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wmj201603<\/a><\/p>\n

COUNTRY
\nvol. 62
\nMedicalWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 3, October 2016
\nContents
\nCurrently the Earth is a Planet of Plastics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t81
\nInterview with Sir Michael Marmot, President of the World Medical Association. . . . . . . . . \t82
\nMigration of Doctors and Working Time Arrangements from an International
\nPerspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t83
\nWomen in Migration: Beyond Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t84
\nThe Growing Threat of Nuclear War and the Role of the Health Community . . . . . . . . . . . . . \t86
\nWMA Calls on Governments to Ban and Eliminate Nuclear Weapons . . . . . . . . . . . . . . . . . . \t95
\nThe Value of Resiliency Training in Postgraduate Medical Education . . . . . . . . . . . . . . . . . . . \t95
\nThe Role of Physicians Fighting Children Trafficking and Illegal Adoptions:
\nthe Use of Genetic Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t96
\nWhy Should the World Medical Association not Change its Policy towards
\nEuthanasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t99
\nVoluntary Euthanasia and Physician-assisted Suicide: Should the WMA Drop its
\nOpposition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t103
\nOne Health and Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t108
\nGlobal Development of Medical Science and Publication Opportunities and
\nChallenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t112
\nSoutheast European Medical Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t114
\nPaul Cibrie: Defending the Medical Profession in the Age of Internationalization . . . . . . . . \t117
\nIntroduction to work at COP22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t119
\nEditor in Chief
\nDr. P\u0113teris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nMaira Sudraba, Velta Poz\u0146aka; lma@arstubiedriba.lv
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher, \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nThe Latvian Medical Association, \u201cLatvijas \u0100rstu biedr\u012bba\u201d,
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nSir Michael MARMOT
\nWMA President
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Donchun SHIN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nKorean Medical Association
\n46-gil Ichon-ro
\nYongsan-gu, Seoul 140-721
\nKorea
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nWMA Vice-Chairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Xavier DEAU
\nWMA Immediate Past-President
\nConseil National de l\u2019Ordre des
\nM\u00e9decins (CNOM)
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nFrance
\nDr. Joseph HEYMAN
\nWMA Chairperson
\nof the Associate Members
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nDr. Masami ISHII
\nWMA Treasurer
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Heikki P\u00c4LVE
\nWMA Chairperson of the Medical
\nEthics Committee
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFinland
\nDr. Miguel Roberto JORGE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr. Ardis D. HOVEN
\nWMA Chairperson of Council
\nAmerican Medical Association
\nAMA Plaza, 330 N. Wabash,
\nSuite 39300
\n60611-5885 Chicago, Illinois
\nUnited States
\nDr. Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of The World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n81
\nBACK TO CONTENTS
\nPlastic is known to mankind for more than 100 years, and it has be-
\ncome part of our lives. It is hard to picture how many times per day
\neach of us has something to do with plastics. Plastics are produced in
\nthe form of resin from oil, natural gas and coal, while there are also
\nplastics of biological origin. Elements can be arranged around carbon
\nin a number of ways to obtain the necessary properties for the plastic.
\nGlobally, right now the four main health concerns for mankind are:
\n1.\t global heating and pollution of the planet;
\n2.\t agents impeding the development of hormonal system, the
\nplanet as a \u201cchemical warfare\u201d;
\n3.\t shortage of potable water;
\n4.\t social determinacy problems and inaccessibility to health care
\nservices
\nAs to plastics,global doctors focus on two aspects \u2013 the world is being
\npolluted with plastics to such an extent that the global ocean will soon
\nbe kind of plastic soup, as well as bisphenols, phthalates, brominated
\nflame retardants that are serious disruptors of hormonal system.
\nPlastics contain BPA or bisphenol,and most of plastics release it when
\nheated. Bisphenols make plastics harder and more endurable. Bisphe-
\nnol A is an agent impeding the functioning of glands of internal secre-
\ntion; technically it is artificial oestrogen (the female hormone) which
\ncan get from a plastic bottle (including baby bottles) or a vessel into
\nfood or water.As artificial oestrogen,it affects the development of foe-
\ntus of both sexes, hampers the development of hormonal system and
\ncontributes to the development of breast and prostate tumours.
\nIt is the production of testosterone and sperm quality for males,
\nincreases the insulin resistance and promotes obesity.
\nPhthalates are chemical substances that are added to plastics to
\nmake it flexible, as well as for other organoleptic reasons. Phthal-
\nates cause damage to reproduction organs of foetus, damages DNS
\nin sperm, damages liver, kidneys and lungs, causes inborn defects,
\nanaemia, infertility and cancer. They have a serious impact on male
\npotency and inhibit spermatogenesis in boys.
\nApart from bisphenols and phthalates, also brominated flame re-
\ntardants and other constituents of plastics and heavy metals cause
\ndisturbances to internal secretion system.
\nPlastics break down very slowly: the decomposition process takes
\nabout a thousand years. This means that all plastics that have ever
\nbeen manufactured are still here on the Earth (even recycled) unless
\nburnt down and polluted the atmosphere with poisonous smoke,
\nthereby destroying the ozone layer, which is our sole shield against
\nthe solar and cosmic radiation.
\nPlastics can be recycled 10-15 times. Umbrellas, backpacks, carpets,
\nblazers, artificial cobble stones, covers for mobile phones and new
\nPET bottles are made of recycled PET bottles. However, currently
\nit is about 12% of plastics that get recycled, while the rest is buried in
\nlandfills,and the major part,especially plastic bags,end up in environ-
\nment, because part of people still are not aware that a forest, a mead-
\now or a desert, mountains or roadside is not a dumpsite. Large part
\nof plastics gets into waters and further on to seas and oceans. Most of
\nthis polluting plastic is various types of film, packets and boxes.
\nThe main pollutants of environment are 15\u201350 micron thick plastic
\nbags,usually available free of charge in shops.They constitute higher
\nenvironmental risk than thicker bags, because are no used repeat-
\nedly \u2013 in 89% of occasions they are discarded after one-time use.
\nThese bags quickly disintegrate in small pieces and are blown by the
\nwind till end up in water bodies.The 15\u201350 micron plastic bags have
\nbeen found in the stomachs of all water birds.
\nAccording to different estimates, 500\u2013700 billion of plastic bags are
\nused annually worldwide. No less than one third ends up in environ-
\nment or ocean.The sources of ocean waste are rivers,contributing 80%,
\nand vessels, contributing the remaining 20%.The UN Environmental
\nProgramme has estimated each square mile of ocean water to contain
\n46,000 floating items of waste, mainly of plastic origin. At this mo-
\nment, the ocean is kind of plastic soup consisting of plastic objects of
\nvarious sizes and their remains, and forming a layer of waste with dif-
\nferent density from the surface of the ocean down to the very bottom.
\nPlastic piles up mainly in ocean gyres, which is water vortex limited
\nby currents, formed under no wind and high atmospheric pressure.
\nVortex keeps the plastic soup in continuous motion. The largest
\ngyre, North Pacific Gyre, between 1350\u20131550 west longitude and
\n250\u2013450\u00a0north latitude, is a 1760.000 square kilometres large field
\nof plastic waste,which is equal to the aggregate area of three Iberian
\npeninsulas (Spain and Portugal).
\nPlastics also pollute beaches and discourage tourists. Sea wildlife,
\nlike animals, birds and crustaceans, is trapped in plastic waste and
\ngets constricted, drowned, immobilised, and dies.
\nIn the sea, plastic is not biodegradable; however, being exposed to the
\nsun and mechanical forces, it gets decomposed to minute \u00adparticles.
\nCurrently the Earth is a Planet of Plastics
\n82
\nWMA News
\n1. First of all,I would like to ask you aboutTur-
\nkey.We know that televisions are being closed,
\njudges and teachers are being removed from
\ntheir positions,is this affecting physicians,too?
\nIs Turkey becoming an authoritarian regime
\nwhere doctors are also the aim of politicians?
\nM.\u00a0M. Turkey. I will answer this question
\nabout Turkey\u2019s current situation the way
\nI\u00a0try to answer all questions concerned with
\nthe public\u2019s health: an appeal to evidence
\nand to notions of social justice. Overall,
\nevidence suggests that well-functioning
\ndemocracies are good for health.There may
\nbe one or two exceptions. But, certainly, the
\nhistory of Europe, post war, shows remark-
\nable divergence between the good health
\nof Western democracies, and the relatively
\npoor health of communist countries of
\nCentral and Eastern Europe.There are am-
\nple reasons for the health-promoting effects
\nof democracies: greater attention to human
\nrights; greater possibility for enlightened
\ndebate; a free press,which includes the free-
\ndom to be critical of the powers that be. My
\nown view is that satire, and other brands of
\nhumour, are vital to the functioning of de-
\nmocracy (perhaps that is a British point of
\nview). The trend in Turkey has been toward
\nerosion of democracy, with a dramatic turn
\ndownwards after the aborted coup. A mili-
\ntary coup is always to be condemned. But
\none might have hoped that Turkey\u2019s presi-
\ndent would have emerged as an even more
\nvigorous champion for democracy. Regret-
\ntably, the opposite has occurred. Turkey\u2019s
\ndoctors have stood up and defended the
\nethical principle of providing health care to
\nall members of the population, regardless of
\nethnic or political persuasion. This ethical
\nprinciple, too, is under threat.
\n2. Unfortunately this is not new in our
\nworld. Can you remember any other coun-
\ntry going through a situation like this and
\nhow that affects the public health (e.g.\u00a0Ven-
\nezuela) ?
\nM. M. Is this unique to Turkey? As de-
\nscribed above,the later stage of communism
\nin Europe appeared to be bad for health.
\nThis can be illustrated simply by comparing
\nAustria, and Czechoslovakia\u00a0\u2013 both impor-
\ntant parts of the previous Austro-Hungari-
\nan Empire. Post war, health (as measured by
\nlife expectancy) was approximately equal in
\nthe two countries, and improved in parallel
\nup until the 1970s. It is consistent with the
\nview that, on both sides of the Iron Curtain,
\nmaterial conditions for health improved.
\nThere were reductions in poverty, and im-
\nprovements in school, jobs and transport.
\nBut, from the 1970s on, life expectancy
\ncontinued to improve in Austria, as it did
\nin all countries in Western Europe. Life ex-
\npectancy stagnated in Czechoslovakia, as it
\ndid in all countries of Central and Eastern
\nEurope. People do need the basic material
\nconditions in order to enjoy good health.
\nBut they also need the freedom to lead
\nInterview with Sir Michael Marmot,
\nPresident of the World Medical Association
\nBy Dr. Peteris Apinis. August, 2016
\nIn\u00a02010,the proportion of the minute plastic particles to zooplankton
\nwas as high as 60:1.This means that 5% of a blue whale\u2019s body weight
\nis plastic which he has consumed instead of plankton.
\nThere is nothing more dangerous for the Earth than burning plas-
\ntics in low temperature.The end products of burning plastics are in-
\ncredibly poisonous to human beings, plants and animals. The gases
\nreleased in burning destroy the ozone layer (plastics can be burnt
\nonly in furnaces in extremely high temperatures, notably over 1000
\ndegrees, where the plastic combustion products are carbon dioxide,
\nsulphur dioxide and some other relatively simple compounds).
\nRelatively more girls die in childhood compared to boys.The reason
\nis that in not so well-to-do countries boys play football, while girls
\nare supposed to be indoors and help their mothers with cooking.
\nIn many countries trees have already been cut down and cooking is
\ndone by burning trash, namely, plastics. Such smoke in the room is
\nthe cause of unbelievably high mortality of children (girls).
\nThe World Medical Association should become the initiator of in-
\ntroducing a global environmental tax on plastic, imposing a tax on
\nall plastic bags.We trust that the World Medical Association is able
\nto lead this initiative and promote it to the UN and other global
\norganisations for discussion. It is critical that it is the manufacturer
\nwhich is to be taxed, because traders will be compelled to pay this
\ntax in the price as value added tax.
\nP\u0113teris Apinis, President,
\nLatvian Medical Association
\nSir Michael Marmot
\n83
\nBACK TO CONTENTS
\nMigration
\nflourishing lives. Such freedoms were more
\nlikely to be delivered by healthy,functioning
\ndemocracies.
\n3. Turkey is hosting a huge number of
\nrefugees from Syria, Iraq and Afghanistan.
\nWhat do you think how this new situation
\nmay affect them?
\nM.M. What will happen to refugees in Tur-
\nkey? Central to the functioning of a healthy
\nsociety is high quality data,and free and open
\ndiscussion of the implications of what the
\ndata show.There are two million official Syr-
\nian migrants in Turkey, and probably many
\nmore unofficial,in addition to migrants from
\nIraq and Afghanistan.With an authoritarian
\nregime restricting the free flow of informa-
\ntion, and taking arbitrary action against any
\nindividual it sees as threats, this is a pre-
\ncarious situation: it is quite conceivable that
\nrefugees could be seen as threats. The result
\ncould be calamitous.
\n4. How do these social determinants and
\nmigration correlate with public health in
\nEurope? How can we help to improve the
\nsituation?
\nM.\u00a0 M. Migrants in general, and refugees
\nin particular, illustrate the importance of
\ntaking action on the social determinants of
\nhealth. Conditions from which people fled,
\nthe circumstances of migration, and condi-
\ntions in the new country can all influence
\nhealth. One obvious way this works is that
\nrefugees are poorer than the host popula-
\ntion, and suffer ill health as a result. More
\ngenerally, the conditions in which people
\nare born,grow,live,work,and age,and ineq-
\nuities in power, money and resources \u2013 the
\nsocial determinants of health \u2013 will all im-
\npact on the health of refugees.
\n5. Terrorist attacks are affecting many
\ncountries in the world. Fear is installing in
\npeople\u203as minds and can lead to psychological
\nproblems. Do you think this might become
\na\u00a0social determinant of \u00abmental\u00bb health? Ex-
\nplain your considerations about this.
\nM.\u00a0 M. There is a huge disparity between
\nrates of crime, and fear of crime. In many,
\nif not most, advanced countries, crime rates
\nhave been falling, but the public\u2019s fear of
\ncrime isn\u2019t. Each terrorist attack is appalling,
\nand,rightly,fuels public anxiety about terror-
\nism. But, overall, the number of deaths from
\nterrorist attacks is small. Take the U.S. as an
\nexample. There are approximately 34,000
\ndeaths a year caused by firearms. A tiny mi-
\nnority of these can be linked to terrorism.
\nYou would not guess that from some of the
\npublic rhetoric of politicians, which fuels
\npublic anxiety.That being said,we should not
\nbe complacent about terrorism. We need to
\nadd the medical voice to the argument for
\nimproving the social determinants of health,
\nfor all members of our populations, and re-
\nducing racism and intolerance.
\nThe main aim of the first international
\nconference of doctors\u2019 unions was to build
\na network between doctors\u2019 unions around
\nthe world and to discuss common problems
\nand challenges. In his opening speech the
\nChairman of the Marburger Bund, Rudolf
\nHenke, pointed out that such an exchange
\nof experience and information will not only
\nhelp to improve working conditions for
\ndoctors but contribute, in the end, towards
\nbetter care for patients.Lutz Stroppe,a high
\nranking civil servant who reports to the
\nGerman Minister of Health, emphasised
\nthe important role that foreign doctors play
\nin maintaining high quality medical care in
\nGermany. At the same time he considered
\nthe possible negative effects the emigra-
\ntion of doctors might have on the source
\ncountries. With his welcoming speech he
\nreached representatives of 24 different na-
\ntions from five continents.
\nParticipants from 11 countries made use of
\nthe opportunity to give on the first day a
\nsnapshot presentation on the topic of emi-
\ngration from and\/or immigration of doctors
\nto their countries. As the situation in the
\ndifferent countries is diverse the speakers
\nwere free to focus on those issues that are
\nof special interest to their union. The repre-
\nsentative from the Sindicato M\u00e9dico do Rio
\nGrande do Sul, for example, reported on the
\nexploitation of Cuban doctors who take part
\nin a government programme and work in
\nunderserved rural areas in Brazil. Presenta-
\ntions given by the Austrian Medical Cham-
\nber, Swedish Medical Association and Hong
\nKong Doctors\u2019 Union explained the system
\nof recognition of foreign diploma and the in-
\ntegration process of foreign doctors. In order
\nto facilitate the free movement of doctors the
\nrepresentative of Sindicato M\u00e9dico del Uru-
\nguay drew upon practical experiences to ad-
\nvocate better co-operation between countries
\nRuth Wichmann
\nMigration of Doctors and Working
\nTime Arrangements from an International
\nPerspective
\n84
\nTURKEYMigration
\nMigration is a move somewhat reliant on
\nwill. But the majority of the migrants are
\nforced to leave their loved ones, their coun-
\ntry, and their past. Suddenly their lives
\nchange completely and they are forced to
\nmigrate and seek refuge in a foreign country.
\nData on the magnitude of the problem
\nvaries according to the source. Migration
\nis intertwined with human tragedy. This
\nshort article will try to explain the human
\ndimension of migration, with an emphasis
\non women.
\nWomen in Migration: Beyond Statistics
\nand a facilitation of the recognition process
\nof foreign diplomas.
\nMajor push factors which make doctors leave
\ntheir country such as poor working condi-
\ntions, bad training opportunities, unemploy-
\nment or political circumstances where point-
\ned out by the Tanzania Medical, Dental and
\nPharmaceutical Workers\u2019 Union, Portuguese
\nNational Federation of Doctors, Bahamas
\nDoctors\u2019Union, Myanmar Medical Associa-
\ntion Young Doctor Society and Slovak Doc-
\ntors\u2019 Trade Union. Workforce shortages in
\nNew Zealand as well as low retention rates
\nof foreign trained doctors were elaborated on
\nby the New Zealand Association of Salaried
\nMedical Specialists.
