newwmj_2_2020_WEB

COVID-19
vol. 66
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 2, April 2020
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
COVID-19: the Asian Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Corona Virus Outbreak on South African Medical Schemes . . . . . . . . . . . . . . . . . . . . . . . 13
Reform Proceeding of Organ Donation and Transplantation System in China. . . . . . . . . . . . 15
The Impact of Climate Change on Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Physical Activities of Doctors in Rivers State, Southern Nigeria. . . . . . . . . . . . . . . . . . . . . . . . 21
Palliative Care: What, Who, When, How? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues . . . . . . . . . . . 28
Appeal for Policy Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
This Month Consider Indoor Air Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Singapore Medical Association – sixty years on. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Miguel Roberto JORGE
WMA President,
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
Dr. David Barbe
WMA President-Elect,
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300
60611-5885 Chicago, Illinois
United States
Dr. Mari MICHINAGA
WMA Vice-Chairperson of Council
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
PO Box 8829 Wuse
Abuja
Nigeria
Dr. Leonid EIDELMAN
WMA Immediate Past-President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Andreas RUDKJØBING
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
Kristianiagade 12
2100 Copenhagen 0
Denmark
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
Editorial
Editorial
Every day this year is to be marked as the World Doctors’ Day. Ev-
ery day tests the knowledge,endurance,ability and health of doctors
all over the world.
Covid-19 is a podium talk for politicians and journalists, but the
front line for doctors. Politicians squander public money like their
own, journalists invent catchy headlines and clusters of exclamation
marks, but doctors risk their lives and those of their loved ones.
Several studies show that doctors are not particularly worried about
the possibility if they themselves get sick; sacrifice is a keystone of
doctors’ professional ethics. Doctors fear for the lives of their be-
loved, especially for their parents.
Doctors all over the world are aging together with the public. On
average, doctors become specialists later than other professionals do
because they need a high level of training. Moreover, doctors get
sick with all acute and chronic diseases just like all population.Soci-
ety believes that doctors,as its most educated and wealthy members,
keep in good health longer, they are more accurate in targeting their
own treatment, and are more committed to physical and mental ac-
tivities.
There are some truths, which National Medical Associations should
repeat to their colleagues. If possible, doctors over the age of 65
should not accept patients directly.They should fully switch to con-
sulting patients on the phone or on the Internet. Likewise, direct
contacts with patients should be avoided by colleagues who are old-
er than 50 years, have diabetes and heart problems. Unfortunately,
patients with chronic diseases suffer worse from Covid-19 and the
cases are more severe.
We entreat every doctor on this planet to take care of their own
health at this time.If Covid-19 beats doctors,then it will beat every-
one else.Therefore,these are doctors who should be especially careful
with distancing and disinfecting their hands, changing the cloth-
ing, washing and sterilizing it. These are doctors who need to find
time for a long walk,running or cycling and breathing exercises every
day. These are doctors who need to take care of their own chronic
diseases, and they should tolerate neither unstable blood sugar nor
high blood pressure. There is no more important task for National
Medical Associations than to care for the protection and safety of
doctors through their governments.Governments must provide doc-
tors with better pay, longer breaks between patient reception, longer
rest time, shorter (6 minutes) communication with patients, and en-
sure that a sick doctor is treated with the best available medicine.
The World Medical Association keeps track of events, collects in-
formation and provides advice every day. The World Medical As-
sociation currently cares about every doctor on this globe. Let every
doctor in our world has enough strength and endurance! Let our
WMA leaders have enough strength and endurance!
I thank Dr. KK Aggarwal, President of CMAOO, who shares the
latest world findings on Covid-19 with me every day.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
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2
COVID-19
We are grappling with a pandemic of mam-
moth proportions. Coronavirus Disease
(COVID-19) is spreading with a rapidity
and ferocity that has caught the world un-
aware and therefore unprepared and, more
often than not, underprepared. Almost ev-
ery country has now reported COVID-19
cases. The numbers are spiraling, especially
in the European continent. Expectedly, an
atmosphere of alarm and panic now prevails
worldwide.
Increased globalization has made the world
more connected today; this has accelerated
the spread of the disease.. Predominantly,
it were the travel-related cases, which have
driven the pandemic in most countries [1].
More than 7 lakh (700,000) persons the
world over are infected with the virus and
the global death toll will cross 45,000 with
the current trends (current deaths + current
serious patients x 15%).
The World Health Organization (WHO)
has now cautioned that the coronavirus
disease pandemic is “accelerating”. It took
over three months to reach the first 100,000
confirmed cases, 12 days to reach the next
200,000, four days to reach 300,000, 3 days
to reach 400,000, 2.5 days to reach 500,000,
two days to reach 600,000 and two days to
reach 700,000.
Perhaps Bill Gates was prescient when he
said, “The worst pandemic in modern history
was the Spanish flu of 1918, which killed tens
of millions of people. Today, with how inter-
connected the world is, it would spread faster.”
(2014)
The onset of the current pandemic can be
traced back to Wuhan,China,where a group
of patients with viral pneumonia was report-
ed on 31 December 2019 [2].These patients
were categorized as “pneumonia of un-
known etiology”as no cause could be identi-
fied [3]. Subsequent investigations revealed
the etiopathogen to be an unknown beta-
coronavirus and a new coronavirus, named
2019-nCoV, was isolated as the cause of the
viral pneumonia [2]. On February 11, the
disease was officially named as Coronavirus
Disease-2019 (COVID-19) by the WHO.
