benefit you at all.
\nAlso one more thing to note here is that the
\nmedical information is much more useful in
\na social context than credit information. It
\nis easy to prove it. Let us compare a person
\nwho is bankrupt with another person who
\nhas an infectious disease. From the view-
\npoint of society as a whole, the latter infor-
\nmation is much more important than the
\nformer. Thus, it is much harder for us to
\nstick to the consent principle in the medical
\ncontext.
\nA second lesson from the credit example is
\nthat the individual Information Protection
\nAct has some significance, nevertheless.
\nLet us suppose that the creditor tells a third
\nparty about the debtor in each of the follow-
\ning ways.
\n(A) The third party happens to be the
\nemployer of the debtor, and he decides to
\nmake use of credit information for the
\nemployment and promotion context. Or,
\n(B) The third party wants to know every-
\nthing about the debtor, and the creditor
\ninforms the debtor\u2019s family matters, med-
\nical history, and the number of tickets he
\ngot from the police in the past. Or,
\n(C) The creditor makes mistakes and wrong
\ninformation about the debtor\u2019s credit status
\nis transferred to the third party, who makes
\na misjudgment on it.
\nThese hypos vividly show that free infor-
\nmation transfer should have its own limita-
\ntions. We need some rules against these
\nthings happening for the protection of the
\ndebtor. And that is the very reason for the
\nInformation Protection Act.
\nIn the medical context, these examples sug-
\ngest that patients\u2019 concern about informa-
\ntion transfer is natural and justified in the
\nfollowing cases.
\n(A) Information transferred may be used for
\ndiscrimination.
\n(B) Information transferred may be more
\nthan necessary for the legitimate uses of
\ninformation.
\n(C) The information transferred may be
\nwrong and it may harm the patient\u2019s interest
\nsome way or other.
\nFrom the credit example, therefore, we
\ncould draw a couple of important lessons.
\nThe first one is that we should not believe
\nin the consent principle too much in the
\ninformation context. The second lesson is
\nthat can we still find legitimate concern of
\npatients about information handling in
\nmedical context. Also that improvement of
\ninformation protection would help not only
\npatients but also society as a whole. We
\nshould think seriously about the strategy in
\nthat direction without relying only on the
\nconsent principle.
\nIII A strategy for the better
\nfuture
\n1) From the wishes of patients
\nIn order to make a good strategy for future
\nwe need to get back to patients\u2019 wishes and
\nask what they want. They want at least the
\nfollowing:
\n(A) Patients wish to see their own medical
\nrecord. Since medical information relates
\ntheir health condition, their interest is natur-
\nal. The rhetoric that they own the informa-
\ntion is unnecessary, and what they need is
\n\u201cthe right to know.\u201d Thus section 25 of the
\nInformation Protection Act prescribes the
\nduty of disclosure on the part of hospitals.
\n(B) Patients want physicians and hospitals to
\ntake good care of their medical information.
\nThey fear that it may be leaked to others, and
\nthat they may receive some day those mail
\nads which clearly show that others know
\ntheir illness.They fear discrimination by the
\nreason of illness in the context of insurance,
\nemployment, or other social activities. Here
\nas well, the rhetoric of metaphor of informa-
\ntion ownership is not needed. What they
\nneed is the reight to monitor or check han-
\ndling of information by medical experts.
\nUnder the Japanese law, it prohibits hospitals
\nfrom making use of information for other
\npurpose than the specific ones appropriately
\nnotified in advance. Also, disclosure of med-
\nical information to a third party requires con-
\nsent by patients in principle.
\n(C) In some cases, patients\u2019 main concern
\nmay not be their information, but informa-
\ntion about their health and medical treat-
\nment. That may be the precise reason for
\nclaiming the right to know access or med-
\nical records, by which they try to check the
\nmedical treatment itself. Also it may be true
\nthat those physicians, who manage medical
\ninformation well treat patients well and
\ntake good care of them. In other words,
\npatients wish to trust towards physicians.
\nSecond, although patients\u2019 wish should be
\nalways important, I would repeat again and
\nagain that it is unnecessary and wrong for
\nthem to claim ownership of medical infor-
\nmation. It is not logically correct, since
\ninformation is not subject to ownership in
\nmost cases, but also it is not desirable for
\npolicy reasons. Patients should not monop-
\nolize their information. Of course, physi-
\ncians should not monoplize it, either. It is
\neasy to understand this, when you imagine
\na case in which a patient suffers from an
\ninfectious disease, and also when a physi-
\ncian finds a new method of treatment and
\ntries to keep it secret. nnn The information
\nshould be reported and responded to, and in
\nthe case of new method of treatment, it
\nshould be shared. In a word, medical infor-
\nmation is too precious and too valuable in
\nsocial terms to be monopolized by anyone.
\n2) A strategy for protection and uses of
\nmedical information
\nWe thus should seek for a new strategy to
\npursue two aims at the same time: best
\nmedical treatment for the individual patient
\nand also best uses for the benefit of entire
\nsociety. I have studied the so called
\n\u201cHIPAA privacy rule\u201d, which took effect in
\n2003 in the United States.
\nThe most important characteristic of the
\nHIPAA privacy rule is the fact that it seeks
\nfor two aims at the same time. It tried to
\nspeed up the standardization of medical
\ninformation through electronic means and to
\nreduce the health costs to society. Since stan-
\n9
\nMedical Ethics and Human Rights
\ndardizing in the form of electronic data
\nincrease the risk of privacy, they introduce a
\ncomprehensive nation-wide rule to protect
\nmedical information. Put another way, they
\nfound the accumulation of medical informa-
\ntion in a standard form beneficial to society
\nas a whole, and, in order to realize its benefit,
\nfound it necessary and indispensable to set up
\na legal system to protect medical privacy.
\nThe same reasoning should apply to Japan as
\nwell. The first goal, then, is to set up a scheme
\nto gather as much useful information as possi-
\nble. The goal can be justified in two ways.
\nFirst, it is beneficial to patients. As we saw,
\nthe most basic and fundamental wish of
\npatients was and has been the best medical
\ntreatment for them, and the best health care
\ncould be realized on the maximum of rele-
\nvant information.
\nSecond, accumulation of medical informa-
\ntion is beneficial to the society as well. It
\ncan be used for variety of useful activities
\nsuch as public health, medical research
\noversight of clinical practice etc.
\nThus, we come to a conclusion that the first
\nbasic goal is to accumulate medical informa-
\ntion. But the information to be gathered has a
\npeculiar character, quite different from things
\nor property we saw in the first part. Inaccurate
\ninformation is useless and harmful. Even
\nthough it is accurate, if disseminated and used
\nfor bad purposes, then patients would be
\nreluctant to share information, since it is
\nextremely hard to recover the original status.
\nThe specific character and importance of
\nmedical information requires us to be cau-
\ntious with making up a legal strategy to pro-
\ntect medical privacy. The system should be
\nequipped with three principles.
\n(1) Prevention principle to deter leakage of
\ninformation.
\n(2) Discovery principle to find out viola-
\ntions as fast as possible.
\n(3) Sanction principle to punish intentional
\nwrongdoings.
\nThe first principle of prevention is realized
\nby setting clear and concrete rules to be fol-
\nlowed by both physicians and patients. The
\nprivacy rule should be clear cut in content
\nand make no traps for those who deal with
\nmedical information. Also patients should
\nunderstand, how their information is used,
\ndisclosed, and kept secret. Each hospital
\nshould publish a privacy statement or a priva-
\ncy policy. It should include how the patients\u2019
\n\u201cright to know\u201d is respected and realized.
\nAs to the second principle of discovery,
\nthere are a couple of means to make it easi-
\ner to discover privacy violations. One is the
\npatient\u2019s right to accounting, by which they
\ncan claim for tha actual use and disclosure
\nof their inforamtion. More specifically, they
\nhave the right to know how has made access
\nto their inforrmation has been used. Te
\nAmerican HIPAA privacy rule recognizes
\nthis right to accounting, but Japanes Act
\ndoes not. We should consider seriously
\nmaking use of monitoring incentives on the
\npart of patients to discover privacy viola-
\ntions. It would help to deter violations. The
\nother means for early discovery of viola-
\ntions is to give a privacy officer in medical
\ninstitutions a high status and strong power.
\nHe or she should be responsible for compli-
\nance with the privacy rules. Under the
\nInformation Protection Act in Japan, every
\nentity is required to have a privacy officer,
\nbut who it will be and what kind of expertise
\nand power will be given remains to be seen.
\nThe third principle of sanction is the most
\nweak under Japanese law. The maximum
\nsanction against privacy violations is six
\nmonths imprisonment and 2,700 U.S. dol-
\nlars fine. Let me contrast this with U.S.
\nHIPAA privacy rules in which the maxi-
\nmum penalty is ten years imprisonment and
\na fine up to 250,000 dollars. Of course,
\ncriminal sanction is just a part of the whole
\nscene.We should not forget that other sanc-
\ntions could work well, but we should recon-
\nsider the comparatively lenient attitude
\neven in the case of intentional wrongdoing
\nwhen we think of the importance of medical
\nprivacy.
\n10
\nMedical Ethics and Human Rights
\nEuropean Forum of National Medical Associations
\nStatement on healthcare in prisons
\nand other forms of detention
\nThe European Forum of Medical
\nAssociations and WHO meeting in Oslo
\non 11 \u2013 12 March 2005,
\nNotes that healthcare in prisons, detention
\ncentres and police institutions raises spe-
\ncific ethical and health issues;
\nWelcomes the activities and initiatives of
\nnational medical associations to provide
\nsupport and education (such as the
\nNorwegian Medical Association\/WMA
\ninternet course) for doctors working in
\ncustodial care;
\nURGES national medical associations to
\naddress these issues, working to the fol-
\nlowing broad principles:
\n\u2022 Detained persons should receive a stan-
\ndard of medical care equal to that avail-
\nable within the general community.
\n\u2022 Healthcare in prisons should be struc-
\ntured to reflect the high level of men-
\ntal health and substance abuse prob-
\nlems within the detained population,
\nas well as its social, economic and
\neducational makeup.
\n\u2022 While recognizing that physicians
\nworking in prison have dual loyalty,
\nthe healthcare and confidentiality of
\nthe patient should always be the doc-
\ntor\u2019s primary concern.
\n\u2022 Healthcare policies should recognize
\nthe financial benefit of effectively
\ntreating health problems which, if left
\nuntreated, will result in significant
\noverall additional cost to the commu-
\nnity.
\n\u2022 Patients in prison should have the nec-
\nessary access to secondary care ser-
\nvices.
\n\u2022 Investment in after-care and support
\nfollowing release is essential.
\n11
\nWMA
\nIV Conclusion
\nMedical information and its protection are
\nimportant worldwide. The discussion about
\nit, is however sometimes surrounded by
\nmisunderstandings or wrong metaphors.
\nMedical information is not a thing anyone
\ncould or should own. Still, it may be critical-
\nly important in some cases. Also it is bene-
\nficial not only to patients but also to society
\nas a whole. We should seriously consider
\nboth the best uses and best protection of it.
\nDiscussion uses and protection in an adver-
\nsarial way would lead in a wrong direction.
\nJust to say that we should make good balance
\nof uses and protection is useless or helpless.
\nWe should set up a goal and make up a legal
\nstrategy to realize it. I know that Japan is just
\nbeginning to start in that direction. The World
\nMedical Association would provide a good
\nopportunity to discuss, compare, and
\nimprove the strategy each country should
\nadapt.And through the support and efforts by
\nthe great Association, I hope that the wishes
\nof patients to trust physicians come true.
\nWMA Secretary General
\nFrom the Secretary General\u2019s Desk
\nSome feel that Medical ethics nowadays is
\nmore important than ever. And indeed many
\nethical questions in medicine have had public
\nattention during the last ten years: Questions
\nconcerning the beginning and end of life,
\nresearch on embryos, cloning, euthanasia and
\nassisted suicide, embryo transfer, substitute
\nmotherhood, together with subjects such as
\norgan trade and doping, are just a few of
\nthose ethical questions which tend to be most
\nvisible in the public discussion. They all have
\nbeen on the agenda of the World Medical
\nAssociation and most likely they will return.
\nBut the work of the WMAis much more than
\nthe high profile and much disputed questions
\nwith vibrant public attention: Patients\u2019Rights
\n\u2013 especially concerning children, research on
\nhumans, professional conduct \u2013 the questions
\nof every day medical life are the ones that
\nmake the work of the WMA indispensable.
\nSince World War II the WMA has been the
\nvoice of physicians on ethical and social
\nquestions in medicine worldwide.
\nIn times of change this role is becoming
\nmore and more important. Our economical
\nand political world has changed and so does
\nour medical world. More and more people
\nand governments see or deal with medicine
\nas a commodity business. The work of
\nphysicians and other professionals in the
\nfield of health is under the threat of being
\nturned into a plain commercial activity,
\nignoring the very special relationship
\nbetween patients and their physicians.
\nAnd with that change both market and gov-
\nernment influence on medicine grow in prac-
\ntices and in hospitals alike. Economic inter-
\nventions in medicine driven by managed care
\norganisations, insurers or governments
\nthreaten the professional autonomy of physi-
\ncians. Our professional freedom \u2013 the free-
\ndom to provide care in the best interest of the
\npatient is threatened in most, if not in all
\ncountries of this world regardless how differ-
\nent the health care systems are structured.
\nIn a survey among the members of the
\nWorld Medical Association during last
\nsummer, health reforms and their effects on
\nmedical practice got the highest attention.
\nIn all parts of the world questions of struc-
\nture and reform move and affect physicians
\nand patients alike. The WMA will tackle
\nthese questions. We will analyse and speak
\nout on what health care reforms will do to
\nthe care for patients. Our commitment was
\nand is to keep medicine as a free profession,
\ndedicated to people, committed to health,
\ndemanding freedom from undue influence
\nboth from market and from inappropriate
\ngovernmental influence.
\nMedicine is the unique combination of car-
\ning for people and the ethical application of
\nscience and art. The freedom it requires is
\nno \u201cdivine right\u201d and no permission for
\nfoolishness. It is rather a derivative of the
\npatients\u2019right to good and accessible health
\ncare and protection.