\nAfter the presentations, Armin Ehl, Chief
\nExecutive Officer of the Marburger Bund,
\nopened the floor for a fruitful discussion
\nwhich resulted in the adoption of a resolu-
\ntion. The participants supported the imple-
\nmentation of the 2010 WHO Code of
\nPractice on the International Recruitment of
\nHealth Personnel.It was particularly stressed
\nin the statement that all countries should
\nstrive to train enough doctors to meet their
\nown internal needs. Furthermore, the par-
\nticipants agreed that doctors\u2019 unions should
\nensure that migrant doctors enjoy the same
\nworking conditions as domestically trained
\ndoctors and do not suffer any discrimination.
\nAll doctors\u2019unions present agreed to dissem-
\ninate relevant information to foreign doctors
\nand to co-operate with one another in order
\nto support migrant doctors.
\nThe main topic of the second day of the
\nconference was the working time of doctors.
\nAs all EU member states have to adhere
\nto the European Working Time Directive
\n(EWTD) the key elements of this Direc-
\ntive were explained by Richard Pond, Pol-
\nicy Officer of the European Federation of
\nPublic Service Unions (EPSU). Pond also
\ndescribed the continuous fight of EPSU to
\nsafeguard the health and safety provisions
\nof this directive.
\nExamples of the transposition of the
\nEWTD into national law were given by the
\nGerman Marburger Bund, Slovak Doctors\u2019
\nTrade Union, Portuguese National Fed-
\neration of Doctors and Austrian Medical
\nChamber. All four presentations focused
\non the average maximum weekly working
\ntime and the assessment of on-call periods
\nas working time in theory and in practice.
\nWhereas the Austrian Medical Chamber
\nexplained that the use of the opt-out clause
\nwill be gradually phased out so that from July
\n2021 onwards,the average maximum weekly
\nworking time in Austria will be 48\u00a0 hours,
\nappalling working time arrangements of up
\nto 120 hours per week were reported by the
\nJamaica Medical Doctors\u2019Association.Doc-
\ntors in Jamaica severely compromised not
\nonly their own physical and mental health
\nbut, as a result, are not being able to give ap-
\npropriate care to their patients.
\nLong working hours are also a problem
\nin Hong Kong. The presentation from the
\nHong Kong Doctors\u2019 Union showed that
\nwhile the average weekly working time of
\npeople in Hong Kong is 50 hours many
\ndoctors work more than 65 hours a week. A
\nrecent survey conducted by the Hong Kong
\nDoctors\u2019 Union revealed that over 92% of
\nthe participants longed for a significant re-
\nduction in their working time.The Union of
\nEmployees in the Health and Social Protec-
\ntion of Serbia also complained that due to a
\nshortage of doctors, long working hours of
\ndoctors are a reality.However,so far Serbian
\ndoctors are not willing to take action. Other
\ninteresting snapshot presentations were
\ngiven by the Sindicato M\u00e9dico del Uru-
\nguay, Bahamas Doctors\u2019 Union, Myanmar
\nMedical Association Young Doctor Society
\nand New Zealand Association of Salaried
\nMedical Specialists before the audiences
\nengaged in a lively discussion.
\nAgain a resolution was adopted in which the
\nparticipants demanded that patient safety
\nand the health and safety of doctors should
\nbe the guiding principles of any working
\ntime regulations that cover doctors. The
\nparticipating doctors\u2019 unions called upon
\nthe responsible authorities to enforce exist-
\ning working time laws and expressed their
\nwill to fight against any attempts to reduce
\nthe health and safety provisions in existing
\nworking time regulations. Moreover, the
\nunion leaders wanted to reduce long work-
\ning hours in accordance with their members\u2019
\nneeds and preferences.
\nThe Marburger Bund who organised the
\nmeeting in mid-June in Berlin was delight-
\ned that the Sindicato M\u00e9dico del Uruguay
\nexpressed an interest in holding a follow-up
\nconference in Uruguay next year. Also the
\nBahamas Doctors\u2019 Union is considering
\nhosting a future meeting of doctors\u2019 unions.
\nIt is likely that the international co-opera-
\ntion between doctors\u2019 unions will thrive.
\nRuth Wichmann, Head of International
\nOffice of the Marburger Bund
\nE-mail: wichmann@marburger-bund.de
\n85
\nBACK TO CONTENTS
\nTURKEY Migration
\nHundreds of determinants such as coun-
\ntry of origin, the international status of
\nthe country, the prestige of the country,
\nwhether they have legal documents, how
\nthey arrived in the country, whether they
\nare exiled, the reasons of migration, re-
\nligion, gender, age, profession, etc. con-
\ntribute to determining not only the legal
\nstatus but also the social prestige of the
\nrefugees [1]. The conditions in which mi-
\ngrants travel, live and work can carry ex-
\nceptional risks for their physical and men-
\ntal well-being. These include inequality in
\naccess to healthcare and services; vulner-
\nabilities associated with migrant status,
\nmarginalization and abuse, and are often
\nlinked to restrictive immigration and em-
\nployment policies, economic and social
\nfactors, and dominant anti-migrant senti-
\nments in societies.These are often referred
\nto as the social determinants for migrants\u2019
\nhealth\u00a0[2].
\nShelter, hygiene and nutrition are the
\nmost problematic areas. There are serious
\nproblems in access to food, both in terms
\nof quantity and quality, the number of the
\nmeals provided are very few and irregular,
\nand food hygiene is poor. Basic personal hy-
\ngiene is also very poor due to poor living
\nconditions.
\nWomen are among the most vulnerable.
\nAs was highlighted by the United Nations
\nCommittee on the Elimination of Dis-
\ncrimination against Women (CEDAW),
\nmigrant women face specific challenges in
\nthe field of health throughout the migration
\ncycle. Migrant women, for example, may be
\nsubject to sex and gender based discrimi-
\nnation such as mandatory HIV\/AIDS, or
\nother testing, without their consent as well
\nas sexual and physical abuse by agents and
\nescorts during transit [3]. Refugee women
\nhave lower status than men [4] and need
\nmore protection; especially victims of sex-
\nual violence, isolated, single parent women,
\nlesbians and women in custody (The UN
\nRefugee Agency (UNHCR)).
\nThere are many variables affecting refugees\u2019
\nhealth that are not easily controlled. They
\ninclude: stress caused by migration, dam-
\nage of refugees\u2019 social networks, religious
\nand cultural factors, culturally insensitive
\nreproductive health services, discrimina-
\ntion in health services provision and also
\na lack of information about the services
\navailable. There are striking differences
\nbetween the health status of refugees and
\nthe settled population, and their access to
\nhealth care. Refugees are one of the most
\nneglected groups of the world. They are
\nusually excluded from health and social
\nservices.
\nReproductive health is particularly impor-
\ntant. There is an increase in fertility during
\nmigration. There are factors that make the
\nsituation more complicated such as: early
\nmarriages, multiple marriages etc. In gen-
\neral family planning needs are unmet.
\nIn war and migration situations, exploita-
\ntion of women and sexual abuse increases.
\nGender based violence is very common for
\nrefugees. During conflict, before escape
\nthe ruling parties abuse women. There are
\nreports of sexual violence and torture in-
\nflicted by soldiers, gang rape and abduc-
\ntion by the conflicting parties. During the
\nescape, bandits, border guards and human
\ntraffickers assault women. In the country
\nof asylum, during the return journey and
\neven in the reintegration phase, many
\nsimilar incidents have been reported [5].
\nWomen point out that human traffickers
\nabuse women, there is systematic abuse
\nand violence against women both in cus-
\ntody and at control points [6]. In other
\nwords, women\u2019s bodies are used as battle-
\nfields by conflicting parties and captured
\nby the dominant powers. Women continue
\nto carry all the burden of the conflicts, war
\nand migration.
\nPhysicians and health care workers should
\nbe aware of and sensitive to needs of refugee
\nwomen and advocate their right to health
\nand the right to access to health care. Refu-
\ngees with and emphasis on refugee women
\nshould have the right to live in dignity and
\nrespect. The ultimate solution is the con-
\nstruction and protection of peace. Health
\ncare workers can have a crucial impact in
\nbuilding a less violent world and ensuring
\nthe protection of peace.
\nReferences
\n1.\t \u00d6zgen, Ne\u015fe. Refugee and Woman: Nationalist
\nBody politics. 10th
\nInternational Cultural Stud-
\nies Symposium. Ege University\u00a0\u2013 British Coun-
\ncil, 4\u20136 May, 2005, I\u0307zmir.
\n2.\t UNGA High Level Dialogue (HLD) on Mi-
\ngration and Development, 2013
\n3.\t WHO. Health of migrants: the way forward.
\nReport of a global consultation. Madrid, Spain,
\n3-5 March, 2010
\n4.\t \u00d6zgen, Ne\u015fe, ibid
\n5.\t UNHCR, http:\/\/www.unhcr.org\/turkey\/home.
\nphp?page=15, (accessed 30.06.2016)
\n6.\t FIDH Violence Against Women In Syria:
\nBreaking The Silence Briefing Paper, 2013.
\nBased on an FIDH assessment mission in Jor-
\ndan in December 2012
\nProf. Dr. Feride Aksu Tan\u0131k
\nFaculty of Medicine,
\nDepartment of Public Health
\nEge University
\nE-mail: ferideaksu59@gmail.com
\nFeride Aksu Tan\u0131k
\n86
\nNuclear War
\nThe Growing Risk
\nof Nuclear War
\nAfter the end of the Cold War the in-
\ntense military rivalry between the Soviet
\nUnion and the United States\/NATO was
\nreplaced by a much more cooperative re-
\nlationship, and fears of war between the
\nnuclear superpowers faded. As recently
\nas the 2014 US Quadrennial Defence
\nReview, conflict between the two former
\nadversaries was not considered a realistic
\npossibility [1].
\nUnfortunately, relations between Rus-
\nsia and the US\/NATO have deteriorated
\ndramatically since then. In the Syrian and
\nUkrainian wars, the two have supported op-
\nposing sides, raising the possibility of open
\nmilitary conflict and fears that such conflict
\ncould escalate to nuclear war.
\nOver the past two years, both sides have
\nengaged in nuclear sabre rattling that is
\nreminiscent of the worst periods of the
\nCold War. Speaking about the conflict in
\nUkraine in August 2014, Russian Presi-
\ndent Vladimir Putin warned \u201cit is better
\nnot to come against Russia as regards a
\npossible armed conflict \u2026 I want to re-
\nmind you that Russia is one of the most
\npowerful nuclear nations\u201d [2]. In the
\nmonths following the Russian annexation
\nof Crimea, the European Leadership Net-
\nwork (ELN) documented a large increase
\nin incidents involving close encounters
\nbetween nuclear capable NATO and Rus-
\nsian military forces. A report issued by the
\nELN concluded, \u201cThese events add up to
\na highly disturbing picture of violations
\nof national airspace, emergency scrambles,
\nnarrowly avoided mid-air collisions, close
\nencounters at sea, simulated attack runs
\nand other dangerous actions happening on
\na regular basis over a very wide geographi-
\ncal area\u201d [3]. Further, both sides have con-
\nducted large scale military exercises in Eu-
\nrope, leading the ELN to conclude,\u201cRussia
\nis preparing for a conflict with NATO, and
\nNATO is preparing for a possible con-
\nfrontation with Russia\u201d [4]. The danger
\ninherent in this situation is magnified by
\nthe current Russian military doctrine of
\n\u201cnuclear de-escalation\u201d. Rather than seeing
\nnuclear weapons purely as a deterrent to
\nnuclear attack, this doctrine embraces \u201cthe
\nidea that, if Russia were faced with a large-
\nscale conventional attack that exceeded its
\ncapacity for defence, it might respond with
\na limited nuclear strike\u201d in order to force
\nthe other side to quickly end the conflict
\nand return to the status quo ante\u201d [5]. US\/
\nNATO military planning has always envi-
\nsioned possible first use of nuclear weapons
\nin the face of a Soviet\/Russian convention-
\nal attack in Europe.
\nIn this setting prominent leaders on both
\nsides have expressed alarm about the grow-
\ning danger of nuclear war.
\nSpeaking in January, when the Bulletin of
\nthe Atomic Scientists announced that its
\nDoomsday Clock would remain at three
\nminutes to midnight, former US Secre-
\ntary of Defence William Perry stated, \u201cThe
\ndanger of a nuclear catastrophe today, in
\nmy judgment is greater that it was during
\nthe Cold War \u2026 and yet our policies sim-
\nply do not reflect those dangers\u201d [6]. His
\nassessment was echoed two months later
\nby Igor Ivanov, Russian Foreign Minister
\nfrom 1998 to 2004. Speaking in Brussels
\non March 18, Ivanov warned that,\u201cThe risk
\nof confrontation with the use of nuclear
\nweapons in Europe is higher than in the
\n1980\u2019s\u201d\u00a0[7]. The increased tensions between
\nthe US and Russia have been matched by a
\nsimilar escalation in the danger of nuclear
\nwar in South Asia.
\nSince the nuclear weapon tests of May 1998
\nby India and then Pakistan, the two states
\nhave expanded many-fold their respective
\nnuclear weapon and fissile material stock-
\npiles, and undertaken extensive develop-
\nment and testing of a diverse array of ballis-
\ntic and cruise missiles (with ranges from 60
\nto 5000 km) to acquire the ability to deploy
\nand launch nuclear weapons from the air,
\nThe Growing Threat of Nuclear War and the Role of the
\nHealth Community
\nIra Helfand Andy Haines Tilman Ruff Hans Kristensen Patricia Lewis Zia Mian
\n87
\nBACK TO CONTENTS
\nNuclear War
\nfrom land, and from submarines at sea.They
\nhave put in place command and control sys-
\ntems and doctrines that involve, in the case
\nof Pakistan, first use of nuclear weapons in
\na conflict and, in the case of India, massive
\nretaliatory strikes against population centres
\n[8\u201310].
\nIn May-July 1999,the two countries fought
\na war which apparently included mobiliza-
\ntion of nuclear weapons by Pakistan, mak-
\ning it the most significant military conflict
\nbetween two nuclear armed states [11].
\nThey also went through a major military
\ncrisis (December 2001 to June 2002) trig-
\ngered by an attack on India\u2019s parliament by
\nIslamist militants believed in India to be
\nbacked by Pakistan,which included the two
\ncountries moving a combined total of over
\nhalf a million troops to their border\u00a0[12].
\nThe slow pace of Indian deployment and
\ninconclusive outcome of the stand-off led
\nIndia\u2019s army to begin planning and train-
\ning for a more decisive and rapid conven-
\ntional attack on Pakistan [13]. Pakistan
\nbegan testing a short-range truck-mounted
\nmobile missile to deliver low-yield nuclear
\nweapons on the battlefield [14]. This latter
\ndevelopment has increased long-standing
\ninternational concerns about the security
\nof nuclear weapons and fissile materials in
\nPakistan given the large-scale and frequent
\nIslamist militant attacks on military targets
\nin the country and the ideological polariza-
\ntion within the armed forces and broader
\nsociety associated with the rise of hard-line
\nIslamist political groups over the past three
\ndecades [15].
\nPotential triggers for armed conflict be-
\ntween Pakistan and India include another
\nmajor attack on India by Islamist militant
\ngroups like the one in Mumbai in Novem-
\nber 2008 that was linked to intelligence
\nagencies in Pakistan [16]. A second possible
\ntrigger is the recurring artillery exchanges
\nalong the line of control in Kashmir,and oc-
\ncasionally the international border between
\nPakistan and India, which often claim sig-
\nnificant military and civilian casualties [17].
\nIn April 2016, at the conclusion of the Nu-
\nclear Security Summit, the White House
\nPress secretary expressed concern about,
\n\u201cthe risk that a conventional conflict be-
\ntween India and Pakistan could escalate to
\ninclude the use of nuclear weapons\u201d\u00a0 [18].
\nShould Pakistan use nuclear weapons
\nagainst Indian conventional forces in such
\na situation, Indian nuclear doctrine calls for
\nmassive retaliation directed at Pakistani cit-
\nies and Pakistan has threatened to respond
\nin kind.
\nWith Pakistan building ever closer mili-
\ntary and economic ties to China, and India
\nbecoming a strategic partner of the United
\nStates, such a future South Asian conflict
\nmay quickly take on a global dimension
\ngiven the increasingly tense nature of the
\ngreat power rivalry between China and the
\nUS [20].
\nNorth Korea has a track record of repeatedly
\nthreatening the use of nuclear weapons; for
\nexample, in March 2016 it warned it would
\nmake a \u201cpre-emptive and offensive nuclear
\nstrike\u201d in response to joint US-South Ko-
\nrean military exercises [21]. It is capable of
\nenriching uranium and producing weapons-
\ngrade plutonium and has deployed short-
\nand medium-range ballistic missiles as well
\nas testing long\u2013range missiles [22].
\nUnintended Use of
\nNuclear Weapons
\nWhile these growing tensions amongst nu-
\nclear armed states could lead to the deliber-
\nate use of nuclear weapons, there is also the
\ncontinuing danger that they could trigger
\nthe unintended or accidental use of these
\nweapons.