The new corona virus was found to have
86% genetic similarity with Severe Acute
Respiratory Syndrome corona virus (SARS-
CoV). Hence, it was called severe acute re-
spiratory syndrome coronavirus 2 (SARS-
CoV-2) [4]. But unlike SARS, COVID-19
has a higher transmissibility. The average
reproduction number (R0
) of COVID-19 is
3·28 and median R0
is 2·79, which is higher
than that of SARS [4].
The spread of the disease on the Diamond
Princess Cruise ship in Japan corroborates
the high transmissibility of the COVID-19
virus. On February 9, there were 20 cases
on board; but, by the end of the quarantine
period,this number had increased to around
700 cases (23%), despite preventive mea-
sures in place (CDC).
Transmission of the virus
The disease was initially presumed to be
only due to wild animal-to-human trans-
mission since the outbreak was linked to
the Huanan Seafood Wholesale Market of
Wuhan. Subsequently, human-to-human
transmission was confirmed [3].
COVID-19 is mainly transmitted among
humans through infected large (>5 microns
size) droplets from coughing and/or sneez-
ing (also speaking loudly, singing, talking
face to face, shouting) and close contact
with an infected person (symptomatic or
asymptomatic) [3].
In a retrospective multicenter study of lab-
oratory-confirmed COVID-19 cases from
China, the median duration of viral shed-
ding was 20 days in patients who survived,
but shedding of the virus continued until
death in fatal cases. Viral shedding was ob-
served for as long as 37 days [5].
It has been suggested that mild cases and
even asymptomatic persons can transmit
the infection as well [6].
The virus can also be transmitted indirectly
via surface fomite [7]. A new study pub-
lished online 17 March 2020 in the New
England Journal of Medicine has shown
that the virus can survive on surfaces even
for several days [8]. The virus remained
viable on plastic and stainless steel for up
to 72 hours, on copper for 4 hours and on
cardboard for up to 24 hours. On plastic
surfaces, the virus exhibited a median half
life of 6.8 hours, while on stainless steel,
it was 5.6 hours. This study also suggested
that aerosols generated in the health care
settings (high pressure oxygen, nebulizer,
intubation, forced coughing procedures)
may also be a possible route of transmission
of the new corona virus.The virus remained
March 31
COVID-19: the Asian Perspective
Krishan Kumar Aggarwal
BACK TO CONTENTS
3
COVID-19
viable in aerosols for the entire 3 hour dura-
tion of the experiment.
The CDC recommends that before disin-
fection,dirty surfaces should first be cleaned
with soap and water.
Diluted household bleach solutions, 70%
alcohol-based solutions and products con-
taining hydrogen peroxide, peroxyacetic
acid, sodium hypochlorite, quaternary am-
monium can be used for disinfection [9].
The incubation period for COVID-19
ranges from 1–14 days, usually around
5 days (WHO). So, persons potentially ex-
posed to the virus on a particular day will
surface as cases on the 5th
day. This forms
the basis of testing close contacts between
5–14 days.
The spectrum of the disease ranges from
mild infection to critical disease. A sum-
mary of a Report of 72,314 cases from the
Chinese Center for Disease Control and
Prevention shows that majority (81%) of
cases were mild (nonpneumonia and mild
pneumonia), while the disease was severe
in 14% of patients (presenting as dyspnea,
respiratory rate ≥30/min, blood oxygen
saturation ≤93%, partial pressure of arterial
oxygen to fraction of inspired oxygen ratio
50% within
24–48 hours). Five percent of patients had
critical disease (respiratory failure, septic
shock and/or multiple organ failure) [10].
The overall case-fatality rate (CFR) was re-
ported to be 2.3%; CFR was higher in the
elderly. However, the WHO has estimated
the global death rate for the novel corona
virus to be 3.4%. The CFR will also change
in countries with high aging population, for
instance, Italy.
Clinical manifestations
Covid-19 most commonly manifests clini-
cally as fever (43.8% on admission and
88.7% during hospitalization), cough
(67.8%) and diarrhea (3.8%). The most
common finding on Chest CT was ground-
glass opacity (56.4%); 18% patients with
nonsevere disease and 3% patients with se-
vere disease had no abnormal findings on
CT. Around 84% patients had lymphocyto-
penia on admission [11].
Severity of illness
COVID-19 can be categorized into three
stages based on the severity of the illness:
early infection, pulmonary phase and hy-
perinflammatory phase.
Early infection is the first stage of the ill-
ness.The patient has only mild constitution-
al symptoms such as fever (>99.6º F), dry
cough, headache and diarrhea. At this stage,
laboratory tests show lymphopenia and in-
creased levels of PT, d-dimer and LDH.
Undetected or untreated, the patient moves
into the next stage of the illness, the pul-
monary phase. The patient develops short-
ness of breath and hypoxia (PaO2/FiO2
<300 mm Hg).Lab tests reveal transamnitis
and low to normal procalcitonin. Chest im-
aging will show an abnormal CT.