\nHigher cost and higher demands for medi-
\ncine and rapidly changing demographics in
\nmany of our countries are only two of many
\nreasons pressing for change. The rapid
\nchanges we are experiencing and their
\ninfluence on our ethics and the care we pro-
\nvide would be an important, if not the most
\nimportant global questions in medicine.
\nWhoever in this world uses scarce resources
\nshould be prudent and should handle those
\nresources with regard to society at large,
\nespecially if those resources are not renew-
\nable, critical for life or in the public domain.
\nOur work concerns all of these types of
\nresources and most of us are aware of that.
\nHowever, commercialisation or socialisa-
\ntion is no answer to the problem. Both limit
\nthe freedom necessary to provide choices,
\nto allow confidentiality, to build trust. Both
\ncome with the inherent threat of rationing.
\nThe WMA gives us the platform to work
\ntogether on answers to these questions.
\nAs our governments work closely together
\non the international scene, exchange their
\nviews and discuss their tools, we have to do
\nthe same. Whoever believes that the inter-
\nnational context is not important for medi-
\ncine and health care will find him or herself
\nin an isolated position very quickly.
\nThe WMA consists of people with very dif-
\nferent cultural backgrounds and traditions,
\nwith different economic situations, with
\ndifferent political views and different
\nbeliefs. And yet it is the ideal ground for
\nthe establishment and protection of com-
\nmon values and principles. The WMA is a
\nmembership organisation and the members
\nare the heart and the brain of this organisa-
\ntion. It is their contribution and engage-
\nment that counts. It is the Secretary
\nGeneral\u2019s duty and service to make that
\nwork.
\nMore than fifty years of very successful
\nwork of the WMA are a solid basis to work
\non, and to be a successor to the prominent
\npersons, who have served in this position is
\nan honour.
\nOtmar Kloiber
\n12
\nWMA
\nOn 18 January 2005 the WMA released its
\nnew Medical Ethics Manual. The Manual is
\na concise introduction to ethics for medical
\nstudents and physicians worldwide. It deals
\nwith the basic ethical concepts in clinical
\nmedicine and research and related princi-
\nples of human rights and medical profes-
\nsionalism, and it provides references to
\nmore detailed treatments of specific issues
\nand other appropriate resources. It can be
\nviewed and downloaded free of charge on
\nthe WMA web site (www.wma.net\/e\/ethic-
\nsunit\/resources.htm) and a print version is
\navailable in limited quantities. A Japanese
\ntranslation has been completed and French
\nand Spanish ones are in progress. Other lan-
\nguage versions will be produced as funds
\npermit.
\nThe manual is a product of the WMA Ethics
\nUnit. It is an educational resource, not a
\nWMA policy document (although it pre-
\ndominantly cites WMA policies).
\nBackground
\nThe WMA has a long-standing interest in
\nmedical ethics and medical education. In
\n1999 the WMA Assembly adopted the fol-
\nlowing Resolution on the Inclusion of
\nMedical Ethics and Human Rights in the
\nCurriculum of Medical Schools World-
\nWide:
\n1. Whereas Medical Ethics and Human
\nRights form an integral part of the
\nwork and culture of the medical profession,
\nand
\n2. Whereas Medical Ethics and Human
\nRights form an integral part of the his-
\ntory, structure and objectives of the
\nWorld Medical Association
\n3. It is hereby resolved that the WMA
\nstrongly recommend to Medical
\nSchools world-wide that the teaching
\nof Medical Ethics and Human Rights
\nbe included as an obligatory course in
\ntheir curricula.
\nTo assist in the implementation of this resolu-
\ntion, the WMACouncil designated the devel-
\nopment of an ethics manual as the principal
\nactivity of the WMA Ethics Unit, which was
\nlaunched in 2003. It is also a primary objec-
\ntive in the WMA Strategic Plan 2003-2007.
\nA preliminary survey of medical ethics cur-
\nriculum materials revealed that there are a
\nlarge number of textbooks and monographs
\nbut these are generally written for a specif-
\nic country and, moreover, are too expensive
\nfor most medical students in developing
\ncountries. The WMA Ethics Manual differs
\nfrom these by being international in scope
\nand available free of charge. Moreover, it
\nrelates medical ethics to both medical pro-
\nfessionalism and human rights, three sub-
\njects that are usually treated separately.
\nDevelopment
\nWork on the Manual began in the autumn of
\n2003 following my appointment as Director
\nof the WMA Ethics Unit. I developed a pros-
\npectus for the Manual and circulated it to an
\ninternational group of medical ethics teachers
\nfor comment. Following revision of the
\nprospectus, I began writing the Manual early
\nin 2004 and completed a first draft in June.
\nThat was sent to an expanded group of advi-
\nsors, including a number of medical students.
\nA second draft of the Manual that incorporat-
\ned their comments and suggestions was com-
\npleted by the end of September and that, too,
\nwas circulated to the advisors and to members
\nof the WMA Council, along with a proposed
\ndesign of the covers and layout. The final ver-
\nsion of the text was completed in December
\nand the PDF version of the Manual was pre-
\npared for its launch in January 2005.
\nContent
\nThe Manual consists of an introduction,
\nfive principal chapters, a conclusion, and
\nseveral appendices. Four of the five chap-
\nWMA
\nThe WMA Medical Ethics Manual
\nters begin with a paradigm case study that
\nillustrates the issues dealt with in the chap-
\nter and end with suggestions for how the
\ncase should be resolved.
\nThe Introduction states the goals and scope
\nof the Manual and explains what medical
\nethics is, why it is important, and how it is
\nrelated to medical professionalism, human
\nrights and law.
\nChapter One presents the principal features
\nof medical ethics: its values of compassion,
\ncompetence and autonomy; its pluralistic
\ncharacter; its gradual evolution over time;
\nits differences and similarities from one
\ncountry to another; and the role of the
\nWMA. The chapter also provides a brief
\ndescription of the different ways that indi-
\nviduals make ethical decisions.
\nChapter Two, the longest in the Manual,
\ndeals with the patient-physician relation-
\nship. It discusses six topics that present chal-
\nlenges to physicians in their daily practice:
\nrespect and equal treatment; communication
\nand consent; decision-making for incompe-
\ntent patients; confidentiality; beginning-of-
\nlife issues; and end-of-life issues.
\nChapter Three is concerned with the rela-
\ntionship of physicians and society, includ-
\ning those situations where there is an
\napparent or real conflict between the needs
\nof patients and the demands of third parties
\n(governments, employers, police, family
\nmembers, etc.). The chapter also deals with
\nthe difficult matter of resource allocation or
\nrationing and the role of physicians in pub-
\nlic health and global health.
\nChapter Four discusses the relationship of
\nphysicians and their colleagues in patient
\ncare, both other physicians and non-physi-
\ncians. It describes what medical profes-
\nsionalism requires of physicians in their
\nbehaviour towards their physician col-
\nleagues, teachers and students, including
\nreporting unsafe or unethical practices. It
\nalso stresses the need for cooperation with
\nnon-physician health professionals to pro-
\nvide optimal care for patients, and it sug-
\ngests guidelines for dealing with conflicts
\nabout patient care.
\nChapter Five focuses on the ethical
\nrequirements for medical research on
\nhuman subjects, as set out in the WMA
\n13
\nMedical Science, Professional Practice and Education
\nMedical Science, Professional Practice and Education
\nMedical Implants For Higher Performance
\nAnd Longer Life
\nLong-lifecycle MICS architecture ideal for
\npacemakers, defibrillators, remote tele-
\nmonitors, orthopaedic devices, pump con-
\ntrollers, nerve stimulators and swallowable
\nimaging systems
\nCambridge UK and Boston MA, January
\n18, 2004 \u2013 Cambridge Consultants has
\ndesigned a new \u2018control and communica-
\ntions\u2019 radio architecture for in-body med-
\nical diagnostic and therapeutic applications.
\nCalled SubQuore, it supports medical
\ndevice manufacturers\u2019drive for implantable
\ndevices which combine very low power
\nrequirements with robust wireless commu-
\nnications.
\nCambridge Consultants\u2019 design combines
\nexceptional power economy with great
\nflexibility. In a typical pacemaker for exam-
\nple, SubQuore would deliver more than 10
\nyears of activity from a lithium cell, but it is
\nequally capable of meeting short term
\nrequirements for high volumes of data, in a
\nswallowable video imaging device for
\nexample.
\nThe implantable device market is current-
\nly growing at double digit rates: wireless
\ncommunications have added a valuable
\nnew dimension to in-body therapeutic
\ndevices, and enabled a whole new gener-
\nation of diagnostic aids. For device
\ndesigners, the challenge is to exploit
\nthese new capacities within extreme size
\ncontraints, and with minimal power
\nrequirements. SubQuore is designed for
\nimplementation on system-on-chip (SoC)
\nsolutions, to provide a tiny control and
\ncommunications platform suitable for
\ndevices using Medical Implant
\nCommunications Services (MICS) fre-
\nquencies, the medical band now emerging
\nas a global standard.
\n\u201cAdvances in electronics technology are
\nenabling a host of new implantable applica-
\ntions, and this design draws on three of
\nDeclaration of Helsinki. These include
\nethics review committee approval, scientif-
\nic merit, social value, acceptable manage-
\nment of risks, informed consent, confiden-
\ntiality, avoiding conflict of roles (physician
\nvs. researcher), honest reporting of results,
\nand dealing with unethical research.
\nThe Conclusion calls attention to the fact
\nthat medical ethics should address the rights
\nof physicians as well as their duties. It also
\ndeals with the responsibilities of physicians
\nto themselves, and it concludes with some
\nreflections on the future of medical ethics.
\nFive Appendices complete the Manual: a
\nglossary; a list of resources that are avail-
\nable on the Internet; WMA and World
\nFederation of Medical Education statements
\non medical ethics education; suggestions for
\nstrengthening ethics teaching in medical
\nschools; and additional case studies.
\nNext Steps
\nAn intensive communication program is
\nunderway to make the Manual known to
\nteachers of medical ethics, medical students
\nand practising physicians throughout the
\nworld.
\nThe WMA Ethics Unit is developing a pro-
\nposal to link teachers of medical ethics in a
\nvirtual network using the WMA website.
\nThe network could serve as a means of
\ncommunication and exchange of experi-
\nences and suggestions for the teaching of
\nethics.
\nThe Ethics Unit may also develop an online
\nCME\/CPD course based on the Manual.
\nJohn R. Williams, Ph.D.
\nDirector of Ethics
\nthose trends: ultra low power consumption
\ntechnology, more intelligent radio perfor-
\nmance and extreme miniaturization\u201d says
\nRichard Traherne, head of Cambridge
\nConsultants\u201d wireless business unit.
\n\u201cCombined with the opportunities offered
\nby the MICS frequency allocation \u2014
\nwhich is emerging as a worldwide standard
\nendorsed by the FCC and ETSI \u2014 we see
\ngreat demand for an optimized single-chip
\nwireless platform that delivers the econo-
\nmy required for mass-volume medical
\napplications\u201d.
\nThe new implantable transceiver design
\nleverages Cambridge Consultants\u2019 portfo-
\nlio of field-proven intellectual property for
\nultra-low power radio, as well as the con-
\nsultancy\u2019s lean RISC processor core, XAP.
\nExtreme attention to power economy has
\nbeen applied throughout the design, both to
\nconsumption in the transceiver architec-
\nture, as well as the power-saving algo-
\nrithms that are employed to wake up and
\ncontrol the device. The architecture would
\nconsume an average current of less than
\n1\u00b5A, and less than 1.7mA peak, for a
\n0.05% duty-cycle, 400 kbits\/second bi-
\ndirectional communications application.
\nAlthough the range of implantable medical
\napplications is expanding exponentially,
\neach application is different and requires a
\nparticular mix of control, monitoring and
\ncommunications facilites \u2013 and Cambridge
\nConsultants expects to fine-tune the IC
\ncore for individual applications.
\nThe SubQuore radio operates in the 402-
\n405 MHz \u201cMICS\u201d frequency band \u2013 com-
\npatible with new FCC and ETSI standards
\n\u2013 and offers a communications range of 6
\nfeet\/2 metres when implanted under the
\nskin. The only other use of this band is for
\nmeteorological equipment, minimizing the
\npotential for interference and providing an
\nexcellent platform for economy of scale
\nthrough standardization.
\nAmong the applications foreseen are for
\nhigh-performance\/long-lifecycle an MICS
\ndevices implantable pacemakers, defibril-
\nlators, remote telemonitors, orthopaedic
\ndevices, pump controllers, nerve stimula-
\ntors and swallowable imaging and diagnos-
\ntic systems.
\nAdvanced medical technologies include
\norgan transplants, reproductive medicine,
\ngenetic diagnosis, gene therapy and regener-
\native medicine. Among others, this presenta-
\ntion will primarily focus on genetic diagno-
\nsis and regenerative medicine and outline
\nrelated bioethical issues.
\nFirst, in regard to genetic diagnosis, global
\ncollaborative research on human genome
\nanalysis (Human Genome Project) that start-
\ned in 1990 advanced faster than was initially
\nexpected. The draft sequence of the human
\nDNA base pairs was elucidated ten years
\nlater in June 2000, and further relate details
\nwere uncovered in February 2003. Many
\nwill remember that a variety of events cele-
\nbrating this accomplishment together with
\nthe commemorative events celebrating the
\nfiftieth anniversary of the discovery of the
\nDNA helical structure by Dr. Watson and Dr.
\nCrick, were held worldwide. It can be said
\nthat the elucidation of draft sequences of the
\nhuman genome has finally led us to the age
\nof new medical science and medical care
\nthat is identified as the \u201cpost-genome era\u201d
\nIt goes without saying that elucidating the
\ndraft sequence of human DNA itself has
\nextremely great scientific significance.
\nFurthermore, the global consensus is that the
\nbiggest goal of medical studies in the post-
\ngenome era is to elucidate the functions of
\neach respective human genome for which the
\ndraft sequences were made clear as mentioned
\nearlier, as well as to apply the results of such
\nstudies to medical science and medical care.
\nWith regard to genetic disorders caused by a
\nsingle abnormal gene, almost 1,000 kinds of
\nabnormal genes, including notably less com-
\nmon genetic diseases, have already become
\nclear, and the results of the studies concern-
\ning some of the genetic diseases have been
\nwidely used clinically for genetic diagnosis.