\nThere have been at least five occasions
\nsince 1979 when either Washington or
\nMoscow prepared to launch nuclear weap-
\nons in the mistaken belief that the other
\nside had already launched a nuclear attack
\nor was preparing to do so [23]. In 1979
\nand again in 1980 computer errors in the
\nUS caused American radar systems to dis-
\nplay, incorrectly, incoming Soviet missiles
\non their monitors. In September 1983,
\nSoviet military radar incorrectly reported
\na NATO attack in progress. In November
\nof that year the Soviet leadership incor-
\nrectly concluded that a NATO military
\nexercise was the cover for an actual attack
\nthat was about to be launched. On Janu-
\nary 25, 1995, a full 5\u00a0years after the end
\nof the Cold War, Russian military radar
\nincorrectly identified a Norwegian Black
\nBrant XII rocket launched to study the
\naurora borealis as a Trident missile aimed
\nat Moscow.
\nIn each of these situations preparations for
\na counterstrike were initiated and nuclear
\nwar was averted by minutes.
\nThe danger of this kind of mistake oc-
\ncurring again is amplified by current de-
\nficiencies in Russian radar warning sys-
\ntems. Russia has no space-based satellite
\nearly warning systems to alert them to the
\nlaunch of nuclear-armed ballistic missiles
\nfrom the ocean, so their warning time
\ncould be as short as 10 to 15 minutes. The
\nonly way for Russia to guarantee the abil-
\nity to launch its forces before they are de-
\nstroyed by a pre-emptive attack would be
\nto pre-delegate launch authority to field
\ncommanders. Under these conditions, the
\ntime pressure to make a launch decision
\ncould greatly increase the chance of an ac-
\ncidental launch, especially if a computer
\nerror caused a false warning of attack dur-
\ning a crisis [24]. Recently, military lead-
\ners have begun to warn of a new threat
\nthat might cause the unintended launch
\nof nuclear weapons: cyberterrorism. In a
\nJune 2015 speech, retired Marine Gen.
\nJames Cartwright, former head of the
\nUS Strategic Command, warned that it
\nmight be possible for terrorists to hack
\ninto Russian or American command and
\ncontrol systems and launch one or more
\nnuclear missiles, a launch which would
\nhave a high probability of triggering a
\n88
\nwider nuclear conflict. This danger is in-
\ntensified by the continued US and Rus-
\nsian policy of \u00admaintaining their missiles
\non hair trigger alert, fully prepared for use
\nand simply awaiting an order to launch
\n[25]. There is also extensive evidence that
\nindividuals with responsibility for nuclear
\nweapons have breached safety \u00adregulations.
\nIn 2003, for example, half of the US Air
\nForce units responsible for nuclear weap-
\nons safety failed their safety inspections.
\nIn 2007 six cruise missiles armed with
\nnuclear warheads were mistakenly loaded
\nonto a B-52 bomber which sat on the
\ntarmac overnight without armed guards
\nbefore taking off and flying 1500 miles
\nin violation of regulations which prohibit
\ntransportation of nuclear weapons by air
\nover the USA\u00a0[26].
\nNuclear Weapons
\nModernization
\nThe nuclear danger is amplified further by
\nthe extensive plans of all nine nuclear armed
\nstates to enhance their nuclear arsenals.
\nAlthough the world\u2019s inventory of nuclear
\nweapons has declined significantly over the
\npast two-and-a-half decades, from around
\n58,300 warheads in 1991, there remain
\nroughly 15,375 warheads today of which
\n4,200 are deployed with operational forces.
\nNearly 1,800 warheads are on alert and
\nready for use on short notice [27]. (Figure)
\nWhile Russia, the US, and Britain con-
\ntinue to reduce their inventories, the pace
\nof reduction has slowed compared with the
\npast two decades. In fact, four of the world\u2019s
\nnuclear-armed states (China, Pakistan, In-
\ndia and North Korea) are increasing their
\nnuclear arsenals.
\nThere are currently no negotiations between
\nnuclear-armed states about reducing war-
\nhead inventories or curtailing operations
\nand modernizations. Instead, there are signs
\nthat the deepening crises in Europe and the
\nSouth China Sea are causing nuclear-armed
\nstates to increase the role of their nuclear
\nforces.
\nInstead of moving decisively toward deep
\ncuts of their nuclear arsenals and mak-
\ning plans for the eventual elimination of
\nnuclear weapons, the nuclear-armed states
\nare reaffirming the importance of nuclear
\nweapons and are carrying out extensive and
\ncostly modernizations of their nuclear arse-
\nnals\u00a0[28]. (see table)
\nThe scope of these modernization plans has
\nled observers to characterize them as the
\nbeginning of a new arms race and a new
\nCold War [29].
\nThe Health Consequences
\nof Nuclear War
\nGiven the growing danger of nuclear war, it
\nis important to consider the health conse-
\nquences of such a conflict.
\nThe acute effects of nuclear weapons are
\nwell described in previous major reports by
\nWHO and the US Institute of Medicine
\n[30,31]. While there have been important
\ndevelopments regarding ionising radiation
\nhealth effects in recent decades, it is in rela-
\ntion to the impacts of nuclear war on cli-
\nmate, agriculture and nutrition that scien-
\ntific advances of the greatest moment have
\nbeen made in the past decade, and these are
\ntherefore our focus here.As a result of these,
\nwe have come to understand that it is not
\njust large scale nuclear war between the US
\nand Russia that poses a global threat. A\u00a0se-
\nries of studies have shown that localized,
\nregional nuclear war will also have cata-
\nstrophic effects worldwide.
\nWe undertook a literature search using
\nthe Web of Science database Topic Search
\nfunction, on 14 March 2016, covering doc-
\numents in English published from 2005 to
\n2016, using the search strategy: ((\u201cNuclear
\nWeapon*\u201d OR \u201cnuclear war*\u201d OR \u201catomic
\nweapon*\u201d OR \u201catomic war*\u201d OR \u201cnuclear
\nconflict*\u201d) and (Climate OR \u201cClimate
\nChange\u201d OR environment* OR \u201cOzone
\nDepletion\u201d OR ozone OR Starvation OR
\nfamine OR Agriculture* OR crop* OR
\nFood)).
\nThe scenario that has been studied most fre-
\nquently is a limited nuclear war between In-
\ndia and Pakistan involving 100 Hiroshima
\nsized warheads, small by modern standards,
\ntargeted on urban centers. (This is a delib-
\nerate underestimate of the full potential of
\nwar in South Asia: the combined arsenals
\nRussia IndiaPakistanUKChinaFranceUSA Israel
\n7000
\n6000
\n5000
\n4000
\n3000
\n2000
\n1000
\n8000
\n0
\n7300
\n6970
\n120130215260300
\n80
\nNote: North Korea has produced \ufb01ssile
\nmaterial for 10\u201312 warheads and detonated
\n4 test assemblies, but we\u2019re not aware of public
\ninformation that shows it has yet
\nstockpiled weaponized warheads.
\nRetired
\nStockpiled
\nDeployed
\nFigure. Estimated Global Nuclear Warhead Inventories, 2016
\nNuclear War
\n89
\nBACK TO CONTENTS
\nRussia
\n\u2003 \u2022\u2002\u0007replacing all Soviet-era SS-18, SS-19 and SS-25 intercon-
\ntinental ballistic missiles (ICBMs) by the early-2020s with
\ndifferent versions of the SS-27 and a new \u201cheavy\u201dsilo-based
\nICBM.
\n\u2003 \u2022\u2002\u0007building eight new ballistic missile submarines (SSBNs)
\nwith the new SS-N-32 (Bulava) missile to replace eight op-
\nerational Soviet-era Delta-class SSBNs and their missiles.
\n\u2003 \u2022\u2002\u0007upgrading its old Tu-160 (Blackjack) and Tu-95MS (Bear)
\nbombers so they can continue to operate until a new bomber
\ncan replace them sometime in the 2020s.
\n\u2003 \u2022\u2002\u0007gradually replacing the old AS-15 air-launched cruise mis-
\nsile (ALCM) with a new ALCM known as the Kh-102.
\n\u2003 \u2022\u2002\u0007modernizing some of its non-strategic nuclear forces, re-
\nplacing the old SS-21 short-range ballistic missile (SRBM)
\nwith the SS-26 (Iskander), replacing the old SS-N-21
\nsea-launched land-attack cruise missile (SLCM) with the
\nSS-N-30A (Kalibr), and replacing the old Su-24 (Fencer)
\nfighter-bomber with the Su-34 (Fullback).
\nUnited States
\n\u2003 \u2022\u2002\u0007building a new fleet of 12 SSBNs to replace the current 14
\nSSBNs.The new submarines will carry an improved version
\nof the Trident II D5 sea-launched ballistic missile (SLBM)
\nwith new guidance system and enhanced warheads.
\n\u2003 \u2022\u2002\u0007modernizing its B-2 and B-52 bombers and developing the
\nnew B-21 stealth-bomber to replace the B-52s (and B-1s)
\nfrom the late-2020s.
\n\u2003 \u2022\u2002\u0007developing a new guided nuclear bomb (B61-12) with in-
\ncreased accuracy, and a new ALCM with longer range and
\nenhanced warhead.
\n\u2003 \u2022\u2002\u0007designing a new ICBM with enhanced warheads to replace
\nthe current Minuteman III ICBM by 2030.
\n\u2003 \u2022\u2002\u0007modernizing its non-strategic nuclear forces by replacing
\nF-16s (and eventually F-15E) fighter-bombers with the F-
\n35A stealthy fighter-bomber that will be carrying the new
\nB61-12 guided nuclear bomb.
\nChina
\n\u2003 \u2022\u2002\u0007replacing old liquid-fuel land-based missiles with DF-26
\nand DF-31A solid-fuel missiles on road-mobile launchers.
\n\u2003 \u2022\u2002\u0007equipping some of its missiles with multiple warheads.
\n\u2003 \u2022\u2002\u0007deploying a small fleet of Jin-class SSBNs with the new Jl-2
\nSLCBM.
\nFrance
\n\u2003 \u2022\u2002\u0007modernizing its SSBN fleet with the new M51 SLBM that
\nwill soon receive a new warhead.
\n\u2003 \u2022\u2002\u0007arming its bomber force with ALCMs.
\n\u2003 \u2022\u2002\u0007replacing Mirage 2000N aircraft with the Rafale which will
\nbe armed with a new ALCM.
\nUnited Kingdom
\n\u2003 \u2022\u2002\u0007developing a new SSBN class to replace the current Van-
\nguard-class SSBNs which will carry the life-extended Tri-
\ndent II D5 with a new guidance system.
\n\u2003 \u2022\u2002\u0007equipping current SLBMs with enhanced warheads.
\nPakistan
\n\u2003 \u2022\u2002\u0007deploying new and longer-range Shaheen-III ballistic mis-
\nsiles, Ra\u2019ad ALCMs, Babur ground-launched cruise mis-
\nsiles, and developing a nuclear SLCM.
\n\u2003 \u2022\u2002\u0007deploying a tactical nuclear weapon, the 60-kilometer
\nNASR missile.
\n\u2003 \u2022\u2002\u0007increasing production of fissile material for additional war-
\nheads.
\nIndia
\n\u2003 \u2022\u2002\u0007deploying and developing longer-range ballistic missiles
\nthat can target all of Pakistan and China, including several
\nnew versions of the Agni missile family.
\n\u2003 \u2022\u2002\u0007conducting sea-trials of its first SSBN, which will carry new
\ntypes of SLBMs.
\n\u2003 \u2022\u2002\u0007building new reactors that can produce plutonium for ad-
\nditional warheads and expanding uranium enrichment ca-
\npacity.
\nIsrael
\n\u2003 \u2022\u2002\u0007modernizing its Jericho ballistic missiles and probably also
\nits fighter-bombers.
\n\u2003 \u2022\u2002\u0007Possibly equipping its new German-built Dolphin-class
\nsubmarines with a nuclear cruise missile.
\nNorth Korea
\n\u2003 \u2022\u2002\u0007deploying two new ballistic missiles (Musudan and Hwa-
\nsong-13) that could potentially in the future be equipped
\nwith weaponized versions of the nuclear devices it has tested.
\n\u2003 \u2022\u2002\u0007developing a new longer-range missile.
\nTable. Modernization Activities of the Nine Nuclear-armed States
\nNuclear War
\n90
\nof India and Pakistan actually contain more
\nthan 220 nuclear warheads.) The direct ef-
\nfects in South Asia are catastrophic. Some
\n20 million people would die in the first
\nweek from the direct effects of the explo-
\nsions, fire and local radiation [32].
\nThe global consequences-global climate
\ndisruption and resultant famine-would be
\nfar more devastating. The fires caused by
\nthese nuclear weapons would loft 6.5 mil-
\nlion tons of soot into the upper atmosphere.
\nThe impact of this soot has been examined
\nby three teams of climate scientists using
\nthree different climate models and mak-
\ning the conservative assumption that only
\n5 million tons of soot are injected into the
\natmosphere [33-35]. Each model shows
\nsignificant drops in average surface temper-
\nature and average precipitation across the
\nglobe with the effects lasting for more than
\na decade.The most sophisticated and recent
\nmodel shows the most persistent declines in
\ntemperature and precipitation, which have
\nnot yet returned to baseline after 26 years,
\nas long as the model was run. While the
\nfuel density of modern cities varies, there
\nis nothing specific to India\/Pakistan about
\nsuch a scenario. Nuclear weapons are ex-
\ntremely efficient at igniting, over large areas,
\nsimultaneous fires which rapidly coalesce
\nand inject large volumes of soot and smoke
\ninto the stratosphere.
\nThis climate disruption would in turn have
\nprofoundly negative impact on food pro-
\nduction. The maize crop in the US, the
\nworld\u2019s largest producer, would decline
\nan average of 12% over a full decade [36].
\nIn China, the world\u2019s largest producer of
\ngrain, middle season rice would decline
\nby 17% over a full decade, maize by 16%,
\nand winter wheat, by a truly catastrophic
\n31%\u00a0[37].
\nUnder current conditions, adequate human
\nnutrition cannot be sustained in the face of
\ndeclines of food production of this magni-
\ntude. Total world grain reserves in January
\n2016 amounted to only 84 days of global
\nconsumption, and would not begin to offset
\nthe shortfall over a full decade [38]. Fur-
\nthermore, there are currently 795 million
\npeople who are already undernourished at
\nbaseline [39]. There are also some 300 mil-
\nlion people who enjoy adequate nutrition
\ntoday, but live in countries highly depen-
\ndent on food imports which would probably
\nnot be available as grain exporting countries
\nsuspended exports to feed their own people.
\nIn addition, there are nearly a billion people
\nin China with incomes of $5 a day or less
\nwho are adequately fed today, but who have
\nshared little in China\u2019s growing prosperity
\nover the last several decades. All of these
\npeople, around two billion, would be at risk
\nunder the potential famine conditions that
\nwould result from this limited, regional nu-
\nclear war [40]. Large scale war between the
\nUS and Russia would be far worse. In early
\n2016, Russia and the US were estimated to
\npossess 7300 and 6970 nuclear warheads re-
\nspectively, 93% of the global total of 15,375.
\nUnder the provisions of the New START
\ntreaty, each of these countries will retain
\nsome 1550 strategic (long range) nuclear
\nwarheads when the Treaty is fully imple-
\nmented in 2018. Most of these weapons
\nare 10 to 50 times more powerful than the
\nbombs which destroyed Hiroshima [41]. A
\n2002 study showed that if just 300 of the
\nweapons in the Russian arsenal hit urban
\ntargets in the US, 75 to 100 million people
\nwould die in the first half hour from the
\nfirestorms and explosions [42]. This attack
\nwould also destroy most of the infrastruc-
\nture\u00a0 \u2013 the electric grid, internet, banking
\nand public health systems, food distribution
\nnetwork\u00a0\u2013 needed to support the rest of the
\npopulation, most of whom would succumb
\nto exposure,starvation and epidemic disease
\nin the months following. A US counterat-
\ntack would be expected to cause the same
\nlevel of destruction in Russia, and if NATO
\nwere involved in the conflict, Canada and
\nmuch of Europe would face similar destruc-
\ntion.
\nThese direct effects are only part of the
\nstory, however. As is true for a limited war
\nin South Asia, the global climate effects
\nwould be far worse. A war involving only
\nthe strategic weapons that will still be de-
\nployed when New START is fully imple-
\nmented would put some 150 million tons
\nof soot in the upper atmosphere, and drop
\ntemperatures around the world by 8\u00b0C. In
\nthe interior regions of North America and
\nEurasia, temperatures would fall by 25 to
\n30\u00b0C. These conditions would persist for
\nmore than a decade.Temperatures on Earth
\nhave not been that cold since the last ice
\nage. In the temperate regions of the North-
\nern Hemisphere, the temperature would fall
\nbelow freezing for some portion of every
\nday for at least two years [43]. Under these
\nconditions food production would stop and
\nthe vast majority of the human race would
\nstarve.
\nEfforts to Eliminate
\nNuclear Weapons
\nUnderstanding of the unprecedented ex-
\nistential threat posed by nuclear weapons
\nwas widely recognized in the very first
\nresolution of the United Nations General
\nAssembly in January 1946, calling for the
\nelimination of atomic weapons [44]. The
\npreamble of the 1970 nuclear Non-Prolif-
\neration Treaty (NPT) opens: \u201cConsider-
\ning the devastation that would be visited
\nupon all mankind by a nuclear war and the
\nconsequent need to make every effort to
\navert the danger of such a war \u2026\u201d [45]. Yet
\nfor most of the past 71 years, the shared
\ninterests of humanity, based on the real
\nconsequences of any use of nuclear weap-
\nons, have been sidelined by the perceived
\ninterests of the 9 governments that pos-
\nsess and threaten use of nuclear weapons,
\nwhich have dictated the pace and extent
\nof nuclear arms control and disarmament.