The hyperinflammation phase or the third
stage is the critical stage characterized
by acute respiratory distress syndrome
(ARDS), systemic inflammatory response
syndrome (SIRS) and/shock and cardiac
failure. The inflammatory markers (CRP,
IL-6, D-dimer, ferritin), troponin, NT-
proBNP levels are raised and are indicative
of poor prognosis.
Since COVID-19 is a new disease, there is
no specific antiviral drug for its treatment.
Potential therapies are being explored.
In the event of any infection, the host reacts
by initiating an immune response to fight
off the infection in the early phase (“viral
response phase”). In the later stages of the
illness (“host inflammation response phase”),
the host may have an exaggerated or out
of control immune response to the trigger,
which is the COVID-19 virus infection.
This is called “cytokine storm”.At this stage,
the virus is lethal and is responsible for the
Figure 1.
Stages of Covid-19 illness
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4
COVID-19
critical condition of the patient and is of-
ten fatal. Tests for inflammatory markers
(CRP, IL-6, D-dimer, ferritin), troponin,
NT-proBNP levels can detect the presence
of cytokine storm.
Diagnosis
In its interim guidance for surveillance,
the WHO has defined criteria for suspect
case, probable case and confirmed case as
follows [12]:
Suspect case
• A patient with acute respiratory illness
(fever and at least one sign/symptom of
respiratory disease, e.g., cough, shortness
of breath), AND a history of travel to or
residence in a location reporting commu-
nity transmission of the COVID-19 dis-
ease during the 14 days prior to symptom
onset; or
• A patient with any acute respiratory ill-
ness AND having been in contact with
a confirmed or probable COVID-19 case
(see the definition of contact) in the last
14 days prior to symptom onset; or
• A patient with severe acute respiratory
illness (fever and at least one sign/symp-
tom of respiratory disease, e.g., cough,
shortness of breath, AND requiring hos-
pitalization) AND the absence of an al-
ternative diagnosis that fully explains the
clinical presentation.
Probable case
• A suspect case with inconclusive testing
for COVID-19, or
• A suspect case for whom testing could
not be performed for any reason.
Confirmed case: A person with laboratory
confirmation of the COVID-19 infection,
regardless of clinical signs and symptoms.
All suspect cases (as per the above criteria)
should be tested for the COVID-19 virus,
including other respiratory pathogens such
as influenza, respiratory syncytial virus, etc.
Samples include nasopharyngeal and oro-
pharyngeal swab, or sputum and/or endo-
tracheal aspirate or bronchoalveolar lavage
in patients with more severe respiratory
disease. Samples should be collected with
stringent infection control precautions [13].
The diagnosis of COVID-19 is confirmed
by the detection of virus RNA by reverse-
transcription polymerase chain reaction
(RT-PCR) [13]. However, a negative result
does not exclude the likelihood of the per-
son having the disease. Patients with nega-
tive RT-PCR but high clinical suspicion
should undergo CT scan along with re-
testing for the virus [14]. A report of more
than 1000 cases from China concluded that
chest CT scan has a higher sensitivity for
diagnosis of COVID-19 as compared with
RT-PCR [15].
Treatment
Since COVID-19 is a new disease, there is
no specific antiviral drug for its treatment.
Potential therapies are being explored.
The WHO is conducting a multi-country
clinical trial called the “Solidarity Trial” to
investigate four drugs (or their combina-
tions) for the treatment of Covid-19: rem-
desivir; chloroquine, hydroxychloroquine;
combination of lopinavir and ritonavir;
lopinavir+ritonavir combination plus inter-
feron-beta.
Remdesivir is an investigational broad-spec-
trum antiviral agent. It has shown encour-
aging results in vitro for treating MERS.
Prophylactic and therapeutic remdesivir
improved lung function and also decreased
lung viral loads and severe lung pathology in
vitro [16]. The compassionate use of remde-
sivir has also been reported in the first CO-
VID-19 patient diagnosed in the United
States with no adverse effects [17].
Clinical trials in the United States and Chi-
na are underway to investigate the efficacy
of remdesivir as treatment for patients with
moderate or severe COVID-19.
Lopinavir/ritonavir has been used for the
treatment of COVID-19 [18, 19].
In a trial of adults hospitalized with severe
Covid-19,time to clinical improvement was
comparable between patients treated with
lopinavir–ritonavir (400 mg/100 mg twice
daily for 14 days plus standard care) as com-
pared with those who were given standard
care alone (median, 16 days). Mortality at
28 days was 19.2% in lopinavir-ritonavir
group, whereas it was 25% for the standard
care group; however, this difference was not
statistically significant [20].
In India, Central Drugs Standard Control
Organization (CDSCO),the national regu-
latory body for Indian pharmaceuticals and
medical devices, has approved the “restrict-
ed use” of lopinavir-ritonavir combination
for treating those affected by novel corona-
virus (nCoV).
In Thailand, oseltamivir along with lopina-
vir and ritonavir has been used successfully.
Arbidol, an antiviral drug used in Russia
and China to treat influenza, could be com-
bined with darunavir, the anti-HIV drug,
for treating COVID-19 patients.