\nIn addition, with regard to acquired diseases,
\ngenetic diagnosis along with prognostic
\nexpectation etc., based on the results of such
\ndiagnosis, have been widely used clinically
\nfor many infectious diseases and some
\ntumors. Moreover, in accordance with the
\nrecent elucidation of the complete base
\nsequence of human DNA, further studies on
\nthe relationship between the results of DNA
\nanalyses and certain diseases have rapidly
\ndeveloped. Thus, it is expected that the stud-
\nies will not only contribute to genetic diagno-
\nsis of congenital diseases, infectious diseases
\nand specific tumors caused by a single abnor-
\nmal gene, but also successively clarify the
\ncorrelation between symptoms of a range of
\ndiseases that are classified as lifestyle-related
\ndiseases such as hypertension, diabetes, can-
\ncer, arteriosclerosis and Alzheimer\u2019s disease,
\nwhich are considered to be caused by multi-
\nMedical Science, Professional Practice and Education
\n14
\nBackground In Freedonia report
\n\u201cImplantable Medical Devices\u201d of October
\n2003, US demand for implantable medical
\ndevices is projected to increase nearly 11%
\nannually to $24.4 billion by 2007.
\nCambridge Consultants Inc., 451 D
\nStreet, Boston MA 02210, USA. Tel: +1
\n617 532 4700; Fax: +1 617 737 9889;
\nwww.cambridgeconsultants.com
\nCambridge Consultants Ltd, Science
\nPark, Milton Rod, Cambridge, CB4
\n0DW, UK. Tel: +44 (0) 1223 420024; Fax:
\n+44 (0)1223 423373; www.cambridge-
\nconsultants.com
\nAdvanced Medical Technology and Medical
\nEthics
\nFumimaro Takaku, M.D., Ph.D.
\nPresident, Japanese Association of Medical Sciences
\nPresented at the WMA General Assembly in Tokyo 2004
\nple gene-mutations. As a matter of fact, in
\nJapan, studies on the correlation between
\nmutations in genes including single
\nnucleotide polymorphism (SNP) with regard
\nto the five diseases; hypertension, diabetes,
\ndementia, cancer and bronchial asthma, and
\nclinical conditions of these diseases have
\nbeen conducted with a unified national effort
\nas the Millennium Genome Project since
\n2001. Development of these studies has
\nevery expectation of providing numerous
\nbenefits to all mankind through prevention of
\ndiseases, determination of diagnosis, choice
\nof treatment method, prediction of sensitivi-
\nty to specific medical agents and the emer-
\ngence of side effects caused by medical
\nagents for each individual patient \u2013 the indi-
\nvidualized medical indication. On the other
\nhand, there is also a big possibility that we
\nmust anticipate a large number of bioethical
\nissues, which are presently being raised in
\nconnection with genetic diagnosis of con-
\ngenital diseases, will be raised in a more
\nmagnified form in the future.
\nWhile genetic diagnosis has been conducted
\nfor a great number of congenital and
\nacquired diseases, as mentioned earlier, the
\nmain characteristics of genetic diagnosis are
\nsummarized in the following three points:
\n(1) More definitive diagnosis is possible
\ncompared to traditional diagnostic methods,
\n(2) Diagnosis is possible with an extremely
\nsmall amount of samples, and (3) Diagnosis
\nbefore symptoms develop (presymptomatic
\ndiagnosis) is possible. Of these, the most
\ncontroversial issue from the perspective of
\nbioethics is (3), the possibility of presympto-
\nmatic diagnosis. This kind of problem does
\nnot exist in genetic diagnosis for congenital
\ndiseases, where abnormality is diagnosed by
\nclinical symptoms and the results of labora-
\ntory examinations, or acquired diseases such
\nas cancer and infectious diseases.
\nPresymptomatic diagnosis
\nHowever, it has been pointed out that a wide
\nrange of bioethical issues will arise due to
\ngenetic diagnosis for diseases, for which
\ndiagnosis can be determined using genetic
\ndiagnosis long before symptoms emerge.
\nPatients suffer from serious conditions and
\nno treatment exists for congenital diseases
\nsuch as familial amyloidosis, Huntington\u2019s
\ndisease, etc. For example, according to the
\nresearch by the University of British
\nColombia in Canada announced in 1999, of
\n4,527 patients that were diagnosed with
\nHuntington\u2019s disease, 44 people (0.97%)
\neither committed suicide, attempted suicide
\nor were hospitalized in a mental institution.
\nOf these, half of those who had attempted
\nsuicide or were hospitalized in mental insti-
\ntutions were reported to have not at the time
\ndeveloped any symptoms. This suicide rate
\nis more than times that of the average.
\nAnother example of such problem as this is
\ngenetic diagnosis of breast cancer that clusters
\nwithin a family. As it is confirmed that abnor-
\nmal genes related to the development of
\nbreast cancer are identified as abnormalities
\nof BRCA-1 and BRCA-2 genes, when a
\nmother or sister was affected with breast can-
\ncer and abnormalities are found in BRCA-1
\nand BRCA-2 genes of the patient concerned,
\nit is naturally understood that a healthy female
\nin the family often desires to have the exami-
\nnation to check for the presence of abnormal
\nBRCA-1 and BRCA-2 genes. Although the
\nexpensive cost of this examination of 2,000
\nUS dollars or more is a problem, the psycho-
\nlogical burden stemming from the test results
\nis deemed to be a more serious problem. In
\nother words, although there is no problem if
\nthe test result proves that genes are normal,
\nthere is no doubt that the person who took the
\ntest will suffer serious psychological damage
\nif abnormal genes are found. The responses of
\nhealthy females with abnormal BRCA genes
\nwho have recovered from such psychological
\ndamage to some extent are assumed to be the
\nfollowing three:
\n(1) Cancer screening tests conducted by a
\ndoctor,
\n(2) Starting to take medicines that are recog-
\nnized as preventing breast cancer devel-
\nopment, including Tamoxifen, and
\n(3) Removing a normal breast in which an
\nabnormality is not found in advance. It is
\nreported that a considerable number of
\nwomen choose to remove their normal
\nbreast and then undergo artificial breast
\nreconstruction rather than being forever
\nconcerned with the fear of breast cancer
\ndeveloping in the future. However, since
\nthey have to go through much internal
\nconflict before reaching such a conclu-
\nsion, it is needless to say that counseling
\nwith specialists is regarded to be neces-
\nsary during such a period. Since the fre-
\nquency of breast cancer patients with an
\nabnormal BRCA gene is 5% or less in
\nJapan, (which is remarkably low com-
\npared to European countries and the
\nU.S)., it rarely becomes subject of dis-
\ncussion at present, but similar issues are
\nobviously expected to become a problem
\nin the future.
\nApart from the aforementioned issues, with
\nrespect to presymptomatic genetic diagnosis,
\nit is questionable whether an individual
\nneeds to claim insurance for genetic diag-
\nnoses when the person is covered by health
\ninsurance and life insurance. Although, in
\nJapan where all people are covered by pub-
\nlic health insurance, this kind of situation is
\nunlikely become a problem, genetic testing
\nwhen taking out a life insurance plan has
\nbeen studied for an extended period of time
\nand a conclusion has not yet been reached.
\nHowever, even in Japan, there is an undeni-
\nable possibility that an increased burden for
\nthe general public due to people with gene
\ndefects taking out insurance will come into
\nquestion in the future.
\nGuidelines
\nWithout posing the above mentioned exam-
\nples, you are probably already aware that var-
\nious bioethical issues arise in the research of
\nhuman genes, and as a measure to cope with
\nsuch problems, ethical guidelines concerning
\nthe study on human genome analysis and
\nresearch were publicized as a common guide-
\nline by three ministries ,the Ministry of
\nEducation, Culture, Sports, Science and
\nTechnology; the Ministry of Health, Labor
\nand Welfare; and the Ministry of Economy,
\nTrade and Industry, in March 2001. While
\nthese guidelines are exclusively focused on
\nbasic studies on human genes, the ethical
\nguidelines concerning genetic testing of clini-
\ncal test samples were also publicized in April
\n2001. It was Japan Registered Clinical
\nLaboratories Association that created these
\nguidelines. In many instances, testing compa-
\nnies perform genetic tests as part of daily clin-
\nical examinations, based on the request from
\nhospitals. This is the basic process in which
\nthe said guidelines were created by the associ-
\nation comprising these testing companies
\ngathered together. Further, when conducting
\ngenetic tests in medical facilities, protection
\nof privacy of patients who had had the test,
\ncounseling for patients and other issues will
\nbe an important issue to be addressed. To
\nrespond to these issues, ten societies including
\nthe Japan Society of Human Genetics, Japan
\nSociety of Obstetrics and Gynecology and
\nJapan Society of Genetic Counseling pre-
\npared the guidelines concerning genetic test-
\ning in 2003. Furthermore, the subject of these
\nguidelines is limited to genetic tests for muta-
\ntions in genes of the generative cell system,
\nand thus body cell gene analysis targeting
\ncancer cells and such is not referred to.
\nFurthermore, in Japan, the Ministry of
\nHealth, Labor and Welfare publicized
\n\u201cEthical Guidelines for Clinical Studies\u201d in
\n2003. These are the guidelines dealing with
\nclinical studies in general created basically
\nin line with the \u201cHelsinki Declaration,\u201d
\nadopted at the World Medical Association in
\n1964, which has been modified and added to
\nsix times.
\nAs presented above, regulations on genetic
\ntests are distinctively placed in the format of
\nguidelines. Despite differences in the detail
\nof these guidelines according to the respec-
\ntive objectives and targets, the common
\npoints among them are as follows:
\nProtection of the rights of patients, their fam-
\nilies and relatives,
\nProtection of personal information,
\nLegislation prohibiting genetic discrimina-
\ntion
\nAcquisition of written informed consent
\nfrom search objectives,
\nApproval of facility chief after screening at
\nInstitutional Review Board (IRB), and
\nPreparation of mandatory genetic counseling
\nsystem at testing facilities.
\nIt is highly predictable that the research on
\nthe correlation between gene abnormality
\nand diseases caused by multiple gene defects
\nsuch as lifestyle-related diseases, which is
\ncompetitively conducted on a global scale at
\npresent, will be developed, the correlation
\nbetween the results of DNA analysis of each
\nindividual and the development of these dis-
\nMedical Science, Professional Practice and Education
\n15
\neases will be manifested, and checking
\nmutation in genes will enable the diagnosis
\nof whether or not each individual is likely to
\nbe affected by these diseases. If such a situa-
\ntion is realized, it can easily be presumed
\nthat, in addition to the aforementioned issue
\nof taking out insurance, a broad range of
\nsocial issues including the possibility of
\ngenetic diagnoses in connection with finding
\nemployment, marriage and other daily
\nissues; the issue of protecting confidentiality
\nof personal data on genes etc. will be raised
\ndue to a great many more patients with
\nlifestyle-related diseases being different
\nfrom traditional cases of genetic diagnosis of
\ncongenital diseases. The pace of progress in
\nbioscience is beyond our imagination and
\nthus, we need to use this chance to discuss
\nthese issues, to a satisfactory extent, in
\npreparation for the advent of such situations.
\nDiagnosis in the Fertilised
\nOvum
\nFurther, diagnosis of fertilized ovum is
\nwhat arouses concern in Japan as genetic
\ntests related to reproductive medicine.
\nFertilized ovum diagnosis is among med-
\nical technologies for reproduction, in which
\n\u201cin vitro\u201d fertilization is performed; one of
\nthe fertilized eggs is taken out for genetic
\ntesting when the division of the fertilized
\novum proceeds and it is returned into uterus
\nonly when the results prove it is normal. In
\nits bulletin, the Japan Society of Obstetrics
\nand Gynecology approves fertilized ovum
\ndiagnosis only in the event of serious con-
\ngenital diseases. However, the bulletin of
\nthe society has no legal force. On the other
\nhand, there are some organizations that
\nstrongly oppose fertilized ovum diagnosis.
\nJapanese law does not permit induced abor-
\ntions on the grounds of genetic abnormali-
\nties. This is because of strong opposition
\ninsisting that approval of induced abortion
\nof children with gene defects means dis-
\ncrimination towards disabled people, and I
\nthink opposition against fertilized ovum
\ndiagnosis stems from this same reason.
\nHowever, in effect, it is estimated that
\ninduced abortions of fetuses with congeni-
\ntal diseases has been conducted for differ-
\nent reasons in Japan.
\n\u201cRegenerative Medicine\u201d
\nI would like to change the subject to bioeth-
\nical issues related to \u201cregenerative medi-
\ncine\u201d as in the case of genetic analysis. It
\nwas reported that Dolly, the sheep clone,
\nwas successfully generated by Dr. Wilmut
\nof Roslin Institute in Britain in 1997 and
\nbecame a worldwide topic of discussion.. It
\nis not surprising that the mass media devot-
\ned much space to concerns over the possi-
\nbility that the same technology may lead to
\nhuman cloning. Later, there actually
\nappeared doctors who attempted the cre-
\nation of cloned human beings and there was
\nsome publicity given to those claiming to
\nhave been successful.
\nIn Japan, \u201cThe Law Concerning Regulation
\nRelating to Human Cloning Techniques and
\nOther Similar Techniques\u201d was enforced in
\nJune 2001 and the creation of humans uti-
\nlizing cloning techniques has been prohibit-
\ned by law. For your information, offenders
\nof this law are to be fined up to 10 million
\nyen or 100,000 US dollars and receive
\nprison terms of up to ten years.
\nOn the other hand with respect to human
\nembryonic stem cells (ES cells) that are
\ncapable o being differentiated into a variety
\nof cells, two American research groups
\nreported the establishment of the ES cell
\nline in 1998. ES cells can be differentiated
\ninto every kind of cell and consequently, it
\nis natural that the application of this to med-
\nical transplantation is expected, especially
\nfor neurological disorders, severe cases of
\ndiabetes and critical hematological disor-
\nders that require bone marrow cell trans-
\nplants. On the other hand, it is true that
\nstrong opposition is expressed, because cre-
\nation of ES cells is accompanied by the
\ndestruction of blastocyte generated from
\nhuman fertilized ovum. In Japan, the
\nreview at the Office for Bioethics and
\nBiosafety, Lifescience Division of the
\nMinistry of Education, Culture, Sports,
\nScience and Technology led to the publica-
\ntion of \u201cGuidelines for Derivation and
\nUtilization of Human Embryonic Stem
\nCells\u201d. Consequently, both the production
\nand use of human ES cells have become
\npossible. However, when doing so, a dual
\nscreening system is employed in which the
\nresearch plan submitted by the head of the
\ninstitution after undergoing review by IRB
\nof the respective facilities are to be
\nreviewed again by the governmental review
\nboard. In Japan, the production of the
\nhuman ES cell line as well as research using
\nhuman ES cells has already been conducted
\nat about ten research facilities.