\nHowever, the obligation to pursue effective
\nmeasures towards nuclear disarmament is
\na shared responsibility of all 190 NPT sig-
\nnatory states, and the International Court
\nof Justice in its 1996 Advisory Opinion on
\nnuclear weapons unanimously ruled that
\nNuclear War
\n91
\nBACK TO CONTENTS
\nthere exists an obligation not only to pur-
\nsue in good faith, but to bring to a conclu-
\nsion, negotiations leading to nuclear disar-
\nmament [46].
\nThe contemporary \u2018Humanitarian Initiative\u2019
\non nuclear weapons began with Interna-
\ntional Committee of the Red Cross (ICRC)
\npresident Jacob Kellenberger informing the
\nGeneva Diplomatic Corps in 2010 that the
\nworld\u2019s largest humanitarian organization
\nwould make elimination of nuclear weap-
\nons\u00a0\u2013 something it first called for on 5 Sep-
\ntember 1945\u00a0\u2013 a renewed priority [47]. A
\nfew weeks later, the five yearly 2010 NPT
\nReview Conference outcome document
\nreferred for the first time to \u201cdeep concern
\nabout the catastrophic consequences of any
\nuse of nuclear weapons\u201d [48]. In 2011, the
\nCouncil of Delegates, the highest govern-
\ning body of the Red Cross\/Red Crescent
\nMovement, called on all states \u201cto ensure
\nthat nuclear weapons are never again used\u201d,
\nand \u201cto pursue in good faith and conclude
\nwith urgency and determination negotia-
\ntions to prohibit the use of and completely
\neliminate nuclear weapons through a legally
\nbinding international agreement, based on
\nexisting commitments and international
\nobligations\u201d [49]. A special issue of the
\nMovement\u2019s flagship journal, the Interna-
\ntional Review of the Red Cross, \u201cThe human
\ncosts of nuclear weapons\u201d,was recently pub-
\nlished.
\nBeginning in 2012, at every NPT meet-
\ning and UN General Assembly (UNGA), a
\ngrowing number of states, from 16 in 2012
\nto 144 in 2015, have supported resolutions
\naffirming the centrality of humanitarian
\nconsiderations in advancing nuclear dis-
\narmament, and the need to prevent use of
\nnuclear weapons under any circumstances
\n[50]. In 2013 and 2014 three successive
\nfact-based international conferences on the
\nHumanitarian Impact of Nuclear Weapons
\nwere held in Norway [51], Mexico [52] and
\nAustria [53], the last with participation of
\n146 states. Remarkably, 68 years into the
\nnuclear age, these were the first ever inter-
\ngovernmental meetings dedicated to the
\nhumanitarian impacts of nuclear weapons.
\nThere was no significant disagreement at
\nthese conferences regarding the exten-
\nsive expert evidence presented, leading to
\nthe conclusions 1) that any use of nuclear
\nweapons would be catastrophic; 2) that no
\neffective humanitarian response was pos-
\nsible to even a single nuclear detonation in
\nan urban centre; 3) that the risk of nuclear
\nweapons use had previously been underesti-
\nmated, is growing, and exists as long as the
\nweapons do; and 4) that there is a legal gap
\nfor nuclear weapons, in that the most de-
\nstructive and indiscriminate of all weapons
\nare the only weapon of mass destruction
\nnot yet explicitly prohibited under interna-
\ntional law [54]. At the end of the Vienna
\nconference, the Austrian government is-
\nsued a pledge \u201cto cooperate with all relevant
\nstakeholders \u2026 to stigmatize, prohibit and
\neliminate nuclear weapons in light of their
\nunacceptable humanitarian consequences
\nand associated risks\u201d; to \u201cfill the legal gap
\nfor the prohibition and elimination of nu-
\nclear weapons\u201d\u00a0[55]. As of 20 March 2016,
\n127 states have endorsed this Humanitarian
\nPledge, with an additional 22 states voting
\nin favour of a resolution bringing the Pledge
\nto the UNGA [56].
\nThe 2015 General Assembly also voted
\noverwhelmingly to establish an Open End-
\ned Working Group (OEWG) to address
\nthis legal gap, which though open to all
\nstates, was opposed and boycotted by all the
\nnuclear-armed states. The Working Group
\nwas charged with reporting back to the
\n2016 UNGA on effective legal measures
\nrequired to attain and maintain a world
\nfree of nuclear weapons. It \u201crecommended
\nwith widespread support for the General
\nAssembly to convene a conference in 2017,
\nopen to all States, with the participation
\nand contribution of civil society, to negoti-
\nate a legally-binding instrument to prohibit
\nnuclear weapons, leading towards their total
\nelimination \u2026\u201d[57]. The Working Group\u2019s
\nreport provided detailed suggestions on spe-
\ncific elements that could be included in such
\na treaty. This recommendation was taken
\nforward in a resolution co-sponsored by 57
\nstates [58] and adopted by the UNGA First
\nCommittee on 27 October 2016, with 123
\nStates voting yes, 38 (predominantly nucle-
\nar-armed and nuclear-allied) voting no, and
\n16 abstentions.The full UNGA will under-
\ntake a final vote in early December 2016,
\nand the first negotiating conference will
\nconvene in New York on 27 March 2017.
\nA new international treaty comprehensively
\nprohibiting nuclear weapons is thus within
\nsight.This is increasingly seen by a substan-
\ntial majority of states as the most promising
\nand realistic step which can now be taken to
\nprogress the eradication of nuclear weapons,
\nand the conclusion of such a treaty would
\nconstitute the most significant development
\nin nuclear disarmament since the end of the
\nCold War. Treaties unequivocally prohibit-
\ning unacceptable weapons and providing for
\ntheir subsequent elimination has been the
\napproach successfully used in relation to ev-
\nery other kind of indiscriminate, inhumane
\nweapon\u00a0\u2013 biological, toxin [59] and chemi-
\ncal weapons [60], followed by antipersonnel
\nlandmines [61] and cluster munitions [62].
\nThe Role of the Health
\nCommunity
\nInvolvement of the medical community in
\nthese efforts to eliminate nuclear weapons
\nflows from a long history of medical and
\nscientific concern about nuclear weapons.
\nAfter the hydrogen bomb code named
\nCastle Bravo was detonated at Bikini Atoll
\nwith a yield of around 15 megatons (mil-
\nlions of tons of TNT equivalent), double
\nthat predicted, there was widespread pro-
\ntest from many world leaders together
\nwith Albert Einstein and the Federation
\nof American Scientists [63]. In 1957, as
\natmospheric testing of nuclear weapons
\ncontinued unabated, an appeal from Albert
\nSchweitzer for a ban on nuclear tests was
\nbroadcast to audiences in 50 nations and a
\npetition initiated by Linus Pauling, 1954
\nNobel laureate in Chemistry, also demand-
\nNuclear War
\n92
\ning a test ban was signed by 9000 scientists
\nin 43 countries. Pauling was awarded the
\nNobel Peace Prize in 1963 for his opposi-
\ntion to nuclear testing. Also in 1957 the
\nBritish Atomic Scientists\u2019 Association set
\nup a committee to assess the risks of cancer
\narising from the fallout from atmospheric
\nnuclear tests, chaired by Professor Joseph
\nRotblat, a medical physicist (and during
\nthe 2nd
\nWorld War an atomic scientist,
\nworking on the atomic bomb at Los Ala-
\nmos). It concluded that for every 1 mega-
\nton exploded in the atmosphere, around
\n1000 people were likely to develop bone
\ncancers, and made other estimates of the
\nlikely health consequences of atmospheric
\nnuclear testing [64].
\nA series of four [65-68] influential articles
\nappeared in the New England Journal of
\nMedicine in 1962 describing the medical
\neffects of a thermonuclear attack on Mas-
\nsachusetts, the (limited) role of the medical
\nprofession in dealing with the consequences,
\nand the psychiatric and social aspects of civ-
\nil defence. The authors, who were members
\nof a new organization Physicians for Social
\nResponsibility, concluded that as no effective
\nclinical response was possible,doctors \u201cmust
\nbegin to explore a new area of preventive
\nmedicine, the prevention of thermonuclear,
\nchemical and biological warfare\u201d.
\nNegotiations on a ban on nuclear testing
\ncontinued inconclusively until 1963 because
\nof concerns about the potential to conceal
\nclandestine tests. With evidence of wide-
\nspread radioactive fallout and accumulation
\nof strontium-90 in the deciduous teeth of
\nchildren around the world, public opinion
\nswung strongly in favour of banning atmo-
\nspheric nuclear testing and the Limited Test
\nBan treaty was agreed in 1963, but progress
\ntowards a comprehensive treaty proved
\nfrustratingly slow.
\nIn the early 1980s a number of reports on
\nthe health effects of nuclear weapons ap-
\npeared including a BMA report of 1983
\nwhich concluded that the casualties from
\nthe detonation of a single megaton weapon
\nwould overwhelm the resources of the en-
\ntire UK National Health Service [69]. The
\nWorld Health Assembly adopted a resolu-
\ntion in 1983 including reference to nuclear
\nweapons as \u201cthe greatest immediate threat
\nto the health and welfare of mankind\u201d
\n[70]. Scientific and medical evidence that
\ncivil defence programs against nuclear
\nwar provided at best an illusion of protec-
\ntion led to their widespread abandonment
\n[71]. Evidence on the catastrophic health
\neffects of nuclear war brought by physi-
\ncians to Presidents Ronald Reagan and
\nMikhail Gorbachev had profound effect,
\nbringing them to declare in 1985 that \u201cA
\nnuclear war cannot be won and must never
\nbe fought\u201d; to end their nuclear arms race;
\nagree on the elimination of intermediate
\nrange nuclear missiles; and come close to
\nan agreement to eliminate their nuclear
\narsenals entirely. Gorbachev wrote that
\nwithout the efforts of IPPNW\u00a0\u2013 awarded
\nthe Nobel Peace Prize in 1985\u00a0\u2013 these dis-
\narmament initiatives \u201cwould probably have
\nbeen impossible\u201d\u00a0[72]. Given the potential
\nfor nuclear war to occur as a result of er-
\nror and the lack of evidence that a planned
\nmedical response can have any perceptible
\nimpact on the outcome, it has been sug-
\ngested that \u201csupport for deterrence with
\nthese weapons as a policy for national or
\nglobal security appears to be incompatible
\nwith basic principles of medical ethics and
\ninternational law. The primary medical re-
\nsponsibility under such circumstances is to
\nparticipate in attempts to prevent nuclear
\nwar\u201d\u00a0 [73]. New evidence about the per-
\nvasive threats to health of the detonation
\nof even a small percentage of the world\u2019s
\nnuclear arsenals, together with the failure
\nof the Non-Proliferation Treaty to prevent
\nthe retention and modernization of nu-
\nclear weapons has given impetus to a new
\nglobal movement to ban nuclear weapons.
\nThe health professions therefore have a
\ncentral role in advocating for the abolition
\nof nuclear weapons, reflecting their ethical
\nresponsibility to protect health and prevent
\nillness.
\nIn 2007, IPPNW founded the Internation-
\nal Campaign to Abolish Nuclear Weapons
\n(ICAN)\u00a0\u2013 a broad global campaign coalition
\nworking for a treaty banning nuclear weap-
\nons. ICAN now has 440 partner organisa-
\ntions in 98 countries, is the lead civil society
\npartner for the governments hosting the
\nHumanitarian conferences, and continues
\nto grow as a major civil society coordinating
\ninitiative and partner for governments seri-
\nous about the humanitarian imperative for
\nnuclear disarmament.
\nIn Moscow in October 2015, the World
\nMedical Association General Assembly
\nunanimously updated its Statement on
\nNuclear Weapons, adopted in 1998 and
\namended in 2008, requesting all National
\nMedical Associations to educate their pub-
\nlics and governments about the health im-
\npacts of nuclear war and \u201cto join the WMA
\nin supporting this Declaration and to urge
\ntheir respective governments to work to ban
\nand eliminate nuclear weapons\u201d [74].
\nIn April 2016, the WMA joined with
\nIPPNW, the World Federation of Public
\nHealth Associations and the International
\nCouncil of Nurses, in submitting to the
\nUN Working Group the first such united
\nstatement detailing the health and humani-
\ntarian imperative to ban and eliminate nu-
\nclear weapons [75]. All other global health
\nprogress and efforts could come to nought
\nif we do not succeed in eradicating nuclear
\nweapons before they are again used in war.
\nThere has never been a better opportunity
\nnor greater need for united and effective
\nhealth professional engagement to remove
\nthe most acute existential threat to global
\nhealth and survival.
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\nWeapons. Final Document Vol 1 Part 1 Con-
\nclusions and recommendations for follow-on
\nactions. NPT\/CONF.2010\/50 (Vol. 1). New
\nYork: United Nations, 2010. http:\/\/www.reach-
\ningcriticalwill.org\/images\/documents\/Disarma-
\nment-fora\/npt\/revcon2010\/FinalDocument.pdf
\n(accessed May 6, 2016).
\n49.\tInternational Committee of the Red Cross.
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\n\u00adWorking towards the elimination of nuclear
\nweapons. Geneva: ICRC, 2011. http:\/\/www.
\nicrc.org\/eng\/resources\/documents\/resolution\/
\ncouncil-delegates-resolution-1-2011.htm (ac-
\ncessed May 6, 2016).
\n50.\tUN General Assembly. Humanitarian con-
\nsequences of nuclear weapons. Resolution.
\nA\/C.1\/70\/L.37. New York: United Nations,
\n2015. http:\/\/reachingcriticalwill.org\/disarma-
\nment-fora\/unga\/2015\/resolutions (accessed
\nMay 6, 2016).
\n51.\tMinistry of Foreign Affairs (Norway). www.
\nregjeringen.no\/en\/topics\/foreign-affairs\/hu-
\nmanitarian-efforts\/humimpact_2013\/id708603\/
\n(accessed May 6, 2016).
\n52.\tChair\u2019s Summary. Second Conference on the
\nHumanitarian Impact of Nuclear Weapons. Na-
\nyarit: Government of Mexico,2014.http:\/\/www.
\nreachingcriticalwill.org\/images\/documents\/Dis-
\narmament-fora\/nayarit-2014\/chairs-summary.
\npdf (accessed May 6, 2016).
\n53.\tEurope Integration and Foreign Affairs Fed-
\neral Ministry, Republic of Austria. Report
\nand Summary of Findings of the Conference,
\nVienna Conference on the Humanitarian Im-
\npacts of Nuclear Weapons, 9 Dec 2014. https:\/\/
\nwww.bmeia.gv.at\/fileadmin\/user_upload\/Zen-
\ntrale\/Aussenpolitik\/Abruestung\/HINW14\/
\nHINW14_Chair_s_Summary.pdf (accessed
\nMay 6, 2016).
\n54.\tEurope Integration and Foreign Affairs Fed-
\neral Ministry, Republic of Austria. Humanitar-
\nian Pledge. https:\/\/www.bmeia.gv.at\/fileadmin\/
\nuser_upload\/Zentrale\/Aussenpolitik\/Abrues-
\ntung\/HINW14\/HINW14vienna_Pledge_Doc-
\nument.pdf (accessed May 6, 2016).
\n55.\tEurope Integration and Foreign Affairs Fed-
\neral Ministry, Republic of Austria. Support for
\nPledge. https:\/\/www.bmeia.gv.at\/fileadmin\/
\nuser_upload\/Zentrale\/Aussenpolitik\/Abru-
\nestung\/HINW14\/HINW14vienna_update_
\npledge_support.pdf (accessed May 6, 2016).
\n56.\tUN General Assembly. Taking forward mul-
\ntilateral nuclear disarmament negotiations.
\nResolution. A\/C.1\/70\/L.13\/Rev.1. New York:
\nUnited Nations, 2015. http:\/\/reachingcriti-
\ncalwill.org\/images\/documents\/Disarmament-
\nfora\/1com\/1com15\/resolutions\/L13Rev1.pdf
\n(accessed May 6, 2016).
\n57.\tReport of the Open-ended Working Group
\ntaking forward multilateral nuclear disarma-
\nment negotiations, adopted 19 August 2016.
\nhttp:\/\/www.reachingcriticalwill.org\/images\/
\ndocuments\/Disarmament-fora\/OEWG\/2016\/
\nDocuments\/OEWG-report-final.pdf (accessed
\nOctober 30, 2016).
\n58.\tUnited Nations General Assembly. Taking for-
\nward multilateral nuclear disarmament nego-
\ntiations. UN Document A\/C.1\/71\/L.41. http:\/\/
\nreachingcriticalwill.org\/images\/documents\/
\nDisarmament-fora\/1com\/1com16\/resolutions\/
\nL41.pdf (accessed October 30, 2016).
\n59.\tConvention on the Prohibition of the Develop-
\nment, Production and Stockpiling of Bacterio-
\nlogical (Biological) and Toxin Weapons and on
\nTheir Destruction. http:\/\/www.apminebancon-
\nvention.org\/overview-and-convention-text (ac-
\ncessed May 6, 2016).
\n60.\tConvention on the Prohibition of the Devel-
\nopment, Production, Stockpiling and Use of
\nChemical Weapons and on their Destruction.
\nhttps:\/\/www.opcw.org\/chemical-weapons-con-
\nvention (accessed May 6, 2016).
\n61.\tConvention on the Prohibition of the Use,
\nStockpiling, Production and Transfer of Anti-
\nPersonnel Mines and on their Destruction.
\nwww.icrc.org\/ihl\/INTRO\/580 (accessed May
\n6, 2016).
\n62.\tConvention on Cluster Munitions. http:\/\/www.
\nclusterconvention.org\/the-convention\/conven-
\ntion-text (accessed May 6, 2016).