The WHO does NOT recommend routine
administration of systemic corticosteroids
for the treatment of viral pneumonia outside
of clinical trials,unless there is an indication
to do so (exacerbation of asthma or COPD,
septic shock). Patients given steroids should
be monitored for hyperglycemia, hyperna-
tremia, hypokalemia, signs of adrenal insuf-
ficiency or recurrence of inflammation [21].
Hydroxychloroquine and chloroquine have
also been evaluated for the treatment of
COVID-19 [22, 23].
Both hydroxychloroquine and chloroquine
are immunomodulatory. Of these two,
BACK TO CONTENTS
5
COVID-19
hydroxychloroquine has been found to
have more potent in vitro antiviral activ-
ity against SARS-CoV-2 suggesting that
it may be an ideal therapeutic option for
critically ill patients through its antiviral
action as well as by controlling the cyto-
kine storm via its immunomodulatory
properties [22].
Results of the ongoing open‐label non‐ran-
domized clinical trial “the Marseille study”
show a strong reduction in nasopharyngeal
carriage of Covid-19 virus in only 3 to 6 days
in most patients. Addition of azithromycin
to hydroxychloroquine further augmented
elimination of the virus. After 6 days, 100%
of patients treated with the combination of
hydroxychloroquine and azithromycin were
virologicaly cured as against 57.1% patients
treated with hydroxychloroquine alone and
12.5% in the control group [24].
The National Task Force for COVID-19
set up by the Indian Council of Medical
Research (ICMR), the apex health re-
search body of India, has recommended
hydroxychloroquine for prophylaxis of
SARS-CoV-2 infection for high risk pop-
ulation:
• Asymptomatic Healthcare Workers in-
volved in the care of suspected or con-
firmed cases of COVID-19: 400 mg
twice a day on Day 1, followed by 400 mg
once weekly for next 7 weeks; to be taken
with meals;
• Asymptomatic household contacts of
laboratory confirmed cases: 400 mg twice
a day on Day 1, followed by 400 mg once
weekly for next 3 weeks; to be taken with
meals.
Prognosis
Older age, high Sequential Organ Failure
Assessment (SOFA) score (a diagnostic
marker for sepsis and septic shock) and
d‑dimer levels greater than 1 µg/L on ad-
mission are indicative of poor prognosis and
higher risk of death [5].
Patients with severe COVID-19 illness also
had increased levels of blood interleukin
(IL)-6, high-sensitivity cardiac troponin
I  and lactate dehydrogenase (LDH) and
lymphopenia.
Evolution of the COVID-19
pandemic: chronology
of key events
The COVID-19 pandemic, as it stands to-
day, has moved through various stages since
it first emerged from Wuhan, China, as a
local outbreak. The disease spread to the
entire country within a month, despite ex-
treme measures adopted by China includ-
ing a lockdown of whole cities [25].
On March 19, China reported zero local
transmission rate for the first time since the
pandemic began; the 34 new cases reported
were imported cases. However, on March
22, after three days, China reported its first
case of domestic infection.
The number of confirmed cases worldwide
has exceeded 300, 000. The virus has now
spread to around 200 countries. More than
80% of all cases are from the WHO West-
ern Pacific Region and European Region.
Here is the chronology of key events as they
have occurred.
Dec. 31, 2019: Cluster of cases of pneu-
monia of unknown etiology reported from
Wuhan, China
Jan. 1, 2020: Huanan Seafood Wholesale
Market in Wuhan, suspected to be the
source of the disease, closed
Jan. 7: China isolated a new type of corona
virus as the cause, named 2019-nCoV
Jan. 11: First death due to the new Corona
virus reported in China
Jan. 12: Genetic sequence of the new Co-
rona virus shared by China
Jan. 13: Thailand reported the first case
(lab-confirmed) outside China
Jan. 15: Japan reported its first imported
case of lab-confirmed virus
Jan. 20: First case reported in South Korea
Jan. 21: Human-to-human transmission of
the virus confirmed
Jan.24: France reported the first case
Jan. 25: Australia and Malaysia reported
their first cases
Jan. 30: The WHO declared coronavirus a
“public health emergency of international
concern (PHEIC); India, Finland, Philip-
pines reported their first cases of the new
corona virus
Jan. 31: First two confirmed cases of 2019-
nCoV reported in Italy
Feb. 5: Ten passengers on board the Dia-
mond Princess Cruise ship docked in Yoko-
hama, Japan, test positive
Feb. 11: The WHO officially named the
disease as “COVID-19”
Feb. 13: For the first time, China reported
clinically diagnosed cases in addition to the
laboratory-confirmed cases
Feb. 14: Africa’s first COVID-19 case re-
ported in Egypt
Feb. 19: First COVID-19 cases reported in
Iran
Feb. 26: For the first time, more new cases
were reported from outside China than
from China
Feb. 28: The WHO raised the level of glob-
al risk to “very high”
March 7: The global number of reported
cases crossed 100,000
March 11: The WHO declared the corona
virus outbreak a pandemic
March 13: The WHO declared Europe
to be the new epicenter of the pandemic,
with more reported cases and deaths than
the rest of the world combined, apart from
China
March 15: 2,000 new coronavirus cases and
more than 100 deaths over the last 24 hours
in Spain
March 16: The total number of cases and
deaths outside China exceeded those in
China
March 18: China reported no local trans-
mission for the first time since the pandem-
ic began, only imported cases; the WHO
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6
COVID-19
launched multi-country SOLIDARITY
Trial to compare untested treatments
March 19: The number of confirmed cases
worldwide exceeded 200,000; Italy (3405
deaths) overtook China (3249 deaths) for
the number of deaths related to corona vi-
rus,making it the world’s deadliest centre of
the outbreak
March 22:India attempted the largest study
on the role of over 5% population (critical
mass) on social behaviours by observing
self-restriction based ‘shelter in home’, a
14‑hour restriction at home with mass clap-
ping for 5 minutes at 5pm as an alternative
to forced lockdown.