\nWhen using the cell differentiated from
\nhuman ES cells for medical transplantation,
\nit is no wonder that the difference of HLA
\nbetween the original ES cells and a patient
\nwill become an issue. It is because, needless
\nto say, transplanted cells will be rejected
\ndespite the hard work of transplantation
\nunless HLAs between ES cells and a patient
\nmatch. The most effective method of solv-
\ning this problem at the present stage is ther-
\napeutic cloning technology.This is to create
\ncloned embryos by placing nuclei taken
\nfrom a patient\u2019s somatic cells into donated
\novum after denucleation and then creating
\nES cells from the cloned embryo. In addi-
\ntion, as for this technology, It has been
\nrecently proposed to use the term \u201cnuclear
\ntransfer\u201d since the term, cloning, is easily
\nmixed up with reproductive cloning to cre-
\nate cloned human beings. The countries that
\nadmit the creation of ES cells created by
\nusing the patient\u2019s own nucleus, produced
\nin the aforementioned manner, that is
\nautochtonous ES cells, are the U.K.,
\nBelgium, Sweden, South Korea and China.
\nSouth Korea attracted attention worldwide
\nsince Prof. Hwang, et al. in Seoul National
\nUniversity disclosed the successful creation
\nof autochtonous ES cells on the on-line
\nScience magazine in February 2004. After
\nthat, some people, centering on opponents
\nof human cloned embryo, criticized the ori-
\ngin of donated ovum.
\nIn Japan, the pros and cons of research on
\ntherapeutic cloning has been debated for
\nover two and a half years by the Expert
\nCommittee on Bioethics of the Council for
\nScience and Technology Policy in the
\nCabinet Office and it was finally decided in
\nJuly 2004 to approve therapeutic cloning
\nonly in cases of basic research and to pro-
\nmote the preparation for a system for this.
\nThe reason behind the fact that it took a
\nlong time of two and a half years for the
\ndiscussion to reach this conclusion was that
\ndiverse opinions concerning the pros and
\nMedical Science, Professional Practice and Education
\n16
\ncons of promoting the studies on therapeu-
\ntic cloning among committee members of
\nthe said Expert Committee prevented a
\nconsensus from being reached.
\nI myself participated in the government-affil-
\niated committee as a committee member
\nwith regard to bioethics to deal with the
\nissues including reproductive medicine, gene
\ntherapy, human ES cells and studies on ther-
\napeutic cloning. The impression I got from
\nthe meeting was that the Japanese committee
\nhad only a few opportunities to hear patients\u2019
\nopinions. Actually, an open symposium con-
\ncerning therapeutic cloning was the limited
\nopportunity for me to directly listen to
\npatients\u2019 opinions. In addition, I received the
\nimpression that media coverage was prone to
\nbring up more negative opinions on the sub-
\nject of the advanced medical technology
\nmentioned above even if they were minority
\nopinions. Furthermore, probably due to few
\nopportunities to hear opinions from patients
\nand their related parties at the hearings of the
\ncommittee, I thought there were only a few
\nsituations when news reports raised patients\u2019
\nvoices. On the other hand, partly because
\nregulations on genetic diagnosis and regener-
\native medicine are executed as guidelines
\ninstead of laws, except for the Law
\nConcerning Regulation Relating to Human
\nCloning Techniques and Other Similar
\nTechniques in Japan, it appears to be one of
\nthe characteristics in Japan that a big politi-
\ncal impact has not been made to date.
\nMedical care is certainly embarking on an
\nage of globalization. The latest information
\non advanced medical technologies can easily
\nbe obtained via the Internet and it leads to the
\nera when the most advanced medical care is
\navailable everywhere around the world as
\nlong as the expenses are not brought into
\nquestion. Although the \u201cBrain-Dead
\nTransplant Bill\u201d proposed in Japan does not
\npermit the transplantation of organs from
\nbrain-dead children, families constantly go
\noverseas to have their children undergo
\ntransplantation despite the substantial
\nexpenses. I also hear that many couples
\nobtain fertilized ovum diagnosis overseas,
\nwhich as I described can only rarely be con-
\nducted in Japan.. I suppose other countries
\nprobably have similar situations.
\nTo overcome such conditions, I am looking
\nforward to seeing the World Medical
\nMedical Science, Professional Practice and Education
\n17
\nAssociation create universal ethical guide-
\nlines concerning advanced medical tech-
\nnologies. With admiration for the World
\nMedical Association\u2019s formulation of the
\nHelsinki Declaration that has been revised
\nseveral times, I would venture to insist on
\nthe need to add universal ethical guidelines
\nwith regards to advanced medical technolo-
\ngies. As the perspectives concerning
\nbioethics of advanced medical technologies
\nvary widely depending on cultural and reli-
\ngious background of the respective coun-
\ntries, it is needless to say that difficulties
\ngenerated when creating such universal
\nguidelines could well be foreseen. However,
\nadvanced medical technologies have been
\ndeveloped and put into practical use not for
\nthe special benefit of us, medical experts, but
\nfor the benefit of patients whoreceive diag-
\nnosis and treatment utilizing such technolo-
\ngies. Given this fact, I regard it to be an
\nimportant role that the World Medical
\nAssociation should play to make an appeal
\nso that people throughout the world may get
\nequal benefit of all medical care including
\nadvanced medical technologies.
\nModern Demands in Health Care
\nHaruo Uematsu, MD
\nPresident, Japan Medical Association
\nPresented at the WMA General Assembly in Tokyo 2004
\nIn looking back on the past century, the
\n20th century is noteworthy for achieving
\nscientific progress that is unprecedented in
\nthe history of mankind. In conjunction with
\ndevelopments attained in medical science,
\nphysics, chemistry, biology, and other
\nfields, great strides have been made
\nthrough interdisciplinary exchanges.
\nEspecially noteworthy is the progress made
\nin antibiotics, beginning with the discovery
\nof penicillin, that has especially been very
\neffective in controlling the foremost cause
\nof mortality\u2014the spread of infectious dis-
\neases. So effective was this control, that for
\na short period of time, many people were
\nlulled into the belief that it was possible for
\ninfectious diseases to be completely con-
\ntrolled. However, the manifestation of
\ndrug-resistant strains of bacteria, the emer-
\ngence and re-emergence of infectious dis-
\neases has shown that numerous problems
\nwill arise in tandem with future develop-
\nments. In recent years, the focal point of the
\ndisease structure has shifted from infectious
\ndiseases to cancer, cerebrovascular dis-
\neases, diabetes, and other diseases that stem
\nfrom lifestyle habits. This has led to a
\nreview of lifestyle habits and it has greatly
\naffected the focus of medical care.
\nAnother notable point is the progress that
\nhas been made in clinical imaging technol-
\nogy. The discovery of X-rays was a land-
\nmark discovery, but the development of the
\nCT, MRI, PET in recent years has epito-
\nmized the fruits of interdisciplinary
\nresearch, and the contributions to medical
\ndiagnosis made by these imaging tech-
\nniques have been immeasurable. This has
\nalso been true for biochemical tests.
\nAlthough progress in diagnostic technology
\nthat precedes medical treatment has
\nincurred criticisms of excessiveness or the
\nwaste of financial resources earmarked for
\nmedical costs, progress in medical care is a
\nforegone conclusion.
\nThe twentieth century has been called the
\ncentury of wars as attested to by the numer-
\nous wars that were fought in the last centu-
\nry. In the field of physics, fission phenome-
\nnon developed by nuclear science was not
\nutilized for peaceful purposes, but to pro-
\nduce nuclear weapons; and tragically, there
\nis a history of its actual use, which provides
\nus with an unforgettable moral lesson about
\nwhat occurs when the scientific achieve-
\nments are mistakenly utilized to fulfill
\nhuman or national greed.
\nAlthough with the passing years the growth
\nof various industries led by scientific devel-
\nopments has made our lives much more
\nconvenient, it has also left us with a burden-
\nsome legacy of serious environmental pol-
\nlution and the destruction of the natural
\norder of things. Moreover, it will require
\nadditional years and enormous effort to
\nrecover from these damages.
\nIn Japan, the onset of the Minamata disease
\ncaused by seawater pollution is a tragic case
\nexample, as well as the large number of
\npatients with respiratory disorders stem-
\nming from air pollution. The yin and yang
\nresults of scientific development often
\nbecome apparent only after a fairly long
\nperiod of time. Thus, the effort to acquire
\nthe wisdom to anticipate numerous phe-
\nnomena that may occur over a wide spec-
\ntrum of situations must not be neglected.
\nSince medical science and medical care are
\ndirectly linked to life and death issues, its
\nimpact on the future must be constantly
\ntaken into consideration. In our review
\nabout medical care and its ideal form, an
\nimportant point to consider is the relation-
\nship between medical science and medical
\ncare and recognition of their differences.
\nThe late Dr. Taro Takemi, former JMA pres-
\nident and the president of the WMA, de-
\nfined medical care as \u201cthe social application
\nof medical science\u201d. As to whether this is
\nthe best definition of medical care can be
\ndebated from a myriad of differing perspec-
\ntives, but I believe that it is the most appro-
\npriate in explanations about medical care.
\nThere is a relatively common perception
\nabout medical science that is shared among
\nall countries. But, its social application is
\ntempered by a panorama of factors that
\nrange from the natural environment, histo-
\nry, culture, politics, to the economy of each
\ncountry. These exceedingly diverse condi-
\ntions that surround medical science con-
\ntribute to the complexity of medical care.
\nCold climate and tropical regions, moun-
\ntainous and sea level regions, wet and dry
\nregions the climactic and geographical dif-
\nferences lead to disparate diseases and the
\nmedical care that is needed to treat them
\nalso differs. A prime example is endemic
\ndiseases. Due to developments in trans-
\nportation, infectious diseases that were
\nonce confined to a specific region have
\nbegun to spread rapidly and globally over a
\nwide geographical area forcing each nation
\nto be prepared to cope with these diseases.
\nThe most recent example of this phenome-
\nnon is SARS.
\nDiseases that are linked to the dietary habits
\nin each country or region are effectively
\ntreated through lifestyle guidance measures
\nrather than by medical care. In the northern,
\ncold climate regions of Japan, studies have
\nshown that there was a high incidence of
\nhypertension due to a high dietary salt
\nintake by the population, and lifestyle guid-
\nance measures have effectively helped to
\ncontrol salt intake levels.
\nHowever, medical care issues in countries
\nthat face political and economic hardships
\nare the most difficult to resolve. Due to
\nextremely poor public and environmental
\nhealth conditions, many people are unable
\nto receive needed medical care despite the
\nhigh incidence of diseases. The WMA has a
\nrole to fulfill in such countries where the
\npopulation is unable to receive proper med-
\nical care due to existing economic condi-
\ntions.
\nCurrently, organ transplants, genetic test-
\ning, gene therapy, reproductive medicine,
\nregenerative medicine and other forms of
\nadvanced medical technology are being
\nsuccessively and practically applied. The
\nadvent of medical care that was once con-
\nsidered impossible or the development of
\nminimally invasive treatment methods has
\nraised the fervent expectations of many
\nand has pushed advanced medical technol-
\nogy into the public limelight. Meanwhile,
\nbioethical issues, professional ethical
\nissues that confront physicians, and issues
\nthat question the very essence of medical
\ncare have come to the fore, as attested to
\nby the ethical issues seen in reproductive
\nmedicine.
\nAs a science, medicine has pursued
\nprogress in the treatment of diseases and it
\nhas sought to illuminate the phenomenon of
\nlife. The fruits of these endeavors have
\nmade advanced medical technology and
\nmedical care possible. Medicine as a sci-
\nence seeks to achieve the potential and to
\nattain progress through cumulative
\nresearch, but in order to apply the fruits of
\nmedical science in medical care, the impact
\nof social factors mentioned earlier becomes
\ncrucial. Even the understanding of bioethi-
\ncal issues that are perceived as being analo-
\ngous throughout the global community, will
\ndiffer according to the history, culture, and
\nreligion of each country, as well as the ethos
\nof the times.
\nIn Japan, laws that govern brain death and
\norgan transplants were not legislated for a
\nlong period of time. In truth, one of the
\nunderlying reasons for this delay was pub-
\nlic distrust of medical care, as well as dis-
\nsatisfaction with the traditional system of
\npaternalism, an inadequate understanding
\nof informed consent, compounded by
\nJapan\u2019s own unique religious beliefs and
\nperceptions about death. Thus, it took time
\nto achieve public consensus. In view of the
\nlessons that were learned from this experi-
\nence, there must be adequate public disclo-
\nsure of information and sufficient public
\ndialogue with regard to highly advanced
\nmedical technology.
\nIf there was even one physician who
\nattempted to utilize advanced medical tech-
\nnology without the consensus of society for
\npersonal fame or to satisfy academic curios-
\nity, public distrust of the entire medical
\nfield would be generated that would greatly
\ndamage progress and development. As pro-
\nfessionals working in medical science and
\nmedical care, this is an issue that precedes
\nethics. However, advanced medical tech-
\nnology does contribute to human happiness
\nand well being. It is essential that society
\nrecognizes that it is safe and there is an
\nextremely high probability of success.
\nTherefore, ethics, IT, physician qualifica-
\ntions, professional autonomy, and other
\nissues have been included in the program
\nfor the Scientific Session with the main
\ntheme of advanced medical technology. I
\nwill leave detailed discussions about these
\nissues to the respective speakers who will
\nbe discussing them in the special lectures
\nand symposium that have been planned.
\nIn viewing the situation from a different
\nperspective, advanced medical care has
\nmade it possible to provide treatments for
\ndiseases that were unavailable in the past.
\nSimultaneously, it has forced physicians to
\nspecialize in order to provide this treatment.