\n63.\tHaines A, Hartog M. Doctors and the Test Ban:
\n25 years on. BMJ 1988;297:408\u2013411
\n64.\tBritish Atomic Scientists\u2019 Association. Stron-
\ntium hazards. Bulletin of- the Atomic Scientists
\n1957;XIII:202\u20133.
\n65.\tErvin FR, Glazier JB, Aronow S, et al. Human
\nand ecologic effects in Massachusetts of an as-
\nsumed thermonuclear attack on the United
\nStates. N Engl J Med 1962; 266:1127-37.
\n66.\tSidel V, Geiger.J, Lown B. The physician\u2019s role
\nin the postattack period. N Engl J Med 1962;
\n266:1137-45.
\n67.\tLeiderman PH, Mendelson JH. Some psychiat-
\nric considerations in planning for defense shel-
\nters. N Engl J Med 1962; 266:1149-55.
\n68.\tAronow S. A glossary of radiation terminology.
\nN Engl J Med 1962; 266:1145-9.
\n69.\tBritish Medical Association.The medical effects
\nof\u2019 nuclear war. Chichester: Wiley, 1983
\n70.\tThe role of Physicians and other health
\nworkers in the preservation of peace as the
\nmost significant factor for the attainment of
\nhealth for all http:\/\/apps.who.int\/iris\/bit-
\nstream\/10665\/160590\/1\/WHA36_R28_eng.
\npdf (accessed May 9th 2016).
\n71.\tLeaning J, Keyes L. The counterfeit ark. Crisis
\nrelocation for nuclear war. Cambridge (MA):
\nBallinger, 1984.
\n72.\tGorbachev MS. Perestroika. New Thinking for
\nOur Country and the World. New York: Harper
\n& Row; 1988.
\n73.\tHaines A, White c de B, Gleisner J. Nuclear
\nweapons and medicine; some ethical dilemmas.
\nJournal of Medical Ethics 1983: 9:200-6.
\n74.\tWorld Medical Association. WMA Statement
\non Nuclear Weapons. 66th WMA General As-
\nsembly, Moscow, Russia, October 2015. www.
\nwma.net\/en\/30publications\/10policies\/n7\/ (ac-
\ncessed May 9, 2016).
\n75.\tUN General Assembly.The health and humani-
\ntarian case for banning and eliminating nuclear
\nweapons. Working paper A\/AC.286\/NGO\/18,
\n4 May 2016. https:\/\/ippnweupdate.files.word-
\npress.com\/2016\/04\/health-and-humanitarian-
\ncase-for-banning-and-eliminating-nuclear-
\nweapons_oewg-may-2016.pdf (accessed May 6,
\n2016).
\nIra Helfand, MD
\nCo-President, International Physicians
\nfor the Prevention of Nuclear War,
\nMalden, Massachusetts, 413 320 7829,
\nE-mail: ihelfand@igc.org
\nAndy Haines, MD
\nProfessor, Departments of Social and
\nEnvironmental Health Research and of
\nEpidemiology and Population Health,
\nLondon School of Hygiene and Tropical
\nMedicine, London, WC1H 9SH,
\nE-mail: aphaines@doctors.org.uk
\nTilman Ruff,
\nFRACP, Nossal Institute for Global Health,
\nSchool of Population and Global Health,
\nUniversity of Melbourne, Melbourne,
\nCo-President, International Physicians
\nfor the Prevention of Nuclear War,
\nE-mail: tar@unimelb.edu.au
\nHans Kristensen
\nFederation of American Scientists,
\nWashington DC,
\nE-mail: hkristensen@fas.org
\nPatricia Lewis, PhD
\nChatham House, London,
\nE-mail: PLewis@chathamhouse.org
\nZia Mian, PhD
\nProgram on Science and Global Security,
\nPrinceton University, Princeton, NJ,
\nE-mail: zia@princeton.edu
\nNuclear War
\n95
\nBACK TO CONTENTS
\nMedical Education
\nWorld Medical Association (WMA)
\nStatement on Nuclear Weapons
\nAdopted 17 October 2015
\nThe WMA Declarations of Geneva, of Helsinki and of Tokyo
\nmake clear the duties and responsibilities of the medical profession
\nto preserve and safeguard the health of the patient and to conse-
\ncrate itself to the service of humanity.The WMA considers that it
\nhas a duty to work for the elimination of nuclear weapons.
\nTherefore the WMA:
\n2.1 Condemns the development, testing, production, stockpiling,
\ntransfer, deployment, threat and use of nuclear weapons;
\n2.2 Requests all governments to refrain from the development,
\ntesting, production, stockpiling, transfer, deployment, threat and
\nuse of nuclear weapons and to work in good faith towards the
\nelimination of nuclear weapons;
\n2.3 Advises all governments that even a limited nuclear war
\nwould bring about immense human suffering and substantial
\ndeath toll together with catastrophic effects on the earth\u2019s ecosys-
\ntem, which could subsequently decrease the worlds food supply
\nand would put a significant portion of the world\u2019s population at
\nrisk of famine; and
\n2.4 Requests that all National Medical Associations join the
\nWMA in supporting this Declaration, use available educational
\nresources to educate the general public and to urge their respec-
\ntive governments to work towards the elimination of nuclear
\nweapons.
\n2.5 Requests all National Medical Associations to join the WMA
\nin supporting this Declaration and to urge their respective govern-
\nments to work to ban and eliminate nuclear weapons.
\nWMA Calls on Governments to Ban
\nand Eliminate Nuclear Weapons
\nResidency is a dynamic and stressful
\ntime. Trainees must continually balance
\ntheir roles as both learners and clini-
\ncians within a high-stakes environment.
\nWhether it\u2019s hearing that first code pager,
\nwitnessing a patient death, feeling the cu-
\nmulative impact of long hours and on-call
\nresponsibilities, or missing an important
\nlife event at home \u2013 every resident deals
\nwith stress.
\nStress impacts physician well-being. The
\nmajority of Canadian medical residents
\nreport that work-related fatigue affects
\ntheir mental health, physical health, and
\nrelationships with family and friends
\n(Resident Doctors of Canada National
\nResident Survey, 2015). The overall de-
\npression rate in U.S. medical students and
\nresidents is as high as 1 in 5 [1]. Burnout,
\na work-related syndrome due to chronic
\nexposure to occupational stress, is preva-
\nlent in 27\u201375% of residents, depending on
\nspecialty [2].
\nRDoC\u2019s Resiliency Curriculum
\nResiliency is the ability to recover from or
\nadjust easily to adverse situations, and it is
\na critical trait for resident doctors. Training
\nresidents in resiliency skills equips them to
\neffectively identify, cope with, and recover
\nfrom challenging experiences in their per-
\nsonal and professional lives, while setting
\nthem up for rewarding and sustainable ca-
\nreers.
\nWith content support from the Mental
\nHealth Commission of Canada and the
\nDepartment of National Defence\u2019s Road
\nto Mental Readiness Program, Resident
\nDoctors of Canada (RDoC) has developed
\na practical, skills-based resiliency curricu-
\nlum to help mitigate the negative conse-
\nquences of stress during residency and
\nbeyond.
\nThe curriculum is based on the importance
\nof promoting mental resiliency in physi-
\ncians by fostering supportive and positive
\nThe Value of Resiliency Training in
\nPostgraduate Medical Education
\n96
\nSPAIN
\n1. Human trafficking
\nAccording to UNODC, Article 3, para-
\ngraph (a) of the Protocol to Prevent, Sup-
\npress and Punish Trafficking in Persons,
\n\u201ctrafficking in Persons is the recruitment,
\ntransportation, transfer, harboring or receipt of
\npersons, by means of the threat or use of force or
\nother forms of coercion,of abduction,of fraud,of
\ndeception, of the abuse of power or of a position
\nof vulnerability or of the giving or receiving of
\npayments or benefits to achieve the consent of a
\nperson having control over another person, for
\nthe purpose of exploitation. Exploitation shall
\ninclude, at a minimum, the exploitation of the
\nprostitution of others or other forms of sexual
\nexploitation, forced labour or services, slavery
\nor practices similar to slavery, servitude or the
\nremoval of organs.\u201d [1]
\nHuman trafficking involves the forced trans-
\nfer of a person and the use of their services
\nin order to recruit them for commercial traf-
\nficking. Frequently, the consent is obtained
\nbut through deceitful acts and false promises.
\nMany times, due to the social conditions of
\nthe victim, they are not aware of being ex-
\nploited. To make it easier, a person is traf-
\nficked if she or he is forced or tricked into
\na situation in which he or she is exploited.
\nChild trafficking differs from human traf-
\nficking in that no force or deception needs to
\ntake place in order to prove that a child has
\nbeen trafficked. This difference is based on
\nMedical Affairs
\nThe Role of Physicians Fighting Children Trafficking
\nand Illegal Adoptions: the Use of Genetic Identification
\nJose A. Lorente
\nlearning environments. It advocates for a
\nsystematic approach to understanding and
\naddressing anticipated stresses, and assists
\nresidents in overcoming personal adversity
\nby providing them with tools to better sup-
\nport their peers and patients.
\nRDoC\u2019s resiliency curriculum encourages
\nresidents to learn how to become more
\naware of their own mental health, and to
\ntake action early when they start to notice
\nshifts in their well-being. Students learn
\nand practice a series of tools based on cog-
\nnitive behavioural therapy, performance
\npsychology and mindfulness to build and
\nstrengthen their resiliency. The curriculum
\nalso explores the barriers to seeking help,
\nsuch as concerns regarding privacy or a fear
\nof losing control, as well as some guidelines
\nfor approaching colleagues and peers who
\nappear to be in distress.
\nWhat\u2019s Next?
\nRDoC has completed a pilot project that
\ninvolved delivering and evaluating the re-
\nsiliency curriculum in five clinical special-
\nties at two Canadian faculties of medicine.
\nThe overwhelming response from par-
\nticipants has been that resiliency train-
\ning is highly valuable to residents and is
\nan essential part of medication education.
\nRDoC\u2019s next steps include developing a
\nstrategy to continue delivering resiliency
\ntraining across the country, in order to
\nhelp residents manage stress, support their
\npeers, and ultimately provide better patient
\ncare.
\nFor more information, please e-mail
\nresiliency@residentdoctors.ca
\nReferences
\n1.\t Goebert D, Thompson D, Takeshita J, Beach
\nC, Bryson P, Ephgrave K, Kent A, Kunkel M,
\nSchechter J, Tate J. Depressive symptoms in
\nmedical students and residents: a multischool
\nstudy. Acad Med. 2009; 84(2): 236-41.
\n2.\t Ishak WW, Lederer S, Mandili C, Nikravesh R,
\nSeligman L, Vasa M, Ogunyemi D, Bernstein
\nCA. Burnout During Residency Training: A
\nLiterature Review. J Grad Med Educ. 2009 Dec;
\n1(2): 236\u2013242.
\nKimberly Williams, MD
\nPresident, Resident
\nDoctors of Canada
\nKimberly Williams
\n97
\nBACK TO CONTENTS
\nMedical AffairsSPAIN
\nthe fact that a child is considered incapable
\nof taking an informed decision.
\n2.Trafficking in children
\nChildren, the most fragile members of so-
\nciety, can be subjected to many abuses. In-
\ndeed, one of these abuses is human traffick-
\ning, an apparently lucrative criminal activity.
\nAccording to UNICEF, \u201can estimated 300
\nmillion children worldwide are subjected to
\nviolence, exploitation and abuse including the
\nworst forms of child labour in communities,
\nschools and institutions; during armed conflict;
\nand to harmful practices such as female genital
\nmutilation\/cutting and child marriage\u201d. Only
\nin the United States are there figures to begin
\nto appreciate the magnitude of the missing
\nchildren problem within the country. Ap-
\nproximately 800,000 children are reported
\nmissing each year. Of these, approximately
\n360,000 are runaways and 340,000 are clas-
\nsified as \u201cmissing with benign explanation\u201d,
\nand about 100,000 are abducted either by
\nfamily members or other known individuals
\nor are lost and\/or injured (UNICEF 2004;
\nCrimes 2009). While these figures are dis-
\nturbing,they relate to mostly domestic situa-
\ntions and do not represent the greater inter-
\nnational problem where children are illegally
\nsold for malevolent purposes.These numbers
\nalso mainly show domestic situations and do
\nnot represent the huge international prob-
\nlem of the harmful illegal trade of children.
\nRecent reports give information about the
\nnature of trafficking of children but its real
\nsignificance is still not clear. In 2002, the
\nInternational Labour Organization (ILO)
\nestimated that 1.2 million children are kid-
\nnapped and trafficked in a year [2].
\n3.\u0007The role of Physicians
\nfighting children trafficking
\nand illegal adoptions
\nThe UNICEF\u2019s Convention on the Rights of
\nthe Child (resolution 44\/25 of 20\u00a0\u00adNovember
\n1989, entered into force on 2 September
\n1990), states in art. 24.1 that States Parties
\nrecognize the right of the child to receive
\nthe highest attainable standard of health
\ncare and to have access to appropriate fa-
\ncilities for the treatment of illness and reha-
\nbilitation of health [3]. States Parties shall
\nstrive to ensure that no child is deprived of
\nhis or her right of access to such health care
\nservices.
\nBesides that, and according to art. 21,
\nStates Parties that recognize and\/or permit
\nthe system of adoption shall ensure that
\nthe best interests of the child shall be the
\nparamount consideration and they shall:
\n(a) Ensure that the adoption of a child is
\nauthorized only by accredited authorities
\nwho determine, in accordance with appli-
\ncable law and procedures and on the basis
\nof all pertinent and reliable information,
\nthat the adoption is permissible in view
\nof the child\u2019s status concerning parents,
\nrelatives and legal guardians and that, if
\nrequired, the persons concerned have given
\ntheir informed consent to the adoption on
\nthe basis of such counselling as may be
\ndeemed necessary.
\nThere is no doubt that physicians have a role
\nto play, since their professional activities are
\ncrucial in seeking to ensure the adherence
\nto children\u2019s rights, and in particular to ar-
\nticles 21 & 24. Physicians play a relevant
\nrole in two different positions during the
\nwhole adoption process before the adoption
\nis completed. First, in countries and areas
\nwhere children are going to be given for
\nadoption, because they will deal with chil-
\ndren who are going to be adopted, and they
\nmust be sure that the child is healthy, with
\nno injuries that could show battering or
\nabuses; they must report to the proper au-
\nthorities any suspicious adoption activities
\nrelated to minors whose identities are not
\nclear or where legal safeguards are not in
\nplace. Second, in countries and areas where
\nchildren are going to be adopted, physicians
\nshould advise those families who are con-
\nsidering adoption of minors to verify that
\nthe adoption procedures meet all legal re-
\nquirements in their jurisdiction. Since they
\nare trusted, the fact of providing informa-
\ntion about networks related to illegal adop-
\ntions is important.
\nBeside that, physicians should explain to
\nfamilies about genetic testing (DNA anal-
\nysis) that can be used to confirm the bio-
\nlogical relationship between the children
\nthat are going to be given for adoptions
\nand the relatives (usually parents) who are
\npresenting the children for adoption. It is
\ncrucial to make sure that children are be-
\ning given for adoption on a voluntary basis
\nand by their biological parents or relatives.
\nGenetic analysis can also help to identify
\nmissing children that were not previously
\nidentified and facilitate family reunifica-
\ntion.
\n4. \u0007One example: the DNA-
\nPROKIDS Program:
\nDNA to identify missing
\nand vulnerable children
\nAfter a number of successful missing per-
\nsons identification initiatives, as e.g. the
\nSpanish Phoenix Program [4], DNA-
\nPROKIDS was created in 2004 by Dr. Jose
\nAntonio Lorente, Director of the Genetic
\nIdentification Laboratory of University of
\nGranada. After a pilot study from 2006 to
\n2008 in countries from Central America
\nand Asia, it became a worldwide action.
\nThe goal of DNA-PROKIDS is the use
\nof human genetic identification technolo-
\ngies (i.e. DNA analysis) to identify missing
\nchildren. DNA-PROKIDS is supporting a
\nnumber of countries in Latin America and
\nAsia analysis to generate two independent
\ndatabases, always according to the laws and
\nregulations in each country:
\nQUESTIONED DATABASE: DNA pro-
\nfiles of unidentified children under protec-
\ntion of the authorities living in orphanages,
\n98
\nMedical Affairs SPAIN
\nNGO\u2019s facilities, or other institutions. In all
\ncases these are children whose family is not
\nknown.The legal tutor of the child must au-
\nthorize the collection of the sample.
\nREFERENCE DATABASE: DNA pro-
\nfiles of relatives of missing children: par-
\nents, grandparents, etc. who have reported
\nthat his\/her biologically-related child is lost.
\nThese samples are voluntarily provided by
\nthe relatives and collected after an informed
\nconsent form has been signed.
\nGlobally, DNA-PROKIDS is composed
\nof three tiers.The first tier is at the national
\nlevel with two genetic databases or indices
\nper country, as previously described. The
\nDNA profiles in these two indices will be
\ncompared routinely to assist in identifying
\nmissing children. The second tier implies
\ncoordination amongst different countries;
\nit is highly recommended for neighbor-
\ning countries in affected regions. The lack
\nof coordination plays in detriment of an
\neffective strategy to fight child traffick-
\ning globally. The third tier would be the
\nadoption of international conventions that
\nshould require the correct identification of
\nevery child by using all available method-
\nologies, including DNA analysis. No child
\nshould be given for adoption without be-
\ning sure that his or her family is not look-
\ning for him or her.