COVID-19: Measures
adopted by CMAAO
countries
CMAAO is a Confederation of Medical
Associations in Asia and Oceania. It has
national medical associations (NMAs) of
19 countries as its members. Since it was
first established in 1956, the objective of
CMAAO activities as stated in its consti-
tution has been to promote academic ex-
change and cultivate ties of friendship be-
tween member medical associations.
Many Asian countries have been able to
contain the disease to some extent, unlike
Europe and the USA, where cases are spi-
ralling and a slowdown seems inconceivable.
Strategies like mass testing, timely alerts
and advisories, effective screening and sur-
veillance have been crucial in the efforts to
contain the spread of the virus. However,
this is not the time to be complacent; it is
the time to exercise patience, be cautious
and not let up the constant vigil.
We first issued a CMAAO Alert on CO-
VID-19 on January 8, even as it was still
a mysterious lung infection in China. Since
then CMAAO has been creating awareness
about the disease every day.
India Model
1117 active cases and 32 deaths at the time
of writing this article
India is currently in the early third stage of
the epidemic, most confirmed cases have a
history of travel to corona-affected coun-
tries and their close contacts. There is no
evidence of widespread community trans-
mission yet in India. A sentinel surveillance
initiated by ICMR found no positive sam-
ples in H1N1 negative viral pneumonias.
The survey tested 826 samples of people
suffering from severe acute respiratory in-
fection (SARI)/influenza like illnesses at
51 sites by 15 March 2020 [26].
India issued a travel advisory as early as Jan-
uary 17 and has been regularly updating the
travel advisories keeping with the evolving
situation. Screening of air travellers has been
ongoing since January 18. All existing visas
(except for diplomatic, official, UN/Interna-
tional Organizations, employment, project
visas) have been suspended until 15 April
2020. All international commercial passen-
ger flights have been banned from 22 March
2020 till April 14.All domestic travel too has
been put on hold until March 31.
Countrywide regular surveillance was
initiated for all travel-related and their
close contacts, including those having fe-
ver, cough or breathlessness. India has been
carrying out “need-based testing”, i.e., test-
ing suspected cases with history of travel
to areas with active transmission and their
close contacts. However, the government
has revised its testing policy: “All hospital-
ized patients with severe acute respiratory
illness (fever and cough and/or shortness of
breath) will now be tested for COVID-19
infection. And, all asymptomatic direct
and high-risk contacts of a confirmed case
should be tested once between day 5 and
day 14 of coming in contact”.
The Ministry of Health & Family Welfare
of India has a discharge policy for con-
firmed cases; patients are discharged only
after evidence of chest radiographic clear-
ance and viral clearance in the respiratory
samples (after two specimens test negative
for the virus within 24 hours).
ICMR’s National Institute of Virology has
isolated the COVID-19 virus strain mak-
ing India the 5th
country to do so.The other
four countries are China, Japan, Thailand
and the United States of America.
The Ministry of Health & Family Welfare
has invoked the Epidemic Disease Act, 1897
(Section 2) so that all advisories issued are
enforceable; the Disaster Management Act
to ensure price regulation and availability
of masks, hand sanitizers and gloves, and
the Essential Commodities Act to regulate
production, quality, distribution, etc. of face
masks and hand sanitizers and to ensure
their availability at reasonable prices or un-
der MRP.
Other public health measures include creat-
ing mass awareness about preventive mea-
sures (social distancing, hand washing,),
closing of all educational institutions, mu-
seums, swimming pools, malls and theatres
(except for grocery, vegetables and chemist
shops); work from home (except those work-
ing in emergency/essential services); all citi-
zens above 65 and children below 10 years
have been advised to remain at home.
South Korea Model
9786 cases with 162 deaths
With 4212 confirmed cases, up to March 2,
South Korea was next only to China, which
had 80,026 confirmed cases at that time
[27].
Still, South Korea has slowed down its rate
of infection; from a peak of 851 new cases
per day on March 3, the number of new
cases has declined to 64 cases per day, as on
March 23 [28].
BACK TO CONTENTS
7
COVID-19
The reason for this success has been its test-
ing policy of “Trace, Test and Treat”. In-
stead of putting entire cities under a lock-
down or implementing punitive measures,
South Korea put in place an extensive mass
testing program to quickly identify hotspots
to further prevent transmission and initi-
ate early intervention (contact tracing and
quarantine) and treatment [29].