\nThe curriculum in medical education has
\nbecome excessively concentrated and seg-
\nmented, and medical students are trained in
\nthe partial and individual treatment of dis-
\nMedical Science, Professional Practice and Education
\n18
\neases. But this education does not adequate-
\nly address issues such as patient QOL, does
\nnot consider what is truly beneficial for the
\nwell-being of the patient, and what mea-
\nsures should be taken to achieve this well-
\nbeing from a broader perspective of med-
\nical care. In an increasingly aging society,
\nthese are issues that call for a reaffirmation
\nof the importance of holistic medicine by
\nall medical care providers. It is important to
\nnote that the perspectives about life and
\ndeath that prevail in each country are also
\nimportant contributing factors.
\nThe greatest demand that is being made on
\nmedical care today, is to provide safe and
\nhigh quality medical care that is accessible
\nequally to all people. In Japan, as in other
\ncountries, Japanese society and its citizens
\nhave recently begun to stress the need for
\nsafe medical care due to the frequent occur-
\nrence of medical errors. Consequently, spe-
\ncific measures and results are being
\ndemanded of medical care providers.
\nThe three causes of medical errors are peo-
\nple, equipment, and organization. Of these
\nthree causes, the foremost cause is people.
\nIn other words, measures must be taken to
\nimprove the professional qualifications of
\nmedical care personnel and to raise physi-
\ncian ethics. Although this is the responsi-
\nbility of each individual physician, medical
\nassociations also have a major responsibil-
\nity to fulfill as professional academic orga-
\nnizations for physicians. Likewise, society
\nalso has great expectations of medical
\nassociations in helping to address this
\nissue. To meet these expectations, medical
\nassociations must actively pursue measures
\nto raise the professional ethics of physi-
\ncians and to promote CME programs for its
\nmembers.
\nIn the past, the physician was the focal tar-
\nget of responsibility for medical errors, but
\nit is more important to clarify the cause of
\nthe error, to take measures to prevent its
\nreoccurrence, to reeducate the responsible
\nphysician in lieu of punitive actions, and
\nto pursue measures that allow physicians
\nto provide a higher quality of medical
\ncare. Latent high-risk cases should not be
\nsimply compiled as potential medical error
\ncases. This task should be actively carried
\nout as a means of preventing medical
\nerrors. Although error-proof equipment,
\nimproved pharmaceutical packaging,
\nimproved usage, and other improvements
\nhave been targeted and implemented, ulti-
\nmately, the responsibility returns full cir-
\ncle on shoulders of the physician-in-
\ncharge (the foremost cause of medical
\nerrors).
\nIn the area of organization, there are a vari-
\nety of issues that must be investigated such
\nas the process of providing medical care
\nand other factors; and many medical insti-
\ntutions have created review committees to
\naddress these issues. But, coordination
\nbetween the different medical occupations
\nwithin the medical institution becomes
\nimportant and we return again to the fore-
\nmost cause of people.
\nPresently, every nation is faced with the dif-
\nficulties of securing financial resources to
\npay for medical care and with efforts to
\ncontrol medical costs. It is vital that each
\nNMA actively stresses the importance of
\nthe need to inject funds to cover medical
\ncosts in order to secure safe medical care. It
\nis also important for the WMA to publicly
\nproclaim its viewpoint on this issue.
\nAs of 1961, all residents in Japan have
\nequal access to safe and high quality med-
\nical care at all times under the universal
\nhealth insurance system. Consequently,
\naccording to a WHO report, Japan has the
\nlongest healthy life expectancy and the
\nhighest health record in the world.
\nMoreover, national medical costs are
\nranked 17th in the world denoting the
\nachievement of effective health care at low
\ncosts.
\nHowever, the universal insurance system in
\nits current form was achieved after many
\ntrials and tribulations\u2014nationwide strikes
\nby medical personnel, mass resignations by
\nhealth insurance physicians, political strug-
\ngles against the government over health
\ninsurance measures, and many other activ-
\nities. Medical payments are decided
\naccording to a nationwide, uniform point
\nsystem for medical service fees. In Japan,
\nall medical services that are provided, from
\nconsultation and examination fees, tests,
\ntreatment, surgery, injections, medication,
\nto hospitalizations, are calculated and paid
\naccording to the medical fee schedule. This
\nschedule is applied nationwide, and allows
\nall residents to receive medical care at all
\ntimes throughout the country under a uni-
\nform pricing structure. A breakdown of
\nnational medical cost coverage shows that
\n30 percent is funded by public expenditure,
\n50 percent by health insurance, and about
\n20 percent by individual patients. It is dif-
\nficult to inject national taxes to pay for
\nmedical costs due to national economic
\nconditions, and the government\u2019s recogni-
\ntion that medical care is part of social secu-
\nrity also plays a great role. We are endeav-
\noring to maintain this system amidst suc-
\ncessive applications of costly, advanced
\nmedical technology within a rapidly aging
\nsociety.
\nEach NMA is also undoubtedly striving to
\nachieve a system that will provide equal,
\nhigh quality medical care for all citizens,
\nand it is hoped that Japan\u2019s universal health
\ninsurance system as well as the activities of
\nthe JMA will serve as an example.
\nCurrently, the number of beds in proportion
\nto the total population is high in Japan and
\nthe hospitalization period is lengthy.
\nConsequently, hospitals have been criti-
\ncized for allowing social hospitalizations or
\nlong hospital stays by patients who can be
\ndischarged. This has been toted as a prime
\nexample of wasteful medical costs. As a
\nresult, hospital beds have begun to be cate-
\ngorized as general hospital beds (for
\npatients hospitalized for medical care) and
\nconvalescent beds (for convalescent
\npatients with minimal medical care needs)
\nand there is a move to reduce the number of
\nhospital days.
\nThe foremost problem with regard to out-
\npatient services is the tendency of patients
\nto go to large hospitals, which has con-
\ntributed to extremely long waiting hours
\nand reduced examination periods. This is a
\nserious problem for many patients, that
\nsimultaneously places excessive demands
\non the physician. Thus, immediate counter-
\nmeasures are needed. This is one of the
\ninherent flaws of this universal insurance
\nsystem since it allows patients to receive
\ntreatment at any medical institution with
\nonly a relatively low, initial co-payment
\nfee.
\nMedical Science, Professional Practice and Education
\n19
\nTo compensate for this flaw, to eliminate
\nwasted medical resources, and to provide
\neffective health care, a system of medical
\nprovision has been created. In order to pro-
\nvide medical care, including advanced
\nmedical technology, appropriately to those
\nin need, the functions of medical institu-
\ntions have been divided and coordinated. In
\naddition, information about the functions
\nof each medical institution are openly dis-
\nclosed and measures to provide informa-
\ntion that allow patients easy access have
\nbeen pursued as an important means of
\nimproving the system.
\nIn Japan, a community health and medical
\ncare plan has been created for communi-
\nties with a population of about 300,000
\nthat have been designated as medical
\nzones with all required medical facilities.
\nOne of the focal aims of this plan is to
\nallow community residents to live in secu-
\nrity with regard to their medical care
\nneeds, which are mainly taken care of by a
\nsystem of primary care physicians who are
\nsupported by a network of hospitals. The
\nobjective is to create a comprehensive
\ncommunity health and medical care sys-
\ntem within a designated medical zone.
\nThis is not a system that simply provides
\nmedical care. The aim is to build commu-
\nnities where residents are able to live out
\ntheir lives in relative security within a sys-
\ntem that provides wide-ranging health
\ninsurance and medical care services.
\nMedical association activities also include
\nmaternal and child health, school health,
\ncommunity health, industrial health insur-
\nance, health insurance for the elderly, as
\nwell as activities for health insurance for
\nall ages, vaccinations, emergency medical
\ncare, and nursing care for the elderly. The
\nperspective has shifted from medical care
\nproviders, who have traditionally been
\nresponsible for creating health services
\nand providing medical care, to that of com-
\nmunity residents, in order to establish
\nactive local communities and to carry out
\nactivities that will allow residents to live in
\nsecurity. It is a significant means of renew-
\ning public trust in medical care.
\nLong-term care or nursing care has become
\nan important issue as Japanese society con-
\ntinues to age. In tandem with the national
\nhealth insurance system, a long-term care
\nMedical Science, Professional Practice and Education
\n20
\ninsurance system was created. Initially, nur-
\nsing care for the elderly was covered under
\nthe national health insurance scheme as
\nsocial hospitalization. But, the focus of nur-
\nsing care has begun to shift increasingly to
\nin-home nursing care services. The idea is
\nto support the independence and self-
\nreliance of the elderly and to enable them to
\nlive at home in familiar surroundings. The
\namount of financial support that is provided
\nfor nursing care costs is divided into six
\nlevels, and a ceiling has been placed on the
\nmaximum amount of assistance that will be
\nprovided at each level.
\nUnlike the national health insurance, appli-
\ncants must be certified as being in need of
\nlong-term nursing care in order to qualify
\nfor long-term care insurance. The appli-
\ncant\u2019s primary physician must submit an
\naccurate assessment of the applicant\u2019s need
\nfor nursing care and must follow-up on the
\npatient to ascertain that proper care has
\nbeen provided. Additionally, proper med-
\nical care must also be provided. Therefore,
\nflaws in the system must be corrected and
\nthe physician\u2019s awareness must be
\nreformed. In this respect, these measures
\ncan be included within the comprehensive
\ncommunity health and medical care sys-
\ntem.
\nIn thinking about societies that provide
\nmedical care, the political and economic
\nconditions as well as the structure of the
\ndiseases that exist in each country differ.
\nThus, the issues that medical care faces are
\nmyriad. There are economically rich coun-
\ntries, countries beset by poverty, population
\ngrowth, a declining birth rate, and there are
\ncountries that face problems that are com-
\npletely contrary to these issues.
\nThe major theme of advanced medical care
\nthat have been addressed at the Scientific
\nSession of the WMA Tokyo General
\nAssembly will discuss the fact that there are
\ncountries where ethical concepts and per-
\nceptions have been unable to keep up with
\nthe ever increasing pace of advanced med-
\nical technology and countries that desire to
\nhave access to advanced medical care, but
\ncannot because of economic reasons, attest-
\ning to the complexity of the issues that are
\ninvolved. It is difficult to come up with
\nexpedient proposals that address these
\nissues and many must be addressed as polit-
\nical problems.
\nHowever, if medical care exists to further
\nthe well being and security of the human
\ncommunity, each nation is obligated to pro-
\nmote medical care with in the various con-
\nditions that exist despite the disparities
\nbetween countries. It is important to contin-
\nuously stress the fact that medical care is an
\ninvestment in health and consequently, an
\ninvestment in national strength to govern-
\nments that try to control medical costs by
\ndefining medical care as simply consump-
\ntion.
\nThe medical care delivery system and the
\nconcept of a comprehensive community
\nhealth and medical care system that is being
\npromoted in Japan does not generate inordi-
\nnate costs to implement, and they can be
\nimmediately adopted and implemented in
\ncountries that are economically burdened.
\nHopefully, this plan will also serve to assist
\nsuch countries. I will be reporting periodi-
\ncally on how this system progresses in
\nJapan and hope that the information may be
\nof some assistance.
\nI have attempted to discuss the conditions
\nthat surround medical science and medical
\ncare, and the medical care issues that are
\nbeing demanded by the public. In conclu-
\nsion, what is being demanded today, is
\nsafe, progressive, and \u201cquality\u201d medical
\ncare that can be effectively and fairly
\naccessed by all. Each physician and med-
\nical association must steadily strive to meet
\nthese demands supported by governments
\nthrough national policies and financial
\nmeasures.
\nLastly, I would like to state that we, physi-
\ncians who are entrusted with the task of
\nprotecting the health of humanity through
\ndaily medical care activities and the WMA,
\na major organization of medical associa-
\ntions, must take action and courageously
\nvoice their viewpoints on events that threat-
\nen human life, notably regional conflicts,
\nstarvation, and other hardships that accom-
\npany poverty.
\nMedical Science, Professional Practice and Education
\n21
\n1. Characteristics of
\nInformation Technology (IT)
\nin the 21st
\nCentury
\nTo summarize the advancement of informa-
\ntion technology (IT) in the 21st
\ncentury, we
\ncould say, \u201cIT was utilized by health care
\nproviders at medical institutions in the 20th
\ncentury. But with advancements in the IT
\nworld, IT has been disseminated not only to
\nhealth care providers but also to patients in
\nthe 21st
\ncentury, producing a great impact on
\nhealth care.\u201d Today, I would like to speak
\nabout the harmonization of IT progress and
\nhealth care, focusing on care provider and
\npatient utilization of IT. The next speaker
\nwill discuss the great impact IT has had on
\nmedical research, so I will talk mainly about
\nthe impact of IT on medical practice.
\nFirst, let me summarize the characteristics
\nof IT in the century. The advancement of IT
\nin the century can be represented by 1) per-
\nsonal use of IT, 2) advanced communica-
\ntion, 3) multimedia, 4) large-scale database,
\nand 5) robotics.
\nPersonal use of IT means that IT is utilized
\nby individuals. As of 2002, more than 70%
\nof households in Japan had personal com-
\nputers, and more than 80% of them are
\nusing the Internet. It has become easy for
\nordinary people to utilize information tech-
\nnology. Many people are using the Internet
\nvia cellular phones in Japan; 79% of cellular
\nphones available in Japan are web-ready.
\nAt home personal computers are connected to
\nthe Internet, and users can obtain a variety of
\ninformation from around the world in no
\ntime. For example, national university hospi-
\ntals can transmit high-resolution images using
\nthe satellite communication system, making it
\npossible to exchange lectures such as live
\nsurgeries among universities. It is noteworthy
\nthat the broadband service fees in Japan are
\nlower than in any other area in the world.
\nMultimedia technology has created new
\nimages such as the three-dimensional
\nimage and made it possible to accumulate
\nand store high-resolution moving images
\nfor a long time.
\nIn large-scale databases, life-long medical
\ninformation of patients or the latest medical
\nliteratures can be compiled and stored. For
\nexample, it is widely known that the data-
\nbase of the National Library of Medicine in
\nthe U.S., on which some millions of litera-
\ntures are compiled, is open to the world as
\na service called MEDLINE.
\nRobotics is also one of the characteristics of
\nIT in the 21st century. How the humanoid
\nrobot technology will be applied is yet to be
\nseen.