\nThe application and usefulness of DNA
\nidentity testing are already well-document-
\ned. To date DNA-PROKIDS participating
\ncountries have analyzed over 10.500 sam-
\nples (from Mexico, Guatemala, El Salvador,
\nParaguay, Peru, Bolivia in Latin America,
\nand the Philippines, Thailand, Indonesia,
\nand India in Asia). DNA analyses first, and
\nsubsequent application of accompanying
\nmeta-data, have already helped to identify
\nmore than 860 missing children who have
\nbeen returned to their families; and more
\nthan 250\u00a0 illegal adoptions that have been
\navoided.
\nGuatemala is the first and so far the only
\ncountry in the world that has passed a law
\n(Ley de Alerta Alba-Keneth) in 2010 to
\nrequest DNA analysis on all unidentified
\nchildren and to offer the analysis for free to
\nthe relatives of missing children [5].
\nMore operational data and updated informa-
\ntion can be found at www.dna-prokids.org
\nReferences
\n1.\t UNODC. https:\/\/www.unodc.org\/unodc\/trea-
\nties\/CTOC, 2016.
\n2.\t Hagemann, F. Every Child Counts. New Global
\nEstimates on Child Labour, International Or-
\nganization for Migration, 2011. Counter traf-
\nficking and assistance to vulnerable migrants.
\nAnnual report of activities 2011.
\n3.\t UNICEF Office of Research. https:\/\/www.
\nunicef-irc.org\/portfolios\/crc.html, 2016.
\n4.\t Lorente JA, Entrala C, Alvarez JC, Lorente M,
\nVillanueva E, Carrasco F, et al. Missing persons
\nidentification: Genetics at work for society. Sci-
\nence, 2000, 290(5500), 2257\u20132258.
\n5.\t Ley de Alerta Alb-Keneth-Guatemala. http:\/\/
\nwww.pgn.gob.gt\/ley-alba-keneth, 2016.
\nJose A. Lorente1,2
\n, MD, PhD, Maria\u00a0Saiz1
\n,
\nMaria\u00a0Jesus\u00a0Alvarez\u2011Cubero2
\n,
\nJuan\u00a0Carlos\u00a0Alvarez1
\n,
\nJuan\u00a0Jose\u00a0Rodriguez\u2011Sendin3
\n, MD,
\nFernando Rivas3
\n, MD, PhD
\n1. DNA-PROKIDS Program- Department
\nof Legal Medicine, Toxicology and Physical
\nAnthropology. Faculty of Medicine.
\nPTS Granada. Av. Investigaci\u00f3n
\n11. 18016. Granada. Spain
\n2. GENYO. Centre for Genomics and
\nOncological Research. PTS Granada. Avenida
\nde la Ilustraci\u00f3n 114. 18016 Granada. Spain
\n3. Consejo General de Colegios Oficiales
\nde M\u00e9dicos de Espa\u00f1a, Madrid
\nE-mail: jose.lorente@genyo.es
\n99
\nBACK TO CONTENTS
\nEuthanasiaVATICAN
\nIn Maxence Van Der Meersch\u2019s popular
\nnovel Bodies and Souls Michele Doutreval,
\na young country doctor, the son of a well-
\nknown university professor in Angers, due
\nto several turns of events, finds himself
\nworking in a small town in the North of
\nFrance. One of the episodes in particular
\ndescribes doctor Doutreval\u2019s great human-
\nity and good approach to Medicine. On his
\nway back home after a long day at work,
\nhe meets a man on his doorstep. The man,
\nwho looks clearly sorry to trouble the doctor
\nat such a late hour, tells him that his little
\ndaughter, Franchina Ray is dying of tuber-
\nculosis and wishes to say goodbye.Michele\u2019s
\nanswer is concise but very illustrative: \u201cYes,
\nsure. I\u2019ll be right back\u201d. He enters his house
\nto greet his wife and to tell her that once
\nagain they will not be able to spend the
\nnight together. Then he sets out on his way
\nto the sick girl\u2019s house where he stands by
\nher side until she dies. The episode ends
\nwith the remark that it was late when the
\ndoctor finally got back home [1]. Medical
\nscience has certainly changed in the century
\nthat separates us from doctor Doutreval\u2019s
\ntime, and it has changed irreversibly… Nev-
\nertheless, every doctor would wish to have
\nthe same availability and friendliness that
\nMichele had in his medical practice.
\nIt seems to me that Van Der Meersch\u2019s sto-
\nry can be a useful backdrop for the compli-
\ncated topic of this article. Medical science
\nchanges with society,not only because today
\nwe have more diagnostic and therapeutic
\nmeans than we used to have a few decades
\nago. The introduction of technology into
\nmedical care has caused a great transforma-
\ntion in the way of conceiving the doctor-
\npatient relationship. Patients are each time
\nseen by more and more professionals and
\nthis represents a temptation for the doctor,
\nwho can easily become another stranger at
\nthe bedside [2]. Moreover, autonomy, one
\nof the basic principles of Bioethics, has in-
\nduced many doctors to shirk their duty of
\nproviding advice and orientation, and bar-
\nricade themselves behind technical means.
\nIt is within this complicated medical con-
\ntext and the prolongation of pathological
\nprocesses, that the demand for euthanasia
\ncan insinuate itself. So far and with few ex-
\nceptions, medical science, through its con-
\nstituent bodies,has refused to take this path.
\nHowever, social pressure is strong in some
\ncountries and consequently it is essential to
\nengage in a calm and well-considered de-
\nbate on the topic.
\nThe World Medical Association (WMA),
\nwhich defines euthanasia as \u201cthe act of de-
\nliberately ending the life of a patient,even at
\nthe patient\u2019s own request or at the request of
\nclose relatives\u201d, has condemned euthanasia
\nsince 1987 in a clear and explicit way, stat-
\ning that \u201cit is unethical\u201d. It then goes on to
\nclarify what is and what is not euthanasia,
\nby adding that \u201cThis does not prevent the
\nphysician from respecting the desire of a
\npatient to allow the natural process of death
\nto follow its course in the terminal phase
\nof sickness\u201d[3]. Moreover, according to the
\n2002 resolution on euthanasia: \u201cThe World
\nMedical Association reaffirms its strong
\nbelief that euthanasia is in conflict with
\nbasic ethical principles of medical practice
\nand the WMA strongly encourages all Na-
\ntional Medical Associations and physicians
\nto refrain from participating in euthanasia,
\neven if national law allows it or decriminal-
\nizes it under certain conditions\u201d[4]. In this
\npaper I would like to highlight some of the
\narguments that justify this policy bearing
\nin mind that negative moral prescriptions
\nare not an end in themselves, but are the
\nstarting point for a profound and creative
\nreflection on medical assistance at the end
\nof life; an end of life which has benefited
\nimmensely over the last decades from ad-
\nvances in palliative care. Unfortunately, the
\nteaching of this area of medical science has
\nbeen insufficient in many instances. For
\nthis reason, this reflection is also a call for
\na more substantial engagement in order to
\nstimulate an increase in undergraduate and
\ngraduate training in this important field of
\nmodern medicine.
\nSince its inception, Medical Ethics has re-
\njected euthanasia following a basic deon-
\ntological principle: \u201cdoctors must not kill\u201d.
\nDeontology, which is currently represented
\nby Kantian ethics, highlights what can be
\ndone and what cannot be done. The ratio-
\nnale for these norms may vary according to
\nthe various moral formulations, but what is
\nmore important here is the assumption of a
\nseries of obligations and prohibitions; pro-
\nhibitions of acts which contravene the good
\nof the person or of society. Apart from the
\ndeontological argument, utilitarian argu-
\nments have also been added to recent de-
\nbates on euthanasia. Their argument claims
\nthat a particular action is to be considered
\nwrong not because there is a norm prohib-
\niting it, but rather because the action goes
\nagainst the greatest good for the great-
\nest number of the people. For the case in
\npoint, the utilitarian or consequentialist
\nargument rejects the practice of euthanasia.
\nPablo Requena
\nWhy Should the World Medical Association
\nnot Change its Policy towards Euthanasia?
\n100
\nEuthanasia VATICAN
\nEven though utilitarianism does not con-
\nsider the practice immoral in itself, and in
\nfact considers it justified in some cases, it
\naccepts that allowing it would result in seri-
\nous abuses. This form of argumentation has
\nentered the bioethical bibliography using
\nthe term \u201cslippery slope\u201d.
\n\u201cDoctors must not kill\u201d
\nThe deontological principle condemning eu-
\nthanasia finds its paradigmatic expression in
\nthe Hippocratic Oath,which has constituted
\nthe basis of Medical Ethics from the origins
\nof medical science to this day. This text, dat-
\ning back to the 4th century BC,states: \u201cI\u00a0will
\nneither give a deadly drug to anybody if
\nasked for it, nor will I make a suggestion to
\nthis effect\u201d[5]. This is a brief statement, like
\nthe rest of the statements that are mentioned
\nin the Oath, which instructs doctors not to
\nprovide patients with any means to end their
\nlives. Actually, what the Oath condemns is
\nwhat we know today as \u201cassisted suicide\u201d.
\nHowever, medical tradition has always seen
\nit as a prohibition of any lethal act on the part
\nof the doctor. The anthropologist Margaret
\nMead explains that Greek medicine distin-
\nguished the doctor from the magician, when
\nthe definitive separation between to kill and
\nto cure was achieved [6].
\nAs concerns the current debate on euthana-
\nsia, this ethical rule is extremely important,
\nfor it was written in a social and philosophi-
\ncal context that widely favoured suicide.
\nPlatonists as well as cynics and stoics were
\nin favour of euthanasia in the event of ill-
\nness, and in some cases it was actually seen
\nas an act of courage. Aristotle and Epicu-
\nrus held a less positive outlook on suicide,
\nthough left certain space for its justification
\n[7].This is a significant fact,for even though
\nit was a relatively common and socially jus-
\ntified practice, Medical Ethics considered
\nit important for doctors to avoid in order
\nnot to contradict their profession which is
\nprecisely to cure and not to kill the patient.
\nIt was also important in order to avoid any
\nsuspicion that doctors would anticipate
\ntheir patients\u2019 death.
\nThroughout the centuries, the moral prin-
\nciple \u201cdoctors must not kill\u201dhas been passed
\non from generation to generation as a ba-
\nsic pillar of the doctor\u2019s vocation. For some,
\nthe idea of converting this rule into a mere
\nprima facie principle, or a simple piece of
\nadvice that can be ignored in certain cir-
\ncumstances, constitutes an alteration, not of
\nsome peripheral element of Medicine but
\nof its very essence: \u201cThe very soul of medi-
\ncine is on trial\u201d [8]. Lonnie Bristow, former
\npresident of the AMA, in a statement read
\nbefore the Congressional Committee of
\nthe United States voiced the same opinion:
\n\u201cLaws sanctioning physician assisted sui-
\ncide serve to undermine the foundation of
\nthe physician-patient relationship, which
\nis grounded in the patient\u2019s trust that the
\nphysician is working wholeheartedly for the
\npatient\u2019s health and welfare\u201d [9].
\nDaniel Callahan, in his thought provoking
\nbook The Trouble Dream of Life, holds that
\nthe request for euthanasia is a manifestation
\nof patients\u2019 and society\u2019s lack of trust in the
\nhealthcare system. Euthanasia would repre-
\nsent the illusion of being in control of ill-
\nness at all times and of being able to put an
\nend to life, when considered the best choice,
\nwithout having to succumb to the domi-
\nnance of technology that can keep people
\nalive as long as possible. Fundamentally,
\nthere is a feeling of mistrust towards the
\ndoctor and his medicine. What the author
\nfinds paradoxical is that in order to protect
\nitself from this technological assault, society
\nwould so easily choose this path and happily
\nentrust the doctor with the power of delib-
\nerately ending a life [10]. This view appears
\nas the bottom line in Herbert Hendin\u2019s in-
\nteresting book Seduced by Death, in which
\nthe history of euthanasia in the Netherlands
\nis described directly by the people who have
\nbeen involved in it and which concludes
\nwith the message that it is not worth fol-
\nlowing this path. The author is of the per-
\nsonal view that there is no moral issue in ap-
\nplying euthanasia to specific cases; but the
\nEuropean experience shows the great influ-
\nence the legalisation of this practice has on
\nthe doctor-patient relationship. Ultimately
\nthis means increasing the power of medi-
\ncine to decide end-of-life situations which
\nare extremely complex and which could find
\nin euthanasia a far too easy \u201csolution\u201d [11].
\nAnother important aspect when consider-
\ning euthanasia that goes beyond the doctor-
\npatient relationship is the weighty matter
\nof critically ill patients having to make a
\ndecision, and in a certain sense justify, their
\ndesire to carry on living. Although its pro-
\nponents insist that the choice of euthanasia
\nmust be free from coercion, in practice this
\nhardly ever happens. If the sick person is
\naware that her\/his condition constitutes a
\nburden to their family and the community,
\nit is logical that she\/he would wish to spare
\nthem the burden and decide for euthanasia
\nfor this reason. In 2002, Tonti-Filippini, an
\nAustralian bioethicist (who recently passed
\naway), wrote an open letter in plain and di-
\nrect language to the then Prime Minister
\nof his Country, Mike Rann, concerning a
\nlegislative proposal in favour of euthanasia.
\nHe pointed out that for people like himself,
\nwho found themselves in a situation eligible
\nfor euthanasia, the last thing they needed
\nwas precisely such a possibility. What they
\nneeded was human contact, support and
\ngood medical care, since their critical state
\nof health was already dulling their will to
\nfight\u2026and to live [12]. It seems to me that
\nthis aspect of the matter is rarely taken into
\nserious consideration,whereas it should give
\nhealthcare professionals food for thought.
\nSlippery slope
\nThe debate on euthanasia has increasingly
\ngiven greater weight to moral arguments
\nbased on consequences caused by actions
\nand on healthcare policies. The \u201cslippery
\nslope\u201dargument holds that if a law is passed
\nallowing euthanasia for a number of very
\nconcrete cases and with strict conditions,
\n101
\nBACK TO CONTENTS
\nEuthanasiaVATICAN
\nthis would not prevent abuse. Experience
\nproves, moreover, that in time the restric-
\ntions are weakened and euthanasia ends up
\nbeing applied to patients who in principle
\nshould have been excluded.
\nBefore we move on to study this issue, let us
\nlook at some data. Even though these num-
\nbers do not represent \u201ca fall down the slope\u201d,
\nthey certainly deserve special attention, as
\nthey are illustrative of this situation bear-
\ning in mind that when the law in favour of
\neuthanasia was approved in the Netherlands
\nand Belgium in 2002 the thought was that
\nit would apply to a very limited number of
\ncases. As a matter of fact in the Netherlands
\nit was legalised in 1984 as a result of a deci-
\nsion of the Dutch Suprme Court.In the de-
\nbates previous to the ratification of the law,
\nthey talked of limit cases in which medical
\ncare, it was held, was incapable of provid-
\ning a satisfactory answer. Instead what has
\nbeen witnessed over the years has been an
\nannual increase in the practice of euthanasia
\nas more and more justifications have been
\ngiven for it. It is true that, in the years fol-
\nlowing the approval of the law in favour of
\neuthanasia in the Netherlands, there was a
\nslight decrease in the number of cases com-
\npared to the previous years. In 2001, deaths
\nfrom euthanasia and assisted suicide repre-
\nsented 2.6% of all deaths, whereas in 2005
\nthey represented 1.7% [13]. Nevertheless,
\nafter the numbers settled, there has been a
\nconsiderable increase over the last few years.
\nIn the 2003 report of the Regional euthana-
\nsia review committees which gives data from
\nthe first year of the promulgation of the law,
\n1815 cases of euthanasia and assisted sui-
\ncide were recorded; in 2004, they increased
\nto 1886 and in 2005, they reached 1933
\ncases. In the 2015 report, the total number
\nof deaths by euthanasia and assisted suicides
\nwas 5516 [14]. It is also worth noting as
\nVan Der Heide does in her 2007 article that
\napart from the recorded increase in cases of
\neuthanasia over the years, there has been a
\nparallel increase in cases of continuous deep
\nsedation intended as a means to hasten pa-
\ntients\u2019 death. In 2001, the deaths from con-
\ntinuous deep sedation amounted to 5.6% of
\nall deaths, whereas in 2005 the number had
\nrisen to 7.1%. Increased numbers have also
\nbeen recorded in cases referred to as \u201cvolun-
\ntary stopping of eating and drinking\u201dwhich,
\naccording to the Royal Dutch Medical Associ-
\nation (2011), account for up to 2500 deaths
\na year. Although the Dutch Medical Associa-
\ntion considers this practice distinct from as-
\nsisted suicide, in our opinion there is hardly
\nany difference between the two [15]. These
\nstatistics help give an idea of the situation
\nregarding euthanasia and similar practices
\nat the end-of-life in the country with the
\nmost experience of such issues.
\nGoing back to the \u201cslippery slope\u201d argu-
\nment, special mention should be made of
\nthe works of Professor John Keown, who
\nhas produced one of the most in-depth
\nstudies of the debate over voluntary eutha-
\nnasia from a legal perspective, and who of-
\nfers a good overview of this tool of moral
\nreasoning [16]. He distinguishes two main
\naspects of the argument: an empirical and a
\nlogical one.The first is a simple observation:
\nin those places in which euthanasia was ap-
\nproved for persons with incurable illness as-
\nsociated with intolerable suffering and who
\nwould repeatedly request for an end to their
\nlives, it is has been seen that, over the years,
\neuthanasia has been performed on patients
\nwith curable illnesses, who did not have in-
\ntolerable suffering or who had not requested
\nto die. The logical aspect of the argument,
\nholds that the specific precautions, which
\nare taken with the specific purpose of reduc-
\ning the practice of euthanasia to only limit
\ncases, disappears not only because of the
\npractical question at the moment of imple-
\nmentation, but also because of a theoretical
\nreason. What justifies euthanasia in certain
\nlimit cases, making reference to patient au-
\ntonomy or to the fact that some patients
\nwould be better off dead, can also be used to
\njustify its practice when patients voluntarily
\nask for it even if they do not have intoler-
\nable suffering such as in the case for elderly
\npeople. Similarly, non-voluntary euthanasia
\nwould be also considered justifiable in those
\ncases in which chronically unconscious pa-
\ntients are considered to be better off dead.