South Korea has randomly tested more
than 270,000 people (amounting to more
than 5200 tests per million population);
this number is higher than in any other
country [29]. Under this program, around
12,000–15,000 people are tested daily and
the system is capable of carrying out 20,000
tests a day [30]. Drive-through testing
centres and mobile alerts about those who
tested positive for the virus have further ex-
panded the testing capacity.
Besides travel restrictions, other preventive
measures such as social distancing, use of
masks, hand washing, allowing people to
work remotely, avoiding mass gatherings
(attending online religious services instead)
have helped the country to reduce the num-
ber of infected cases [29].
Japan Model
1953 cases and 56 deaths
Japan initially focused on containment of
the epidemic,but after the COVID-19 out-
break on the Diamond Princess Cruise ship,
the focus shifted to a prevention and treat-
ment policy in anticipation of community
spread within the country.
The new coronavirus was designated as an
“infectious disease” under the Infectious
Diseases Control Law, which allowed the
government to order infected patients to
undergo hospitalization. COVID-19 was
also classified as a “quarantinable infectious
disease” under the Quarantine Act, which
allows the government to quarantine people
suspected of infection and order them to
undergo diagnosis and treatment. A “Clus-
ter Response Section” was formed to quick-
ly identify and contain small-scale clusters
of COVID-19 infections before they turn
into large-scale ones [31].
Japan initially made an error of cohort quar-
antine for 3700 people on the Diamond
ship mixing people of all ages together
for 14 days and ending up with 712 posi-
tive cases and 8 deaths. Cohort quarantine
should have been high risk vs low risk co-
hort quarantine [31].
Singapore Model
926 cases with only 3 deaths
Singapore acted early on in the pandemic
and constituted a Multi-Ministry Task
Force before a case was detected to provide
central coordination during the crisis [32].
Besides temperature screening of all trav-
ellers from Wuhan, all physicians had also
been warned by the Health Ministry to
identify any patient with pneumonia and a
recent travel history to Wuhan, almost right
from the time when the outbreak was first
reported from Wuhan [33].As a result,Sin-
gapore was able to expedite case detection.
Doctors were also allowed to test patients if
they suspected them to be infected, based
on clinical judgment or epidemiological
reasons [32].
More than 800 Public Health Preparedness
Clinics (PHPCs) were activated to treat re-
spiratory infections at the primary care level
[32].
Singapore has a testing capacity of 2200
tests daily for a population of 5.7 million
[32]. Tests are free for all, including visitors
to the country.
Other public health measures, which in-
cluded enhanced surveillance to identify
cases that did not fit the prescribed case
definition [32], aggressive contact tracing
and quarantine of close contacts of con-
firmed cases, travel advisories and entry
restrictions, as well as public education
helped to contain the epidemic in the
country [33]. All events and gatherings
with 250 or more participants had been
suspended.
Singapore also defined punitive actions
(fine of up to $10,000 or up to six months
in prison) against those who violate their
quarantine or give a false account of their
travel history.
Singapore had zero healthcare infection
rate due to its policy of liberal distribu-
tion of masks at every hospital reception,
N95 masks by health care providers and AI
rooms for all positive cases.
Taiwan Model
322 cases with 5 deaths
Taiwan created a data source (also accessible
to health professionals) by integrating the
national health insurance database with im-
migration and customs database to identify
persons at high risk based on their travel
history and clinical symptoms. Patients
with severe respiratory symptoms who had
tested negative for influenza were retested
for COVID-19 [34].
QR code scanning and online reporting of
travel history and health symptoms were
used to stratify risk categories of travellers:
the low risk group was given a health dec-
laration border pass through SMS on their
phones; persons in the higher risk group
were put into home quarantine and moni-
tored through cell phones to ensure compli-
ance with the quarantine [34].
The government has also imposed fines for
hoarding, spread of misinformation and
breach of quarantine.
BACK TO CONTENTS
8
COVID-19
Malaysia Model
2766 cases with 43 deaths
I was in Malaysia on January 18 when we
had the first interaction with MMA re-
garding Corona Virus. Same day, I  had a
meeting with the Myanmar Medical Asso-
ciation, Thailand Medical Association and
China Medical Association regarding the
same.
Malaysia is now experiencing widespread
ongoing transmission of the COVID-19
virus.
Malaysia has been under a nation-wide
lock-down (except for essential services)
since March 18 with the growing num-
ber of corona cases. All persons arriving in
Malaysia mandatorily undergo check for
symptoms of corona. All air travellers are
issued Health Alert Cards indicating their
health status, which must be kept for the
next 14 days.
The Ministry of Health has identified 48
hospitals for coronavirus screening includ-
ing 26 referral hospitals to manage coro-
navirus suspected and positive cases. Con-
tacts of positive cases are being tracked
by the Malaysian Epidemiology Bureau.
Asymptomatic cases are put under home
quarantine, while symptomatic persons are
hospitalized for testing and monitoring as
persons under investigations [35].
Thailand Model
1651 cases with 10 deaths
The situation has begun to change since
mid-March, when health officials reported
a few large clusters of infections in Bang-
kok.
Thailand recorded a spike in the number of
cases for the first time on March 15, with
32 new cases of laboratory-confirmed CO-
VID-19 and increasing the total number of
cases to 114 from 82 [36]. More and more
clusters are testing positive for the virus, in-
dicating a super spreader.