\n2. Impact of IT on Health
\nCare
\nEach characteristic of IT is quite useful. We
\nare witnessing the tremendous influence of
\nmodern science in our daily lives. But the
\nlatest advanced technology has disadvan-
\ntages as well, even though the technology
\nitself is wonderful. Although some technol-
\nogy is directly applied to human beings in
\nhealth care, great technology does not sim-
\nply result in good health care.
\nIn fact, health care in the 21st
\ncentury has
\nbeen changing under the influence of IT.
\nHuman well-being could be enhanced if IT
\nis utilized correctly, but may degenerate if
\nIT is misused.
\nThe changes in health care brought about by
\nIT can be described in a number of ways,
\nbut I think the following four changes are
\nsymbolic of them in general: (1) scientifica-
\ntion of health care, or dissemination of evi-
\ndence based medicine, (2) decentralization
\nof medical practice, (3) merger of public
\nCoordination of Progress in Information Tech-
\nnology with Health Care in the 21st
\nCentury
\nShigekoto KAIHARA, MD
\nVice President, International University of Health and Welfare
\nPresented at the WMA General Assembly in Tokyo 2004
\nhealth, medical administration and clinical
\nmedicine, and (4) expansion of the active
\nrole of patients, or patient empowerment. I
\nwould like to talk about each of these sym-
\nbolic changes in detail.
\nScientification of health care
\nFirst, I will consider the scientification of
\nhealth care, or dissemination of evidence
\nbased medicine. Various clinical trial meth-
\nods have been established, and all clinical
\nprocedures are now required to be per-
\nformed based on scientific evidence. Results
\nof clinical trials are published as medical lit-
\nerature, compiled to establish clinical guide-
\nlines, and made available to physicians on
\nthe Internet. Physicians are expected to prac-
\ntice medicine following these guidelines.
\nResults of such clinical practice are fed back
\nto researchers, serving as cues for new
\nresearch. In this cycle, the results of clinical
\nstudies are shared with clinicians in no time,
\nand new medical knowledge is quickly dis-
\nseminated all over the world. For example,
\nreports on significant adverse drug reactions
\nare made available to physicians in the
\nworld within a few days. Such speedy dis-
\nsemination of important information would
\nnot have been possible without IT.
\nWhile this trend yields benefits for both
\nphysicians and patients, we should consider
\nthe availability of treatments recommended
\nin clinical guidelines to patients in the world.
\nThere are numerous reasons for not being
\nable to receive such treatments. No matter
\nhow advanced the information technology is,
\nit takes time to disseminate information to
\neach individual physician, and clinical guide-
\nlines are not necessarily put into practice
\nimmediately. There are more serious reasons
\nfor not being able to put guidelines into prac-
\ntice, however. One is not being able to obtain
\nthe medical resources necessary to provide
\nrecommended treatments for patients no mat-
\nter how much such treatments are desired.
\nFor example, there may not be any physician
\nwho can perform the procedure, drugs may
\nnot be available in the area, or drugs may be
\navailable but cannot be obtained due to high
\ncosts. When talking about medicine on a
\nglobal basis, it would not be exagerating to
\nsay that there are only a few countries where
\nmedicine can be practiced by following clini-
\ncal guidelines. As long as medicine is practi-
\ncal science, the constant presence of a gap
\nbetween medical knowledge and medical
\npractice is unavoidable.
\nTherefore, we should not criticize it as
\nunscientific if medicine cannot be practiced
\nby following clinical guidelines. Physicians
\nshould have more interest in bridging the
\ngap between scientific medicine and actual
\nhealth care. It is more difficult to close this
\ngap compared with discovering new knowl-
\nedge. In some cases, you may have to use
\nalternative medicine (or traditional medi-
\ncine) that has a long history. We should
\nemphasize that the best medical practice is
\nto do our best with whatever resources are
\navailable in the given environment.
\nDecentralization of medical
\npractice
\nSecondly, IT has brought about decentraliza-
\ntion of medical practice. Health care has been
\nprovided to patients who visit certain places
\nwhere medical resources are centralized as
\nmuch as possible. Since it is impossible for a
\nphysician to treat a lot of patients by visiting
\neach of them with medical and testing
\ndevices, patients have to visit clinics, hospi-
\ntals or health care centres to seek treatment.
\nHowever, this may be undesirable for some
\npatients. Needless to say, it is most desirable
\nif they could receive the best treatment in the
\nplaces where they live with their families.
\nIn the advanced information-telecommuni-
\ncation society, even if decentralization of
\n\u201ctangible\u201d medical resources cannot be
\nachieved, the decentralization of medical
\n\u201cinformation\u201d is now possible. With the
\nadvanced information-telecommunication
\nsystem, information can be delivered any-
\nwhere in the world in no time. It is quite
\ninteresting that a large part of medical prac-
\ntice is receiving or providing information.
\nDiagnosis, for the most part, means informa-
\ntion processing by a physician, with infor-
\nmation provided by a patient. The same can
\nbe said for determining a treatment strategy.
\nIn some treatment, physicians only provide
\ninformation to patients who \u201cact out\u201d what
\nthey have learned. Moreover, in some cases
\nwhat used to be done by physicians may be
\ndone by nurses instead. Taking into account
\nthese perspectives, medical practices, to a
\ncertain extent, could be given to patients at
\nhome by combining information exchange
\nsystems and a medical team of nurses.
\nChanges toward decentralization of medical
\npractice can be seen in a variety of areas. In
\nJapan, the value of home health care has
\nbeen reconsidered. Advanced medicine can
\nnow be practiced on a ship in the Pacific
\nOcean or on a spaceship. Jacque Marescaux
\nof IRCAD\/EITS in Strasbourg, France, has
\nsuccessfully performed a heart operation
\nthrough the intercontinental remote opera-
\ntion of a robot between Strasbourg and New
\nYork; it is called \u201cLindbergh operation\u201d
\nafter the man who achieved the first trans-
\nAtlantic flight. Such medical practice is
\ncalled \u201cdistance medicine\u201d.
\nThese are wonderful achievements in med-
\nicine brought about by IT. However, we
\nshould think about the disadvantages of the
\ntechnology once again. First, we must
\nnever rely on information tools too much;
\nhumane health care must not be forgotten.
\nNo matter how the information technology
\nadvances, it is essential for physicians and
\npatients to face each other as human beings.
\nWe should remember that information
\nexchange through IT is one of complemen-
\ntary tools for medical practice.
\nSecondly, there is an issue of the cost of the
\nsystems. In other words, it is an issue of med-
\nical efficiency. Being efficient means being
\nmore economical. Patients have been required
\nto visit medical institutions because health
\ncare can be provided more efficiently that way.
\nIn this sense, it is quite interesting to examine
\nif distance medicine is more efficient than cen-
\ntralization of health care. The advanced coun-
\ntries are taking different approaches regarding
\nthis issue. In Canada andAustralia where peo-
\nple live scattered across large land areas,
\ndepopulated areas in the U.S. and in the moun-
\ntains in France, distance medicine is consid-
\nered more efficient. The national or the state
\ngovernments in such countries have already
\ninstituted policies promoting distance medi-
\ncine. In densely-populated Japan, there is no
\nconsensus on whether health care can be pro-
\nvided more efficiently with distance medicine
\ncompared with the centralization of medical
\nresources. When we think about harmonizing
\nIT and medicine, we should consider the eco-
\nnomical aspect of the harmonization.
\nMerger of clinical medicine
\nand public health\/medical
\nadministration
\nIT has also had an impact on public health
\nand medical administration. Such an impact
\nis associated with the construction of large-
\nscale databases. Public health and medical
\nadministration services are provided for a
\nlarge number of people in a certain area or in
\nthe whole country. It used to be impossible to
\nhandle data on hundreds of thousands of indi-
\nviduals; decisions on what services to pro-
\nvide and how to provide them were always
\nmade based on compiled data. In other
\nwords, clinical medicine and public health
\nwere totally different forms of health care.
\nHowever, to stretch the point, the technology
\nfor constructing these databases enabled us to
\nbuild reservoirs with medical data on each
\nindividual. For example, the technology
\nchanged infection control measures. When
\nthere is an outbreak of a certain infection, the
\nmeasures to control the infection are estab-
\nlished based on the analysis of data on infect-
\ned individuals compiled in the database.
\nMedical institutions and administrative agen-
\ncies work closely with each other, and analy-
\nsis results are provided for physicians in the
\nclinical sites in real time. Such information
\ndelivery was quite effective in the recent out-
\nbreak of severe acute respiratory syndrome
\n(SARS), as well as the spread of E. coli O-
\n157 infection in Japan several years ago.
\nNot only infection data but also the entire
\nmedical data in a certain area or a country
\ncould be retained, accumulated, and analyzed
\nin a database if they are electronically stored.
\nIn countries where health care insurance is
\ndisseminated, data are usually digitized in the
\nprocess of claiming medical fees. If these
\ndigitized data are compiled to build a data-
\nbase, the current situation of health care in
\nthat country can be completely grasped. Such
\ndatabases are already available in some of the
\nadvanced Western countries. Although elec-
\ntronic data on the health care insurance has
\nbeen promoted in Japan, a database does not
\nMedical Science, Professional Practice and Education
\n22
\nexist because such data have not been stan-
\ndardized. I am concerned that there may be a
\nlack of data that could serve as a basis for the
\nrevision of medical fees.
\nCompilation of accurate medical data on the
\nentire nation is quite useful for the efficient
\nprovision of health care. However, there are
\nsome issues to be considered.Two of the major
\nissues are protection of privacy in the process
\nof handling medical information and autho-
\nrization to access the database. I will skip the
\nprivacy issue because Dr. Higuchi will talk
\nabout it in detail later. Here I would like to refer
\nto authorization to access the database.
\nAnalyzing medical data of individual persons
\nin the database will reveal many facts; there-
\nfore, who will be authorized to access the
\ndatabase is a big issue. If the government has
\nsole authority to analyze the data, the govern-
\nment gains tremendous power and may force
\na variety of policies on its people. Since this is
\nsurely undesirable, the medical database for
\nanalysis should be widely available to those
\nwho are interested in such analysis, while
\nmedical data containing personal information
\nshould be handled with caution. All nations
\nshould share their experiences in considering
\nhow to resolve these conflicting issues. The
\nmost important thing, I believe, is to establish
\nrules for using the database, to make it public,
\nand to authorize anybody who is willing to
\nobey the rules. The present guideline for the
\nmedical database established by the World
\nMedicalAssociation puts emphasis on the pri-
\nvacy issue; however, I wish more considera-
\ntion had been given to the access issue.
\nPatient empowerment
\nThe most important impact of IT is that
\npatients can now play a proactive role in health
\ncare. We can call it patient empowerment.
\nNow that patients can easily obtain health care
\ninformation on the Internet, they will be able to
\nchoose medical institutions according to the
\nobtained information and discuss treatment
\noptions with physicians on equal terms. For
\nexample, patients can review their medical
\nrecords kept at the hospital at home with their
\nfamilies via the Internet. Although the number
\nis still small, some hospitals and clinics offer
\nsuch services for their patients in Japan.
\nMedical Science, Professional Practice and Education
\n23
\nWhile this is a welcome change, we should
\nkeep in mind that much of the information
\navailable on the Internet could be wrong or
\nexaggerated. The quality of information post-
\ned on the Internet may be questionable, and
\nthis is a common and serious problem, not
\nlimited to health care, in the modern, advanced
\nIT world. It is almost impossible to totally
\neliminate bad quality information from the
\nInternet. However, the influence of bad quali-
\nty information can be minimized if medical
\nprofessionals provide high quality information
\nthemselves. A group of physicians may evalu-
\nate the medical information on the Internet to
\nset aside reliable information and give it an
\napproval mark. It will be meaningful if volun-
\ntarily done by people with conscience in the
\nprivate sector; it will be censorship and unde-
\nsirable if done by the government. Physicians
\nnow should consider methods of quality assur-
\nance in providing information to their patients.
\nContrary to reducing the trusting relationship
\nbetween physicians and patients, patients\u2019
\nproactive role in health care should enhance
\nsuch a relationship. Some say the number of
\nmedical lawsuits will increase if patients
\nobtain health-related information; however,
\nthere is no evidence to support such a notion.
\nIn the 21st
\ncentury, patients should proactive-
\nly obtain information to enhance the trustful
\nphysician-patient relationship and improve
\nthe quality of health care.
\nRobotics
\nLastly, I will talk about robotics. Robotics has
\nonly recently been put to practical use.
\nNursing robots and transportation robots are
\navailable now. There has been a growing inter-
\nest in using robots to comfort people. One type
\nof nursing robot will sense a slight movement
\nof the hand of a paralyzed patient and put food
\ninto the patient\u2019s mouth with a spoon.
\nAll the roles robots will have in health care
\nis yet to be seen. There was a time when peo-
\nple considered using robots in health care to
\nbe totally inhumane and unacceptable.
\nHowever, if we carefully choose where to
\napply robotics in health care, robots will be
\nuseful. I will stop here because I do not have
\nenough data to further discuss this issue. We
\nwill have to observe the development and
\napplication of robotics in health care with
\ninterest as medical professionals.
\n3. Conclusion
\nI have spoken about the necessity of harmo-
\nnizing IT and health care in the above-men-
\ntioned five areas. Needless to say, IT is a
\nwonderful technology that will make great
\ncontributions to health care. In order to make
\nsuch contributions worthwhile, it is impor-
\ntant for all physicians to be interested in the
\ntechnology and use it correctly. Health care
\nwill not improve just because IT is used; the
\nquality of health care will improve only if IT
\nis used correctly. Every physician should
\nunderstand the technology and use it as his
\nor her own tool in the 21st
\ncentury.I hope we
\nwill all make efforts to enhance harmoniza-
\ntion of IT and health care.
\nThe Medical Liability System in Germany \u2013
\nAn Accepted System
\nDr. Suzanne Katelh\u00f6n, Auslanddienst, Bundes\u00e4rztekammer, Germany
\nAstronomical claims for damages and esca-
\nlating premiums for medical professional
\nliability insurance, a growing number of
\ncourt cases against doctors – not least
\nbecause of the high profits made by the
\nlawyers and the possibility of aggressively
\nsoliciting suing patients – the snapshot pre-
\nsented by Dr. Palmisano in his article in the
\nlatest issue of the World Medical Journal
\n(WMJ 50 (4)110 is alarming.
\nWorthy of note are the roughly 70% of
\nmedical liability cases that end up before a
\ncourt and are closed without damages being
\npaid.