\nSome authors claim that \u201cthe Dutch experi-
\nence\u201d demonstrates a sufficiently transpar-
\nent system in which the incidence of eu-
\nthanasia abuses would not occur frequently
\n[17]. However, a considerable number of
\nauthors have found flaws in the system, and
\nthe inability of avoiding a slip down the
\n\u201cslippery slope\u201d. Raphael Cohen-Almagor,
\nanother author who has made an in-depth
\nstudy of euthanasia in the countries that
\nhave legalised it, is of the same opinion. In
\none of his articles, he writes that, although
\nsome deny slipping on the \u201cslippery slope\u201d,
\nthe two major studies carried out in Hol-
\nland in 1990 and 1995 show that frequently,
\nit is the doctors who first propose eutha-
\nnasia or the patient\u2019s family members who
\ninitiate the discussion process; these initia-
\ntives in turn have a marked influence on the
\ndecision-making process.In other cases, pa-
\ntients\u2019requests are not adequately evaluated;
\nand more seriously,and in quite a number of
\ncases, people who did not ask for euthanasia
\nend up dead [18].
\nThe entire system controlling euthanasia in
\nthe Netherlands and Belgium relies on the
\ninformation gleaned from questionnaires
\ncompleted by doctors for each case and sent
\nto the relevant Commission for evaluation.
\nThis control system fails in the assessment
\nof less clear cases or when not all the legal
\nprovisions have been followed. In a study
\npublished in the British Medical Journal in
\n2010, Smets et al. analysed questionnaires
\nsent to doctors in Flanders covering a pe-
\nriod in which there had been 137 certified
\ncases of euthanasia out of a total of 6202
\ndeaths.The conclusion of the study was that
\nonly half of the cases of euthanasia were re-
\nported to the Commission. In some cases,
\nthe error was due to the fact that doctors did
\nnot consider the death as due to euthanasia;
\nin others it was due to the feeling that com-
\npleting the documentation was an admin-
\nistrative burden, or that not all the legal re-
\nquirements had been applied. Some doctors
\n102
\nEuthanasia VATICAN
\neven claimed that euthanasia was a private
\nmatter between the doctor and patient [19].
\nA number of monographs have been writ-
\nten on the subject of the \u201cslippery slope\u201d[20].
\nDue to limited space, we will only mention
\nthree major points: euthanasia for the el-
\nderly people who are not suffering from any
\nincurable illness; euthanasia for newborns
\nor minors and euthanasia for patients with
\ndepression. The first point is a clear example
\nof the \u201cslippery slope\u201dargument in action.At
\nthe beginning, the law required an incurable
\nillness, which would cause intolerable suffer-
\ning. However, according to the 2015 \u201cCode
\nof Practice\u201dof the Regional euthanasia review
\ncommittees in the Netherlands,the practice of
\neuthanasia is granted to those elderly peo-
\nple who think that their lives are no longer
\nworth living and would rather die than con-
\ntinue living. The text goes as far as pointing
\nout that this question was the issue of previ-
\nous debate but which has been resolved as it
\nhas been noted that intolerable suffering is
\nnot only caused by terminal illnesses but also
\nby many geriatric conditions [21]. It is easy
\nto understand how difficult it is for doctors
\nto evaluate such a request.There are very few
\nobjective elements foreseen by law on which
\na request could be based to justify a more or
\nless autonomous decision to end one\u2019s life,
\nindependent of one\u2019s health.
\nEuthanasia is also problematic when con-
\nsidered at the opposite extreme of age.In the
\nfirst years of the debate on euthanasia and
\nduring the drafting of the first legislation,
\nthe practice of euthanasia was intended for
\nadults,who could provide a valid consent.In
\nthe Dutch situation, it only took a few years
\nto extend euthanasia to those over 16 with-
\nout their parents consent, and to those be-
\ntween 12 and 16 with parental consent [22].
\nNeither did it take long to justify euthanasia
\nfor newborns born with serious conditions
\n[23]. Although it may be true that these are
\nvery complex cases, in which the best inter-
\nests of the child are being sought, it is also
\ntrue that in their justification the basic mor-
\nal element of autonomous decision is lost.
\nIn 2014, Belgium abolished the age limit on
\neuthanasia. A similar problem arises when
\neuthanasia is granted to people with psychi-
\natric illnesses, and in particular those who
\nsuffer from depression. In these cases, it is
\nvery hard to ascertain that the request to
\ndie is the result of a well informed decision
\nmade with the minimum amount of interior
\nfreedom required for such a decision.
\nA final thought
\nAlthough many points and much of the de-
\nbate on euthanasia could still be analysed
\nand addressed, based on what has been said
\nso far,it appears quite clear that euthanasia is
\npresented as a \u201chelp\u201dand even as a \u201csolution\u201d
\nfor a few hopeless cases. We can conclude
\nthat, from both a medical and ethical point
\nof view, it represents an inadequate solution
\nto a real problem; a solution that, as we have
\nseen, leads doctors and patients to get used
\nto it and to consider it as one more therapeu-
\ntic option.This in turn explains the growing
\nnumber of euthanasia cases every year.
\nWe believe that Medicine has much more
\nto offer and that, today, its ability to deal
\nwith many symptoms is incomparably bet-
\nter than it was a few years ago. In many
\narticles that describe the experience of eu-
\nthanasia in the Netherlands and Belgium,
\npain, and generally pain caused by cancer, is
\none of the major reasons why people ask for
\neuthanasia [24].In some cases,it is true that
\ntreating this kind of pain might be very dif-
\nficult, but modern palliative care is capable
\nof alleviating the majority of this type of
\npain. The problem is that, often, physicians
\ndo not possess the appropriate competence
\nto do so.The fifth report of the Federal Com-
\nmission for Control and Assessment of Eutha-
\nnasia in Belgium (2010-2011) indicates
\nthat, of all the doctors who had received
\nrequests for euthanasia, only 10% had been
\ntrained in palliative care.This figure appears
\nto us to suggest that the solution to requests
\nfor euthanasia, which in reality are always
\na request for help, lies in this direction. A
\nrequest for help can be answered in many
\ndifferent ways, but not all the answers are
\nequally beneficial. As we said at the begin-
\nning, closing the door on euthanasia should
\nrepresent a starting point for substantially
\nimproving professional training in the ter-
\nminal care of patients.
\nTherefore, we believe that WMA should
\nnot change its policy on euthanasia. A pol-
\nicy based on a Medical Ethic thousands of
\nyears old, which does not involve any exter-
\nnal control of medical care but rather is a
\nconstant stimulus to better the care of pa-
\ntients in the final moments of their lives, al-
\nways guaranteeing their personal autonomy.
\nI am very grateful to Dr. Paul Kioko and
\nProf. John Keown for their invaluable help
\nwith the final draft of this article.
\nReferences
\n1.\t Maxence van der Meersch. Bodies and Souls.
\nNew York: Pellegrini & Cudahy, 1948.
\n2.\t David J. Rothman. Strangers at the Bedside:
\nA History of How Law and Bioethics Trans-
\nformed Medical Decision Making. New Brun-
\nswick: AldineTransaction, 2008.
\n3.\t WMA. Adopted by the 39th WMA in Madrid,
\nSpain,October 1987 and reaffirmed by the 170th
\nCouncil meeting in Divonne-les-Bains, France,
\nMay 2005 and by the 200th WMA Council ses-
\nsion in Oslo, Norway, April 2015: http:\/\/www.
\nwma.net\/es\/30publications\/10policies\/e13\/
\n(consulted on 15.09.2016).
\n4.\t WMA.Adopted by the 53rd WMA General As-
\nsembly in Washington,May 2002 and reaffirmed
\nin view of the revision by the 194th Council
\nmeeting in Bali, Indonesia, April 2013: http:\/\/
\nwww.wma.net\/es\/30publications\/10policies\/
\ne13b\/ (consulted on 15.09.2016).
\n5.\t Hippocrates. The Hippocratic Oath. In Ludwig
\nEdelstein Supplements to the Bulletin of the
\nHistory of Medicine. Baltimore: Johns Hopkins
\nPress, 1943; 3.
\n6.\t Cfr. Nigel M. de S. Cameron. The New Medi-
\ncine: Life and Death after Hippocrates. New ed
\nChicago; London: Bioethics Press, 2001; 162.
\n7.\t William Frankena. The ethics of respect for life.
\nIn O. Temkin, W.K. Frankena, S.H. Kadish
\n(eds.) Respect for life in medicine, philosophy,
\nand the law. Baltimore: The Johns Hopkins Uni-
\nversity Press, 1977; 37-38.
\n103
\nBACK TO CONTENTS
\nUNITED STATES OF AMERICA Euthanasia
\nIntroduction
\nThe WMA has long opposed the decrimi-
\nnalisation of voluntary euthanasia (VE)
\nand\/or physician-assisted suicide (PAS)\u00a0[1].
\nIts opposition to lethal injections and\/or
\nprescriptions for lethal drugs, reinforced by
\nthat of national medical associations, has
\nproved a political bulwark against decrimi-
\nnalisation. Precisely because of this, cam-
\npaigners for VE\/PAS will increasingly be
\npressuring the WMA, and national medical
\nassociations, to drop their opposition, and
\nadopt at least a \u2018neutral\u2019 position.
\nThis paper will outline seven arguments
\nthat will likely be pressed on the WMA;
\nand why they all fail [2]. As the first two
\narguments are typically at the forefront of
\nthe case for decriminalisation, more space
\nwill be devoted to them.
\nSeven Arguments for
\nDecriminalisation
\n1. Respect for
\nAutonomy
\n\u201cThe law should respect a patient\u2019s right to
\ndecide the time and manner of their death, at
\nleast if they are \u2018terminally ill\u2019 and\/or experi-
\nencing \u2018unbearable suffering\u2019.\u201d
\n(a) limits to respect for autonomy
\nThe short answer to this argument is there
\nis no such right. While autonomy is an im-
\nportant capacity, respect for autonomy has its
\n8.\t W. Gaylin et al.\u2018Doctors Must Not Kill\u2019. JAMA
\n259, No.14 (April 8, 1988): 2139\u201340.
\n9.\t Massachusetts Medical Society on the Ballot on
\nPrescribing Medication to End Life (November
\n6, 2012), p. 6.
\n10.\tDaniel Callahan. The Troubled Dream of Life:
\nIn Search of a Peaceful Death. Washington DC:
\nGeorgetown University Press, 2000.
\n11.\tHerbert Hendin. Seduced by Death: Doctors,
\nPatients, and Assisted Suicide. New York: W.W.
\nNorton, 1998.
\n12.\tPublished in the Herald Sun (21.11.20110):
\nhttp:\/\/www.heraldsun.com.au\/blogs\/andrew-
\nbolt\/a-dying-man-explains-why-euthana-
\nsia-is-so-dangerous\/news-story\/ec8b23ae-
\n24376e980085f88ef0837b3e (consulted on
\n15.09.2016)
\n13.\tAgnes van der Heide et al. End-of-Life Prac-
\ntices in the Netherlands under the Euthanasia
\nAct.The New England Journal of Medicine 356,
\nNo. 19 (May 10, 2007): 1957\u201365.
\n14.\tThis data can be consulted on the website del
\nRegionale toetsingscommissies euthanasie:
\nhttps:\/\/www.euthanasiecommissie.nl\/ consulted
\n15.09.2016).
\n15.\tRoyal Dutch Medical Association. The Role of
\nthe Physician in the Voluntary Termination of
\nLife.Amsterdam: KNMG,2011; 34\u201336.https:\/\/
\nwww.knmg.nl\/over-knmg\/contact\/about-knmg.
\nhtm (consulted on 15.09.2016).
\n16.\tJohn Keown.Euthanasia,Ethics and Public Pol-
\nicy: An Argument against Legalisation. Cam-
\nbridge: Cambridge University Press; 2002.
\n17.\tBregje D. Onwuteaka-Philipsen et al.Trends in
\nEnd-of-Life Practices before and after the Enact-
\nment of the Euthanasia Law in the Netherlands
\nfrom 1990 to 2010: A Repeated Cross-Sectional
\nSurvey. Lancet, 380, No.9845 (September 8,
\n2012): 908\u201315; Bernard Lo. Euthanasia in the
\nNetherlands: What Lessons for Elsewhere? Lan-
\ncet 380, No.9845 (September 8, 2012): 869\u201370.
\n18.\tThis study shows 1000 cases of speeding death
\nwithout request in 1990 and 900 cases in 1995:
\nRaphael Cohen-Almagor. Non-Voluntary and
\nInvoluntary Euthanasia in the Netherlands:
\nDutch Perspectives. Issues in Law & Medicine
\n18, No. 3 (2003): 239\u201357.
\n19.\tTinne Smets et al. Reporting of Euthanasia in
\nMedical Practice in Flanders, Belgium.
\n20.\tDavid Lamb. Down the Slippery Slope: Argu-
\ning in Applied Ethics. New York: Croom Helm,
\n1988; I\u00f1igo Ortega Larrea. Eutanasia: \u00e9tica y ley
\nfrente a frente.Rome: Pontifical University of the
\nHoly Cross, 1996; Roberto Aguado Aguar\u00f3n. El
\ncuidado del enfermo en la fase terminal: un es-
\ntudio moral a partir de la pr\u00e1ctica de la eutanasia
\nen Oreg\u00f3n \u2013 USA. Rome: Pontifical University
\nof the Holy Cross, 2003; Javier Vega Guti\u00e9rrez,
\nLa pendiente resbaladiza en la eutanasia: una
\nvaloraci\u00f3n moral. Rome: Pontifical University of
\nthe Holy Cross, 2006.
\n21.\tRegional euthanasia review committees.Code of
\nPractice. The Hague, April 2015: https:\/\/www.
\neuthanasiecommissie.nl\/actueel\/nieuws\/2016\/
\nmei\/27\/code-of-pratice-translated-in-english
\n(consulted on 15.09.2016).
\n22.\tMore information on the practice in the Nether-
\nlands can be found on https:\/\/www.government.
\nnl\/topics\/euthanasia (consulted on 15.09.2016).
\n23.\tEduard Verhagen and Pieter J.J. Sauer.The Gro-
\nningen Protocol \u2014 Euthanasia in Severely Ill
\nNewborns. New England Journal of Medicine,
\n352, No.10 (March 10, 2005): 959\u201362.
\n24.\tSee for example the Code of Practice (2015),p.13.
\nPablo Requena
\nAssociate Professor of Moral
\nTheology and Bioethics
\nPontifical University of the
\nHoly Cross in Rome
\nVatican Medical Association
\nE-mail: requena@pusc.it
\nJohn Keown
\nVoluntary Euthanasia and Physician-
\nassisted Suicide: Should the WMA
\nDrop its Opposition?
\n104
\nEuthanasia UNITED STATES OF AMERICA
\nlimits and the law places all sorts of reason-
\nable restrictions on our autonomy.Patients no
\nmore have the right to a lethal injection from
\ntheir physician than they have to the amputa-
\ntion of a healthy limb.Patients have a right to
\nrefuse treatment, but that is a negative right,
\nnot a positive right; a shield, not a sword.
\nOne key limit on respect for autonomy is the
\nprinciple of the inviolability of life (or the
\n\u2018sanctity of life\u2019) [3]. Laws in most countries
\nof the world continue to prohibit a choice
\nto be killed.This prohibition is grounded in
\na recognition of our fundamental equality-
\nin-dignity, however sick or disabled we may
\nbe. As the preamble to the UN Declaration
\nof Human Rights puts it: \u201cRecognition of
\nthe inherent dignity and of the equal and
\ninalienable rights of all members of the hu-
\nman family is the foundation of freedom,
\njustice and peace in the world\u201d [4]. We all
\nenjoy the \u2018right to life\u2019, the inalienable right
\nnot to be intentionally killed. In its 1994 re-
\nport unanimously rejecting the case for VE\/
\nPAS,the UK\u2019s House of Lords Select Com-
\nmittee on Medical Ethics defended the pro-
\nhibition on intentional killing, observing:
\nThat prohibition is the cornerstone of law
\nand of social relationships. It protects each
\none of us impartially, embodying the belief
\nthat all are equal [5].
\nAnd, in any event, how many requests for
\nVE\/PAS would be truly autonomous, espe-
\ncially when suicidal ideation is often asso-
\nciated with clinical depression? The Select
\nCommittee concluded: [W]e do not think
\nit possible to set secure limits on voluntary
\neuthanasia\u2026It would be next to impossible
\nto ensure that all acts of euthanasia were
\ntruly voluntary, and that any liberalisation
\nof the law was not abused [6].
\n(b) protecting the vulnerable
\nConcern for the vulnerable is another pow-
\nerful reason for limiting individual auton-
\nomy. The Select Committee stated: We are
\nalso concerned that vulnerable people\u00a0\u2013 the
\nelderly, lonely, sick or distressed\u00a0\u2013 would feel
\npressure, whether real or imagined, to re-
\nquest early death\u2026 The message which so-
\nciety sends to vulnerable and disadvantaged
\npeople should not, however obliquely, en-
\ncourage them to seek death, but should as-
\nsure them of our care and support in life\u00a0[7].