Thailand has a dedicated national pandemic
influenza preparedness plan, which is in the
process of updating. All educational insti-
tutions, entertainment outlets have been
closed.
Air travellers have been segregated into
three risk groups, based on the origin of
their flight: Disease Infected Zones (man-
datory 14-day self-quarantine, health forms
at check-in certifying that they are not at
risk of COVID-19), countries with ongo-
ing local transmission (home-based 14-day
quarantine, report symptoms to officials)
and other destinations (precautions such as
wearing masks, avoiding mass gatherings
and crowds).
Flattening the curve:
Decontaminate, wash hands
and maintain social
distancing
Countries are engaged in efforts to control
the ongoing pandemic, but there seems to
be no foreseeable end to this.The inevitable
question is whether we will be able to stop
or delay the peak and rapid spread of the
disease.
Addressing the media on March 11, WHO
Director-General Dr Tedros Adhanom
Ghebreyesus said, “This is the first pandemic
caused by a coronavirus. And we have never
before seen a pandemic that can be controlled,
at the same time… We cannot say this loudly
enough, or clearly enough, or often enough: all
countries can still change the course of this pan-
demic.”
Identification and isolation of cases along
with rapid tracing and quarantine of con-
tacts may break the identified chains of
transmission, reduce the number of cases
and contain the epidemic.
Social distancing with no emotional dis-
tancing, i.e., maintaining a distance of at
least 1 m (3 feet) from other people or self-
quarantine or self-isolation; working from
home; virtual meetings; closure of schools;
limiting the size or canceling public gath-
erings; regular handwashing with soap and
water; respiratory hygiene, cough etiquette
or building hygiene are potential mitigation
strategies, which can be implemented when
a chain of transmission is not known.
Instead of moving from containment to
mitigation, adopting a combination of con-
tainment and mitigation measures may slow
the disease spread.
Flattening the epidemic curve, instead of
allowing a steep curve (illustrating an ex-
ponential increase in the number of cases),
slows the transmission of the COVID-19
virus so there are fewer cases and also fewer
deaths; enough resources are available and
patients are able to access the critical care
they need. While a flatter curve may pro-
long the epidemic, it relieves the overbur-
dened healthcare system, where demand
surpasses capacity, for instance, not enough
hospital beds, ventilators, etc. Italy is expe-
riencing this at present.
To control the COVID-19 pandemic, the
aim should be to flatten the curve and delay
the peak.
Results of a latest mathematical model
study conducted by ICMR show that
adopting social distancing as a preventive
measure will flatten the curve. If strictly fol-
lowed, this will reduce the expected number
of cases by 62% and the peak number of
cases by 89% [37].
To achieve this:
• Clean and decontaminate surfaces, wash
hands and stay away from people with fe-
ver and cough.
BACK TO CONTENTS
9
COVID-19
• Using 1 : 1 isolation method kit will help
stop the formation of clusters.
• Avoid handshakes and elbow greet; the
traditional Indian greeting Namaste and
bowing is the best greeting in these times.
• Maintain social distancing of one feet
with others
Conclusion
COVID-19 is hitherto an unknown disease
caused by an unknown virus. Information
about this disease is still evolving. There are
still several questions unanswered. What
will be the fate of the virus? Will CO-
VID-19 become an endemic disease? And
many more.
Preparedness and capacity building are
keys to averting such pandemics in times
to come. A robust surveillance system is the
basis of preparedness for any epidemic. It is
also important to strengthen public health
care systems for optimum utilization of re-
sources and facilitate research and develop-
ment. Communication is crucial for sharing
information. There are lessons to be learnt
from the ways different countries have
managed the situation.
When I took over as President of CMAAO
on 5 September 2019, at the CMAAO
General Assembly in Goa, India, in my
address I said, “As an organization, we too
share several public health challenges such as
vector-borne diseases such as dengue, malaria;
air pollution; communicable and non-com-
municable diseases (NCDs); antimicrobial
resistance (AMR); tobacco use; HIV/AIDS,
to name a few. Violence against doctors and
inequity in health are few other issues that are
a concern. Attaining universal health cover-
age, which is affordable, accessible, available,
appropriate and accountable, still remains a
distant goal for many of us. All these have a
bearing on the socioeconomic progress of our
countries. Therefore, it becomes our collective
responsibility to make certain that these is-
sues are prioritized. Some of these issues are
global concerns and we should try to solve
them as a family and set an example for
the world. In the event of any outbreak or
public health crisis, we can share our health
models besides knowledge and experiences of
a similar situation.”
For the first time (March 19),since the pan-
demic first began, China reported zero local
transmission rate suggesting that it may be
possible to control the disease, although it
had a new case of local transmission 3 days
later.
To achieve this, there needs to be a strategic
shift in our approach to tackle the pandem-
ic; instead of moving from containment to
mitigation in a stepwise manner, it may be
prudent to combine containment and miti-
gation measures.
Could COVID-19 be the Disease X men-
tioned by the WHO in 2018 in its list of
eight priority diseases? We do not know yet.
Still, now we cannot afford to be compla-
cent as the window of opportunity may be
too small in any such future events.