\nMedical Science, Professional Practice and Education
\n24
\nThe USA are not exceptional in this con-
\ntext. Comparable figures can also be found
\nin Germany, the difference being, however,
\nthat the cost of litigation remains within
\nreasonable limits, since many of these cases
\ncan be settled out of court.
\nThe decisive factor behind this situation
\nwas the introduction of Expert
\nCommissions and Arbitration Boards at the
\nState Medical Chambers in 1975. They are
\nindependent bodies that examine differ-
\nences of opinion between doctors and
\npatients to objectively establish whether
\nhealth-related complications are attribut-
\nable to medical treatment giving rise to lia-
\nbility. The aim is to reach an out-of-court
\nsettlement between the doctor and the
\npatient. The Expert Commission draws up a
\nwritten expertise on the question of whether
\nthe doctor can be accused of medical mal-
\npractice, as a result of which the patient has
\nsuffered, or will suffer, damage to his
\nhealth. The Expert Commissions are head-
\ned by a chairman qualified to hold judicial
\noffice, who is usually assisted by two mem-
\nbers from the medical profession, at least
\none of whom is active in the same field as
\nthe doctor in question.
\nIn agreement with the parties involved,
\nmeaning the patient, the doctor or hospital,
\nand the liability insurer, the Arbitration
\nBoards clarify the facts and circumstances
\nof the case and then make a proposal for
\nsettlement of the dispute.
\nThe members of the Arbitration Board are a
\ndoctor as chairman, a lawyer qualified to
\nhold judicial office, and other members
\nfrom the medical profession.
\nIn this context, the statements of the
\nArbitration Boards globally judge compen-
\nsation claims, while the Expert
\nCommissions appraise the activity of the
\ndoctor as such. The decisions of the Expert
\nCommissions and Arbitration Boards are
\ndeterminations or recommendations. If the
\ndoctor or the patient disagrees with the deci-
\nsion, he can resort to the ordinary courts of
\nlaw. According to an evaluation by the
\nExpert Commission of the North Rhine
\nMedical Chamber, only 13% of the petition-
\ners in all appraisal procedures concluded in
\nthe year 2000 (133 out of a total of 1,032)
\ndecided to take such action. The fact that
\nonly 10% of petitioners (63 out of 637)
\nresort to further litigation if medical mal-
\npractice cannot be established, is indicative
\nof the high degree of acceptance of the
\nexpertises. Insofar as the proceedings had
\nalready been concluded, the court and the
\nExpert Commission reached the same ver-
\ndict in the vast majority of cases. Only on
\nsix occasions did the court decision differ
\nfrom the result of the appraisal procedure.
\nThere is no statistical recording of medical
\nliability lawsuits in Germany. Conse-
\nquently, there are likewise no data as
\nregards the decline in the cost of litigation
\nfollowing the introduction of Arbitration
\nBoards. Figures from the Arbitration Board
\nof the Northern German Medical Chambers
\nat least give an indication of the proportion
\nof expensive litigation proceedings that it
\nwas possible to avoid: Of 4,000 petitions
\nfiled in 2004, only 70% (2,813) were
\naccepted for a substantive decision at all.
\n1,208 petitions (30%) were not dealt with
\nfurther, either because they had been with-
\ndrawn again by the petitioner (377 peti-
\ntions), or because they were not pursued
\nfurther for lack of jurisdiction (41 peti-
\ntions). In 656 cases, no decision was
\nreached because of a protest lodged by one
\nof the parties involved. 92 cases were
\nresolved simply by providing advice. The
\nfigures for the other Federal States are sim-
\nilar, making it clear that simple structures
\nand relatively little effort are all it takes to
\navoid unnecessary litigation proceedings
\nand thus save costs.
\nThe advantage of the Arbitration Boards for
\nthe petitioner is also obvious: the arbitra-
\ntion procedure is free of charge for the
\npatient. And with an average completion
\ntime of just 12 months, it is also much
\nfaster than recourse to the courts.
\nThis, and the great acceptance of the deci-
\nsions, has led to an increase in the number of
\npetitions in the last 15 years. While, for exam-
\nple, the Arbitration Board of the Northern
\nGerman Medical Chambers had to deal with
\nsome 1,500 petitions per year in 1990, the fig-
\nure had already risen to over 4,000 in 2003.
\nTheArbitration Boards of other State Medical
\nChambers also recorded an increase in the
\nnumber of petitions received, but not to such
\na great extent as at the Northern German
\nMedical Chambers. For instance, 1,023 peti-
\ntions were filed with the North Rhine Medical
\nChamber in 1990, compared to a total of
\n1,656 recorded in 2001.
\nHowever, the results of the work of the
\nExpert Commissions and Arbitration Boards
\ndo not remain confined to a regional level,
\nbut are collected and analysed centrally. The
\nStanding Conference of Expert Commissions
\nand Arbitration Boards was founded at the
\nGerman Medical Association for this pur-
\npose. Its objective is to improve and stan-
\ndardise the individual procedural workflow.
\nThe results are not only used to compile
\nnational statistics. The information on med-
\nical malpractice is also used in the State
\nMedical Chambers for the systematic analy-
\nsis of the causes of mistakes and to pass on
\nthe findings to doctors in the framework of
\ncontinuing education events. This helps to
\nensure continuous quality assurance.
\nNot only doctors, but also patients and the
\npublic at large, must accept that mistakes and
\ndamage can occur during any activity.
\nPlaying down medical malpractice, or even
\nmaking a taboo of the subject, breeds doubt
\nand suspicion. Mutual mistrust fosters com-
\npensation claims and liability suits.
\nComprehensible and exhaustive patient
\ninformation that is documented in writing,
\nevidence-based and transparent work, and an
\nefficiently functioning system for managing
\nfaults are essential elements for regaining
\nand promoting the confidence of patients
\nboth in the individual doctor and medicine in
\ngeneral. The medical community must learn
\nto openly face up to its own mistakes and
\nlearn from them. Then, the patient will also
\nunderstand that the access of the general
\npublic to medical care is worth more than the
\nright of the individual to compensation.
\nBibliography:
\n(1) \u201eBericht der Gutachterkommission f\u00fcr
\n\u00e4rztliche Behandlungsfehler bei der
\n\u00c4rztekammer Nordrhein\u201c, 2003
\n(2) Heinz D. Laum et al. \u201eSchlichtung mit
\ngrosser Akzeptanz\u201c, Deutsches
\n\u00c4rzteblatt 12\/2003
\n(3) German Medical Association,
\nT\u00e4tigkeitsbericht 2003\/2004, p. 330 ff.
\n(4) www.schlichtungsstelle.de
\nWHO
\n25
\nHuman Evolution
\nOut Of Africa
\nAccording to Professor Fred Spoor of
\nUniversity College, London, man has
\nevolved primarily through his capacity to
\nrun rather than climbing ability. Fossil evi-
\ndence shows that man developed the art of
\nwalking around 4.5 million years ago, fol-
\nlowing ape evolution at 13 million years,
\nand thence the ability to stride and run in
\norder to escape his enemies and hunt in
\ngroups. In response to the changing envi-
\nronment of plate tectonics, man\u2019s legs have
\ngradually become longer, relative to those
\nof his nearest neighbour the chimpanzee,
\nand his forearms have become shorter. The
\nskeleton evolved directly as a reaction to
\nthe way Homo sapiens moved around, a
\nclassical form of evolution, over a 6 million
\nyear period. Efficacy in running emerged
\nabout 2 million years ago, being successful-
\nly better represented through surviving gen-
\nerations and men capable of raising large
\nfamilies. Thus man was enabled to migrate
\nout of Africa and spread around the rest of
\nthe world. The question remains as to
\nwhether survival of the fittest is a product
\nof random chance and deleterious muta-
\ntions or are there specific feedback mecha-
\nnisms operationg on the DNA template in
\nevolution to fill environmental niches?
\nEvolution occurs when natural selection
\noperates in a population containing many
\nvariations in their inheritable characteris-
\ntics. The genetic heritage of a community
\ntends to remain constant unless changed by
\nexternal environmental influences.For
\nexample, a population living on an island
\nwill evolve much quicker than one allowing
\nfree mixing, as in the Galapagos Islands
\noriginally observed by Darwin, where each
\nisland has different varieties of finches and
\ntortoises. Also, Madagascar represents an
\nisolated island where there are no monkeys
\n\u2013 lemurs have developed to fill this envi-
\nronmental niche. In tropical Australia there
\nare many new species that have been free to
\ndevelop in the absence of competition.
\nIn terms of survival of the fittest, of malar-
\nia provides survival value in some native
\nAfrican populations when immunity to the
\nparasite Plasmodium develops. Some muta-
\ntions, perhaps as a result of adaptation to
\nmetabolic requirements, can be advanta-
\ngeous rather than damaging \u2013 and it is these
\ngenes which in the long run may come to be
\nthe norm within a population.
\nIvan M. Gillibrand
\nWHO
\nWHO Supports Global Effort To Relieve
\nChronic Pain
\nGeneva \u2013 The World Health Organisation
\nhas co-sponsored the first Global Day
\nAgainst Pain, which seeks to draw global
\nattention to the urgent need for better pain
\nrelief for sufferers from diseases such as
\ncancer and AIDS. The campaign, organised
\nby the International Association on the
\nStudy of Pain (IASP) and the European
\nFederation of the IASP Chapters (EFIC),
\nasks for recognition that pain relief is inte-
\ngral to the right to the highest attainable
\nlevel of physical and mental health.
\nWHO representatives joined global special-
\nists in chronic pain management and relief
\nat a conference in Geneva convened to
\nhighlight the Global Day Against Pain and
\nto press for urgent action from governments
\nacross the world. The conference coincides
\nwith the release of the Council of Europe\u2019s
\nnewly formulated recommendations on pal-
\nliative care including management of pain.
\nThe recommendations provide detailed
\nguidance for setting up a national policy
\nframework, and are available in 17
\nEuropean languages.
\n\u201cThe majority of those suffering unrelieved
\npain are in low- and middle-income coun-
\ntries where there is an increasing burden of
\nchronic conditions such as cancer and
\nAIDS,\u201d said Dr Catherine Le Gal\u00e8s-
\nCamus, WHO Assistant Director-General
\nfor Noncommunicable Diseases and
\nMental Health. \u201cLimited health resources
\nshould not be allowed to deny sick people
\nand their families the dignity of access to
\npain relief and palliative care, which are
\nintegral to the right to enjoy good
\nhealth.We strongly support the Global Day
\nAgainst Pain and the efforts of IASP and
\nEFIC.\u201d
\nNew statistics released by IASP and EFIC
\nindicate that one in five people suffer from
\nmoderate to severe chronic pain, and that
\none in three are unable or less able to main-
\ntain an independent lifestyle due to their
\npain. Between one-half and two-thirds of
\npeople with chronic pain are less able or
\nunable to exercise, enjoy normal sleep, per-
\nform household chores, attend social activ-
\nities, drive a car, walk or have sexual rela-
\ntions. The effect of pain means that one in
\nfour reports that relationships with family
\nand friends are strained or broken, accord-
\ning to the IASP\/EFIC data.
\nThe statistics also reveal that pain is second
\nonly to fever as the most common symptom in
\nambulatory persons with HIV\/AIDS. Pain in
\nHIV\/AIDS usually involves several sources at
\nonce. The causes include tissue injury from
\ninflammation (including autoimmune res-
\nponses), infection (e.g. bacterial, syphilitic or
\ntubercular) or neoplasia (lymphoma or sarco-
\nma): so-called nociceptive pain. Nearly half of
\npain in HIV\/AIDS is neuropathic, reflecting
\ninjury to the nervous system.
\nOral morphine has proven to be a cost-
\neffective pain medication for the treatment
\nof moderate to severe pain when the under-
\nlying cause is cancer or HIV\/AIDS.
\nHowever, opioid analgesics are not ade-
\nquately available, particularly in develop-
\ning countries with limited resource set-
\nWHO
\n26
\ntings, due to ignorance of their medical use,
\nrestrictive regulations and pricing issues.
\n\u201cPain relief should be a human right,
\nwhether people are suffering from cancer,
\nHIV\/AIDS or any other painful condition,\u201d
\nsaid Professor Sir Michael Bond MD,
\nPresident of IASP. \u201cToday\u2019s Global Day
\nAgainst Pain marks an immense growth in
\nthe interest in this area and WHO co-spon-
\nsorship of our campaign shows that now is
\nthe time to take pain seriously.\u201d
\n\u201cChronic pain is one of the most underesti-
\nmated health care problems in the world
\ntoday, causing major consequences for the
\nquality of life of the sufferer and a major
\nburden on the health care systems of the
\nWestern world,\u201d said Professor Harald
\nBreivik, President of EFIC. \u201cWe believe
\nchronic pain is a disease in its own right. For
\npeople in developing countries, where pain
\nrelief is at its most minimal availability, the
\nconsequences of unrelieved pain are great.\u201d
\nProfessor Breivik said the decision to hold a
\nGlobal Day resulted from the success of the
\nEuropean Week Against Pain, launched by
\nEFIC four years ago under the leadership of
\nits Past President Professor David Niv.
\nFor further information please contact
\nWHO: Dr Cecilia Sepulveda, +41-22-791-
\n3706, or David Porter +41-22-791-3774
\n(o), +41-79-477-1740 (m).
\nIASP: Prof Sir Michael Bond, President,
\nEmeritus Prof of Psychiatry, University of
\nGlasgow. UK, +44-141-330-3692.
\nwww.iasp-pain.org
\nEFIC: Prof Harald Breivik, President,
\nProf of Anaethesology, University of Oslo,
\nNorway, +47-23073-691 www.efic.org
\nClinical Obesity Pandemic
\nFight Childhood Obesity To Help Prevent
\nDiabetes, Say WHO & IDF
\nGeneva \u2014 Worldwide, it is estimated that
\nmore than 22 million children under five
\nyears old are obese or overweight, and more
\nthan 17 million of them are in developing
\ncountries. Each of these children is at
\nincreased risk of developing type 2 diabetes
\n(which used to be known as mature onset
\ndiabetes), say the World Health Organization
\nand the International Diabetes Federation
\n(IDF).