\nSimilarly, philosopher Onora O\u2019Neill has
\nargued: Legalising \u2018assisted dying\u2019 amounts
\nto adopting a principle of indifference to-
\nwards a special and acute form of vulner-
\nability: in order to allow a few independent
\nfolk to get others to kill them on demand,
\nwe are to be indifferent to the fact that many
\nless independent people would come under
\npressure to request the same [8].
\nIt is no surprise, then, that disability groups
\n(like \u2018Not Dead Yet\u2019) [9] are at the forefront
\nof opposition to decriminalisation.They see
\nmore clearly than many that, despite the
\nemphasis placed by euthanasia campaigners
\non choice, the case for VE\/PAS rests funda-
\nmentally on the judgement that certain pa-
\ntients have lives that are not \u2018worth living\u2019,
\nthat they would be \u2018better off dead\u2019.
\n(c) judging patients \u2018better off dead\u2019
\nTypical legal proposals for decriminalisation
\nwould not allow patients obtain VE\/PAS on
\nrequest: patients would also have to satisfy
\nsome other criterion, such as \u2018unbearable
\nsuffering\u2019. In other words, doctors would
\nhave to judge which autonomous requests to
\ngrant, and which to refuse. And how would
\nthe doctor decide, other than on the basis of
\na judgment that the patient would,or would
\nnot,be \u2018better off dead\u2019? (\u201cI\u00a0think patient A\u2019s
\nsuffering is so severe that death would ben-
\nefit her, but that patient B\u2019s suffering is in-
\nsufficient to render his life no longer worth
\nliving.\u201d) Moreover,once a doctor is prepared
\nto make that judgment,that certain patients
\nwould be \u2018better off dead\u2019, why shouldn\u2019t the
\ndoctor make the same judgment in relation
\nto incompetent patients and end their suf-
\nfering, by performing \u2018non-voluntary\u2019 eu-
\nthanasia (NVE)? If death can be a benefit
\nfor a patient with \u2018unbearable suffering\u2019who
\nrequests it, why can\u2019t it equally benefit a pa-
\ntient with \u2018unbearable suffering\u2019 incapable
\nof requesting it? The absence of a request in
\nthe latter case is no reason for denying the
\n\u2018benefit\u2019. In short, anyone who supports VE
\nis, logically, committed to supporting NVE.
\n2. Compassion
\n\u201cPhysicians have a duty of compassion, a duty
\nto relieve their patients\u2019 suffering, even if that
\nmeans administering a lethal injection.\u201d
\n(a) limits to compassion
\nThere is a duty to relieve suffering but, like
\nthe duty to respect autonomy,it is not unlim-
\nited. It is trumped by the duty not intention-
\nally to kill patients. This duty not to kill has
\nformed the bedrock of professional medical
\nethics since the Hippocratic Oath\u00a0[10]. The
\ncore vocation of the physician is to heal, to
\nmake whole, not to make dead [11].
\nThis vocation includes a duty to alleviate
\nsuffering even if, as an unintended side-ef-
\nfect, life is shortened. But it rules out inten-
\ntional killing.Once physicians embrace kill-
\ning as a \u2018therapeutic\u2019intervention,this surely
\nendangers the trust that patients now have,
\nthat their physician will never judge them to
\nbe \u2018better off dead\u2019. As Alexander Capron,
\nthe leading US health lawyer, once starkly
\nput it, he never wanted to have to wonder
\nwhether the physician entering his room
\nwas wearing the white coat of the healer or
\nthe black hood of the executioner [12].
\n(b) palliative care
\nNot only is killing unethical; it is unneces-
\nsary. The enormous progress that has been
\nmade in palliative care, not least since the
\nestablishment of the hospice movement by
\nDame Cicely Saunders 50 years ago, means
\nthat no patient need suffer unbearably.Even
\nin rare cases of refractory pain, there is the
\noption of palliative sedation. In 2014, a poll
\nof the Royal College of Physicians showed
\nthat over 60% of its members agreed that
\npatients could die with dignity under the
\nexisting law, and that relaxation of the law
\nis not needed [13].
\n105
\nBACK TO CONTENTS
\nEuthanasiaUNITED STATES OF AMERICA
\n(c) \u2018unbearable suffering\u2019?
\nAlthough euthanasia advocates typically use
\nemotionally-charged cases of dying patients
\nwith painful symptoms to front their cam-
\npaign, the reality is that after decriminalisa-
\ntion VE and PAS come to be condoned a
\nmuch wider range of cases.
\nThe Dutch Supreme Court decriminalised
\nVE\/PAS in 1984 (the guidelines gaining
\nstatutory force in 2002) [14]. In 1994 the
\nCourt held that purely mental suffering
\ncould qualify [15]. The Dutch government
\nproposes to permit assisted suicide for el-
\nderly people with a \u2018completed life\u2019; and
\neven under the present law elderly people
\nwho are \u2018tired of life\u2019 may obtain VE\/PAS,
\nprovided they can also point to some medi-
\ncal condition in support of their request
\n(and what elderly person does not have
\nsome medical condition?) [16] In Belgium,
\nthe \u2018bracket creep\u2019has been even faster, from
\nVE to PAS (the euthanasia review commis-
\nsion endorses PAS even though the statute
\nmentions only VE); from adults to compe-
\ntent minors; and from physical to mental
\nsuffering [17]. Cases such as the purblind
\ntwins [18], the distressed transsexual [19],
\nand the grieving mother [20], have all illus-
\ntrated the disturbing elasticity of the legal
\ncriteria.
\nMoreover, the official reports from the US
\nState of Oregon, where PAS has been prac-
\ntised for almost 20 years, show that the two
\nmain reasons for requesting PAS have not
\nbeen suffering but \u2018losing autonomy\u2019 and
\na decreasing ability \u2018to engage in activities
\nmaking life enjoyable\u2019 [21].
\n(d) compassion for the incompetent
\nIf compassion justifies killing suffering pa-
\ntients who request it, why does it not justify
\nkilling suffering patients who cannot re-
\nquest it? Why should compassion be con-
\nfined to the competent? Yet again, we see
\nthe logical link between VE and NVE. The
\nDutch courts endorsed VE\/PAS in 1984.
\nTwelve years later, logically, they endorsed
\nNVE, in the form of infanticide\u00a0[22].
\n3. Legal Hypocrisy
\n\u201cThe law allows doctors to end lives by withhold-
\ning\/withdrawing life-prolonging treatment or
\nby administering drugs which, as a side-effect,
\nshorten life, so it is hypocritical of the law to pro-
\nhibit them from performing VE\/PAS.\u201d
\nLeaving aside the fact that, properly ti-
\ntrated, palliative drugs do not in fact hasten
\ndeath\u00a0[23], the short answer to this argument
\nis that there is a cardinal ethical and legal dis-
\ntinction between intending and merely fore-
\nseeing the shortening of life.The US Supreme
\nCourt rejected the argument that respecting a
\npatient\u2019s refusal of life-prolonging treatment is
\nthe same as PAS,noting that in PAS the phy-
\nsician intends to assist the patient\u2019s death, but
\nthisisnotnecessarilysowithrespectingarefus-
\nal of treatment [24]. Chief Justice Rehnquist
\nnoted that the fact that General Eisenhower
\nforesaw on D-Day that he was sending many
\nAmerican soldiers to certain death did not
\nmean he intended their death: his purpose
\nwas to liberate Europe from the Nazis [25].
\nEven the Dutch and the Belgians euthana-
\nsia laws, which reject the Hippocractic ethic
\nagainst medical killing, agree that eutha-
\nnasia involves intentional, and not merely
\nforeseen, life-shortening [26].
\nThis distinction drawn by the law and by
\nprofessional medical ethics is not, then,
\nhypo\u00adcritical: it is Hippocratic.
\n4. A Right to Suicide
\n\u201cIn many countries suicide has been decrimi-
\nnalised.This means that the law now recognises
\na right to commit suicide. If there is a right to
\ncommit suicide, it should be legal to assist some-
\none to exercise that right.\u201d
\nThe argument is misconceived. It does not
\nfollow that decriminalisation represents a
\ncondonation of suicide, let alone recogni-
\ntion of a \u2018right to suicide\u2019. In the UK, for ex-
\nample, legislators made it crystal clear that
\ndecriminalisation did not imply condona-
\ntion [27]. The explanation for decriminali-
\nsation lay elsewhere.
\nLegislators increasingly appreciated, thanks
\nto the development of the specialty of psy-
\nchiatry, that suicidal ideation is associated
\nwith psychiatric disturbance, and that the
\nsuicidal would be better diverted from sui-
\ncide by the mental health system than by
\nthe criminal justice system. Moreover, the
\ncrime stigmatised family members and led
\nto the unfortunate consequence of pros-
\necuting attempted suicides [28].
\nMoreover, assisting or encouraging suicide
\nremained a serious crime, which confirms
\nthat there is no \u2018right to suicide\u2019 and that
\nsuicide remains contrary to public policy.
\n5. Public Opinion Polls
\n\u201cOpinion polls show that a clear majority of the
\npublic want the law to allow VE\/PAS.The law
\nshould reflect the will of the people.\u201d
\nIt does seem that polls tend to show a clear
\nmajority in favour of decriminalisation. But,
\nfirst, polls can be misleading. Much can de-
\npend on the phrasing of questions and on the
\namount of background information, if any,
\ngiven to those polled. One expert commit-
\ntee concluded that the polls tended to reflect
\n\u2018kneejerk\u2019reactions to VE\/PAS,not informed
\nopinion [29]. Second, it may well be that the
\nmajority of the public support the restoration
\nof capital and corporal punishment. Is that a
\nsound argument for their restoration?
\n6. Legal Failure
\n\u201cThe law is ineffective. VE\/PAS are practised
\nillegally. Decriminalisation would bring them
\nout into the open and subject them to effective
\nlegal control.\u201d
\nAll criminal laws are broken to some extent,
\nsometimes (like speeding laws) to a con-
\n106
\nEuthanasia UNITED STATES OF AMERICA
\nsiderable extent, but that is hardly by itself
\na reason to repeal them. And there is little
\nevidence that laws against VE\/PAS are any
\nless effective than many other criminal laws.
\nFor example, research by Professor Clive
\nSeale found that the incidence of VE\/PAS
\nin the UK was \u2018extremely low\u2019 (and signifi-
\ncantly lower than in the Netherlands, which
\npermits them) [30]. There will be breaches
\nof the law, to a greater or lesser extent, in
\ndifferent jurisdictions,depending on a range
\nof cultural factors.This is not by itself an ar-
\ngument for repeal (especially when repeal is
\nvery likely to provoke a substantial increase
\nin the incidence of VE\/PAS).
\nMoreover, the claim that decriminalisa-
\ntion brings VE\/PAS \u2018out into the open\u2019
\nand subjects them to \u2018effective legal con-
\ntrol\u2019 is belied by the experience of the two
\nmain jurisdictions to have decriminalised
\nVE\/PAS: the Netherlands and Belgium.
\nThe Dutch in particular have carried out
\nvaluable surveys into end-of-life decision-
\nmaking. Those surveys have shown that
\ndoctors have failed to report thousands of
\ncases to the Dutch monitoring authorities.
\nIn 1990 only 20% were reported, and al-
\nthough more recently the proportion has
\ngrown to 80% [31], this means that around
\n1 in 5 cases of VE\/PAS is still being il-
\nlegally certified by Dutch physicians as
\ndeath by \u2018natural causes\u2019. Belgian surveys
\nhave disclosed that only 50% of cases are
\nreported to the authorities [32].
\nIt is not surprising that the Dutch law has
\nnow been criticised, twice, by the UN Hu-
\nman Rights Committee. In 2001 the Com-
\nmittee expressed concern not only about
\nthe adequacy of the regulatory system, but
\nabout the extension of the law to minors,
\nand the practice of infanticide [33]. In 2009
\nit remained concerned about the extent of
\nVE\/PAS and the fact that a physician could
\nterminate a patient\u2019s life without any in-
\ndependent review by a judge or magistrate
\nto guarantee that the decision was not the
\nsubject of undue influence or misapprehen-
\nsion [34].
\nAs for Oregon, there have been no compre-
\nhensive surveys, so any claims that its law
\nis achieving effective control lack substan-
\ntiation. Its so-called \u2018safeguards\u2019, which are
\neven laxer than those in the Low Countries,
\nhave been aptly described by Professor Cap-
\nron as \u201clargely illusory\u201d [35].
\nThe regulatory mechanism in all three ju-
\nrisdictions depends on self-reporting by
\nphysicians. It is, therefore, intrinsically inef-
\nfective. How many physicians are going to
\nreport that they have broken the law?
\nIn 2015 the Supreme Court of Canada
\ncontroversially created a legal right to VE\/
\nPAS\u00a0[36]. In arriving at this decision, which
\nwas out of line with decisions of the Su-
\npreme Courts of the US and the UK, the
\ncourt agreed with the trial judge\u2019s factual
\nfinding that the risks of decriminalisation
\n\u2018can very largely be avoided through carefully
\ndesigned, well-monitored safeguards\u2019\u00a0 [37].
\nHowever, three judges of the Irish High
\nCourt,who later carefully reviewed the same
\nevidence as the trial judge, rejected her find-
\ning [38]. And rightly so. Given that no ju-
\nrisdiction has \u2018carefully designed, well moni-
\ntored safeguards\u2019, and given the disturbing
\nexperience of the Low Countries, one can
\nonly guess what led the Canadian judges to
\ntheir strange conclusion\u00a0[39].
\n7. Religion
\n\u201cOpposition to decriminalisation is essentially
\nreligious, and religious views should not be im-
\nposed in secular societies.\u201d
\nThis last argument is as lame as it is fre-
\nquent. The key arguments against legalisa-
\ntion, not least that it would undermine \u2018the
\ncornerstone of law and of social relation-
\nships\u2019 by endorsing intentional killing, and
\nthat it would threaten vulnerable patients,
\nare philosophical, not theological [40].
\nMoreover, many secular bodies have op-
\nposed decriminalisation. One example is
\nthe UK Parliament, which has repeatedly
\nrejected the case for decriminalisation, most
\nrecently in 2015, when the House of Com-
\nmons voted by a margin of 3-1 against a Bill
\nto decriminalise PAS [41]. Another exam-
\nple is the World Medical Association itself.
\nConclusion
\nCampaigners for VE\/PAS will, on the basis
\nof some or all of the above seven arguments,
\nincreasingly urge that the WMA should
\ndrop its opposition to VE\/PAS. Those ar-
\nguments are, however, unpersuasive. The
\nWMA\u2019s opposition is as well-grounded as it
\nis well-established.
\nMoreover, if the WMA were to shift to a
\n\u2018neutral\u2019position, the move would be widely
\nperceived as at least a tacit endorsement of
\nVE\/PAS. It would be used by campaign-
\ners as a powerful lever to prise open the
\ndoor to decriminalisation worldwide, de-
\ncriminalisation which would not only sub-
\nvert the traditional healing vocation of the
\nmedical profession, but would lead to VE\/
\nPAS becoming increasingly perceived as a
\npart of normal medical practice, and even a
\npatient\u2019s right, as appears to be happening
\nin the Low Countries. And with VE\/PAS
\ntransformed from a crime to a \u2018treatment\u2019,
\ndoctors would be expected to deliver it, or
\nat least to refer patients to colleagues pre-
\npared to do so. The recent call by two lead-
\ning advocates of decriminalisation that doc-
\ntors in Canada be legally required to refer
\npatients, and for students with objections to
\nreferral to be denied admission to medical
\nschool\u00a0[42], is but a foretaste of what medi-
\ncal professionals worldwide can expect if
\nthe law in their countries is relaxed.
\nReferences
\n1.\t World Medical Association. WMA Resolu-
\ntion on Euthanasia [Internet] [cited 2016
\nOct 3] Available from: https:\/\/www.wma.net\/
\nen\/30publications\/10policies\/e13b\/
\n2.\t For a fuller treatment of these arguments see
\nKeown, John. Against Legalising Euthanasia;
\nFor Improving Care. In Jackson, Emily and
\n107
\nBACK TO CONTENTS
\nEuthanasiaUNITED STATES OF AMERICA
\nKeown, John. Debating Euthanasia. Oxford:
\nHart Publishing, 2011, hereafter \u2018DE\u2019, 83-174.
\nSee also Keown, John. Debating Euthanasia: A
\nReply to Emily Jackson. In: Heneghan, Mark
\nand Wall, Jesse. Law, Ethics and Medicine: Es-
\nsays in Honour of Peter Skegg (2016) 65-95.See
\nalso Keown,John.Euthanasia,Ethics and Public
\nPolicy. Cambridge: Cambridge University Press,
\n2002; (2nd ed forthcoming 2017).
\n3.\t See generally Keown, John. The Law and Eth-
\nics of Medicine: Essays on the Inviolability of
\nHuman Life. Oxford: Oxford University Press,
\n2012; chapter 1.
\n4.\t United Nations. The Universal Declaration of
\nHuman Rights (1948) [Internet] [cited 2016
\nOct 3] Available from: www.un.org\/en\/univer-
\nsal-declaration-human-rights\/
\n5.\t Report of the Select Committee on Medical
\nEthics. London: HMSO. Paper 21-I of 1993-
\n94; para. 237.
\n6.\t Ibid. para. 238.
\n7.\t Ibid. para. 239.
\n8.\t \u2018A Note on Autonomy and Assisted Dying\u2019. Un-
\npublished memorandum (quoted in DE at 93)
\ncirculated to members of the House of Lords
\nduring its consideration of Lord Joffe\u2019s Assisted
\nDying for the Terminally Ill Bill, which fell in
\n2006.
\n9.\t [Internet] [cited 2016 Oct 3] Available from:<\/p>\n

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