\n\u201cTackling childhood obesity now is a high-
\nly effective way of preventing diabetes in
\nthe future,\u201d said Dr Catherine Le Gal\u00e8s-
\nCamus, WHO Assistant Director-General
\nfor Noncommunicable Diseases and Mental
\nHealth.
\nChronic diseases such as diabetes, heart
\ndisease, cancer and stroke are a barrier to
\neconomic development. While undernutri-
\ntion continues to be a key concern, particu-
\nlarly in developing countries, governments
\nare also facing up to the fact that many chil-
\ndren in all regions of the world have poor
\neating habits and are not getting enough
\nexercise.
\nGlobally, an estimated 10% of school-
\naged children, between five and 17 years
\nold, are overweight or obese, and the situ-
\nation is getting worse. In the United
\nStates, for example, the rate of obesity
\nand overweight among children and ado-
\nlescents aged 6 to 18 years increased to
\nmore than 25% in the 1990s from 15% in
\nthe 1970s.
\nSuch increases are not restricted to devel-
\noped countries. In China, the rate of over-
\nweight and obesity observed in a study of
\nurban schoolchildren increased from
\nalmost 8% in 1991 to more than 12% six
\nyears later. In Brazil, the rate of overweight
\nand obesity among children and adoles-
\ncents 6 to 18 years old more than tripled
\nfrom 4% in the mid-1970s to over 13% in
\n1997.
\nThe link between obesity and diabetes is
\nwell-established. Around 90% of people
\nwith diabetes have type 2 diabetes and of
\nthese the vast majority are overweight or
\nobese. \u201cOverweight and obesity increase
\nthe risk of many chronic diseases, includ-
\ning type 2 diabetes, heart disease, stroke
\nand some cancers. Unless we address the
\nunderlying causes of the obesity epidemic
\nit has the potential to overwhelm health
\nsystems throughout the world,\u201d said Dr Le
\nGal\u00e8s-Camus. \u201cThe direct health care costs
\nof diabetes already account for between
\n2.5% and 15% of annual health care bud-
\ngets.\u201d
\nWHO is working with its Member States
\nthroughout the world to implement the
\nGlobal Strategy on Diet, Physical Activity
\nand Health, which was adopted at the May
\n2004 World Health Assembly.
\nThe strategy recommends a comprehen-
\nsive range of changes at the individual,
\ncommunity, national and international lev-
\nels which, if effectively implemented,
\nhave the potential to turn around the obe-
\nsity epidemic. The strategy addresses
\nchanges needed in lifestyles that have
\nbeen linked to the increase in overweight
\nand obese children over the last twenty
\nyears.
\nIncreased availability and promotion of
\nfoods high in fat and sugar mean that chil-
\ndren no longer eat the way their parents
\ndid. Nor do they do the same amount of
\nphysical activity. In each country the situa-
\ntion is different, but the reasons why chil-
\ndren are less active than a generation ago
\ninclude increased urbanization and mecha-
\nnisation, changes to transport systems and
\nincreased hours spent in front of TVs and
\ncomputers.
\nYet small changes can make a big differ-
\nence. In Singapore, nutrition education
\nin class, combined with a school envi-
\nronment offering healthy foods and
\ndrinks, and special attention for students
\nwho were already overweight or obese,
\nresulted in a significant decline in the
\nnumber of obese students. In the UK,
\nlimiting access to sweet, fizzy drinks at a
\ngroup of primary schools resulted in
\nslimmer children. Other studies have
\ndemonstrated success by increasing
\nWHO
\n27
\nphysical activity in school, making
\nchanges to school lunches, limiting hours
\nspent watching TV and providing health
\neducation.
\nProfessor Pierre Lev\u00e8bvre, President of
\nIDF, underlined the need for urgent
\naction. \u201cChildren and adolescents who
\nare overweight tend to grow into over-
\nweight adults. Poor habits of nutrition
\nand lack of physical activity are likely to
\nendure, putting today\u2019s young people at
\nrisk of type 2 diabetes in the future. Even
\nin childhood, overweight and obesity
\nlead to higher levels of blood glucose
\n(sugar), lipid (fat) and blood pressure. In
\nmany populations, doctors are seeing
\nincreasing numbers of adolescents with
\ntype 2 diabetes, a disease that in the past
\nwas not normally seen until middle or
\nolder age.\u201d
\nDiabetes is a chronic condition that occurs
\nwhen the pancreas does not produce
\nenough insulin or when the body cannot
\neffectively use the insulin it produces.
\nPeople who have type 1 diabetes produce
\nvery little or no insulin and require daily
\ninjections of insulin to survive. People with
\ntype 2 diabetes cannot use insulin effective-
\nly. They can sometimes manage their con-
\ndition with lifestyle measures alone, but
\noral drugs are often required and, less fre-
\nquently insulin, in order to achieve good
\nmetabolic control. Type 2 diabetes used to
\nbe known as non-insulin dependent dia-
\nbetes or mature onset diabetes.
\nWHO and IDF are working together to
\nraise awareness about diabetes worldwide.
\nTheir joint project, Diabetes Action Now, is
\nsupported by a World Diabetes Foundation
\ngrant to IDF and by WHO funds.
\nJakarta\/Geneva \u2013 The Director-General of
\nthe World Health Organization, Dr LEE
\nJong-wook, visited Jakarta for a five-day
\nvisit to Indonesia and Sri Lanka. During the
\nvisit, Dr Lee took part in the Special
\nASEAN Leaders\u2019 meeting on the Aftermath
\nof the Tsunami.
\nDr Lee, together with the Executive
\nDirector of UNICEF, Carol Bellamy, trav-
\nelled to some of the worst hit areas around
\nBanda Aceh in northern Sumatra to meet
\nsome of the victims of the tsunami and to
\nassess the most urgent health needs. He also
\nmet and travelled with the European
\nCommissioner for Development and
\nHumanitarian Aid, Louis Michel.
\nAfter leaving Indonesia, Dr Lee travelled to
\nSri Lanka to review progress in the relief
\neffort and to offer further support to the
\ncountry and to the communities which have
\nbeen most seriously affected by the tsuna-
\nmi.
\nSince the tsunami struck, WHO has been
\nworking together with a core group of
\ncountries helping to provide humanitarian
\nsupport. WHO has mobilised teams of
\nexperts to work with countries to assess the
\nmost urgent health needs and to ensure that
\nthey are met as rapidly as possible.
\nThe most urgent health need now is to pre-
\nvent outbreaks of infectious disease, and
\nparticularly of water-borne diseases such as
\ndiarrhoeal, dysentery and typhoid. It is
\nclear that providing clean water to as many
\nas possible of the affected cmmunities is
\nnow the most pressing health priority.
\nWHO Director-General Travels To Indonesia
\nAnd Sri Lanka
\nAttends leaders\u2019 meeting, tours stricken areas
\nThe following is based on, and extracted
\nfrom the Presidential Address given to the
\nAnnual Scientific Conference of the Fiji
\nMedical Association last year, entitled
\n\u201cProfession, ethics and community in
\nthis Millenium\u201d .
\nDr. Mary Schramm, referred to the princi-
\nples of the Hippocratic Oath as follows
\n\u201cBenefience \u2013 your activity should be ben-
\neficial and never harmful
\nRespect for the patient, his home his fami-
\nly\u201d
\nHonour \u2013 be worthy of the honour of trust
\ngiven you by your patient
\nSpreading your art through learning and
\nteaching \u2013
\nBut Only to those who bind themselves to
\nthis very same code of ethical behaviour\u201d
\nShe held in her hand a leaf from a tree
\ngrown from a seed which had itself grown
\nfrom the tree under which Hippocrates
\ntaught his pupils two and a half millenia
\nago. It was passed from a pupil to his men-
\ntor, ultimately from another pupil and rela-
\ntive to Dr. Schramm herself. She valued the
\nleaf as \u201ca symbol of that continuity and
\ntrust which I had embraced to work out the
\ncore values of my profession in the market-
\nplace of modern medicine\u201d.
\nWhile the values which she had embraced
\nhave survived, despite wars, the fall of
\nempires, civil wars, ages of oppression and
\nages of enlightenment, \u201cmedicine has also
\nchanged\u201d. She continued by referring to
\nHippocratean practice as being that of its
\nown time \u2013 mainly one-to-one medicine.
\nBut medicine has moved on Knowledge of,
\nand incidence of disease has increased, and
\nthe technology for evaluating disease has
\nprogressed even faster. She commented
\nthat the comparatively cheap and simple
\nprocedure of an exploratory operation had
\nbeen almost replaced by highly expensive
\ntechnology. However she considered \u201cthat
\nRegional and NMA News
\nFiji Medical
\nAssociation
\nRegional and NMA News
\n28
\nNorwegian Telemedicine was demonstrated
\nby a consultation between a patient and
\ndoctor in the north and the audience who
\nwere thousands of miles apart, during a
\npresentation at the European Forum of
\nMedical Associations and WHO annual
\nmeeting in Oslo, hosted by the Norwegian
\nMedical Association and attended by 36 of
\nthe 51 NMAs in the European Region of
\nWHO, and by 5 International organisa-
\ntions. The telemedicine network, which
\nconnects hospitals and many general prac-
\ntitioners throughout Norway, enables
\nperipheral hospitals and practitioners to
\nconduct virtual consultations with the
\npatient and practitioner both present: it
\neven permits practitioners to be trained in
\nendoscopic techniques so that expert opin-
\nion thousands of miles away can be given
\non the endoscopy as it proceeds. This not
\nonly assists diagnosis and access to expert
\nopinions in the more distant parts of the
\ncountry, but also reduces the need for
\npatients to travel great distances to hospi-
\ntals and diagnostic centres. In addition to a
\npresentation by the Norwegian Minister of
\nHealth on the Norwegian Health System
\nand the report on WHO activity by
\nDr. Mila Garcia-Barbero from WHO
\nEURO, the meeting appreciated a lively
\npresentation by a previous Minister of
\nHealth on the success of the anti-tobacco
\naction in Norway.
\nEuropean Region
\nEuropean NMAs meet in Oslo
\nthe one-to-one relationship between physi-
\ncian and patient remains central to good
\nmedical care\u201d, which she considered to be
\nonly realised in the primary care setting
\nwhere the patient had chosen the physician
\nand joined himself with the physician in a
\nhealth caring partnership.
\n\u201cModern acute medical care can only be
\ngiven adequately by the team and the mod-
\nern hospital and clinic is the setting in
\nwhich it is done. Yet conversely it can be
\nthe setting for stress and frustration, if, or
\nwhen we depend on the participation of
\npeople who do not share our (the profes-
\nsion\u2019s) open-ended commitment to the
\npatient, persons who were appointed per-
\nhaps to \u201ccommon user\u201d posts; whose pri-
\nmary commitment is to their own promo-
\ntion, their own career path.\u201d
\nShe continued \u201cIn this team setting, the
\ncore principles of ethics still stand, but the
\nways in which they are challenged and test-
\ned are subject to change\u201d. This challenge
\nDr Schramm observed, was to be the chal-
\nlenge which the meeting would discuss
\nover the next three days. She elaborated this
\nto be considering
\n\u2022 \u201cIncreasing understanding of how to
\nfocus our ethical commitment into day-
\nto-day work:
\n\u2022 Examining systems of control and regu-
\nlation of medical practice:
\n\u2022 Looking into who should blow the
\nwhistle \u2013 when why and how loud
\n\u2022 and who should respond, when, for
\nwhatever cause, people given the acco-
\nlade of Registered Medical Practitioner,
\nDoctor, are not practising up to defined
\nethical standards\u201d
\nThe bulk of the rest of Dr. Schramm\u2019s
\nspeech given in the presence of the Prime
\nMinister and other guests, dealt with the
\ncall for legislative action to deal with need-
\ned changes needed in the registration and
\nregulation of Medical Practitioners, and
\nalso the problems of emigrating medical
\nmanpower (see WMJ (50) 1) and movement
\nfrom the government health service to pri-
\nvate medical care.
\nExtracts by kind permission of the Editors,
\nFiji Medical Journal.
\nExcellent presentations and discussions
\nalso covered such diverse topics as
\nPalliative Care, Liability without Fault, the
\nBologna Process and Medicine and Health
\nCare in Prisons.
\nFollowing the lively discussions through-
\nout the meeting three Statements were
\nadopted. The first was on the Bologna
\nProcess and Medicine, in which the Forum
\nfound no evidence of any benefit for medi-
\ncine in the two cycle Bachelor\/Master
\nprocess proposed for medical training and
\nqualification in European Universities. It
\nwelcomed however its proposals concern-
\ning mobility, comparability and harmonisa-
\ntion in medical education in Europe.
\nThe second statement on Tobacco control,
\nreaffirmed NMAs commitment to tobacco
\ncontrol, urged NMAs to continue support
\nfor the Tobacco Convention, asked them
\nalso to campaign actively for effective
\n\u201csmoke free\u201d laws in their countries and
\nrequested all NMA meetings and premises
\nto be made no-smoking areas.
\nThe third statement was on \u201cHealthcare in
\nprisons and other forms of detention\u201d, urg-
\ning NMAs to address these issues in their
\ncountries (see Human Rights page 10) All
\nstatements were adopted by unanimous
\nconsensus in accordance with normal
\nForum procedure.
\nEFMA\/WHO was founded in 1984 as a
\nForum for positive discussions between the
\nNational Medical Association of the whole
\nEuropean Region of 51\u2019 countries and
\nWHO Europe. It holds an annual meeting
\nhosted by one of the National Medical
\nAssociations and aims through dialogue
\nbetween NMAs and WHO Europe:
\n\u2022 \u201cto improve health and health care in
\nEurope,
\n\u2022 to promote information exchange of
\ninformation and ideas between NMAs
\nand between NMAs & WHO,
\n\u2022 to integrate appropriate aspects of HFA
\npolicy into all basic, postgraduate and
\ncontinuing medical education, and
\n\u2022 to formulate consensus policy state-
\nments on health issues\u201d.<\/p>\n"},"caption":{"rendered":"

wmj5 WorldMMeeddiiccaall JJoouurrnnaall Vol. No.1,March200551 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents EEddiittoorriiaall Medical Professionalism 1 Tracing The Aetiology Of Genetic Disorders In Children 1 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss Unesco\u2019s proposed Declaration on Bioethics and human rights 4 Medical Information and Privacy in the Information Society 6 Advanced Medical Technology […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj5.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3531"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=3531"}]}}