Appendix
Three Cs of managing a new disease
First Case – index or the primary (Stage 1)
First Cluster of “person to person” transmission (Stage 2)
First evidence of Community spread (surface to person transmis-
sion)
COVID-19: A snapshot
Causes mild illness in 82%, severe illness in 15%, critical illness in 3%
Death rate: males 2.8% females 1.7%
Death: 3.4% (March 3)
Deaths: 15% serious cases
Deaths: 71% with comorbidity
71% deaths are in patients with comorbidity due to cytokine
storm. [72,314 Chinese cases, largest patient–based study, JAMA)
Coronary artery disease patients most at risk [CAD 10.5%, Diabe-
tes 7.3%, COPD 6.3%, Hypertension 6%, Cancer 5.6%, no pre–ex-
isting disease (0.9%)
Health care provider infection: China 3.8%; 0.3% deaths. Singa-
pore: nil
Deaths: 10% in Iran (under reporting)
South Korea: (0.6%) doing more tests in mild cases
Affects all sexes but predominately males: 56%
Age: 87% (30–79), 10% (80)
Mean time to symptoms: 5 days
Mean time to pneumonia: 9 days
Mean time to death: 14 days
Mean time to CT changes: 4 days
Reproductive number R0
3–4 (flu 1.2, SARS 2)
Epidemic doubling time: 7.5 days
Doubling time in Korea: 1 day probably due to the super spreader
Tripling time in Korea: 3 days
Positivity rate (%): UK 0.2, Italy 5, France 2.2, Austria 0.6,
USA 3.1
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10
COVID-19
Origin: Probably from bats (mammal; central hosts), snakes and
pangolins (intermediate hosts); possible animal sources of COV-
ID-19 not yet been confirmed
Spread: large droplets; predominately from people having LRTI
Precautions: standard droplet for the public and close contacts; air
borne for healthcare workers dealing with secretions
Incubation period: 2–14 days
Mean Incubation period: 5.2 days
Recovery time 2 weeks (mild cases); 4–6 weeks (severe cases)
Case fatality: 80 + 14.8%
Case fatality: 70–79 = 8%
Case fatality 60–69: = 3.6%
Case Fatality 50–59: = 1.3%
Case fatality 40–49: 0.4%
Case fatality 10–39: 0.2%
Case fatality 600 to 164 (in 2008), the hospitals
were scrutinized and regulated strictly ev-
ery year from then on. In the same year,
a registration system for liver and kidney
transplant recipients was established, the
medical quality of the transplant hospitals
was monitored. To standardize the clinical
transplant practice, the Chinese Medical
Association developed serial clinical norms
and guidelines about transplantation, A to-
tal of 23 guidelines, covered aspects like
complications diagnosis, prevention and
treatment, had been published and com-
piled in The clinical guideline for organ trans-
plantation (2010 version). At same times,
the clinical practice regulations of kidney,
liver, heart and lung were also developed
and formed a book on organ transplant clini-
cal technique norms (2010 version) [6, 7].
The application of this clinical norms and
guidelines did improve the standardization
and medical quality of the organ transplan-
tation practice in China.
With the strengthening of the legal frame-
work surrounding organ transplantation,
deceased organ donation was explored in
a three-year pilot program since 2010 [8],
and then was officially promoted nation-
wide on February 25, 2013.The organ Pro-
curement Organizations (OPOs) and or-
gan donation offices were then established
in various transplant medical institutions.
According to China’s socioeconomic de-
velopment level and cultural background,
the Red Cross Society of China (RCSC)
was introduced to participate in propa-
ganda, coordinate, and witness in organ
donation as a third party [9]. The China
Organ Donation Administrative Center
(CODAC) was set up to take charge in
the work related to human organ donation
and promote the concept of organ dona-
tion. An efficient and professional team
of organ donation coordinator is need to
promote the deceased organ donation, and
it was organized and trained by CODAC
since 2011.So far, 34 training courses have
been held, and 2,516 professional coor-
dinators have been trained and certified.
The coordinators are affirmed by inspec-
tion, qualification, and certification every
year to ensure strict implementation of the
certification systems. This has gradually
established an efficient and professional
countrywide coordinator team, which has
become the main force on the organ dona-
Reform Proceeding of Organ Donation and
Transplantation System in China
Bingyi Shi
BACK TO CONTENTS
16
Organ Donation
tion front. Organ donation involves social,
religious, ethical, political, legal, etc. To
better promote the deceased organ dona-
tion, a unique deceased donor classification
system with three categories has been in-
novatively proposed  [9]. Meanwhile, the
criteria and clinical norms for brain death
determination have been developed and
updated, and the latest version (including
adult and child version, respectively) was
revised in 2013 [10, 11], and the national
“Brain Injury Evaluation Quality Control
Center”set in Xuanwu hospital is approved
for training and certifying physicians and
surgeons qualified to declare brain death.
A total of 3,643 professionals qualified in
brain death determination were trained
from 2013 to 2019, who covered all regions
in the mainland China.They are certified to
create suitable conditions for organ dona-
tion based on brain death. In recent years,
China has also explored and introduced
regulations and mechanisms beneficial for
organ donation and transplantation. For
example, the former National Health and
Family Planning Commission, Ministry
of Public Security, Ministry of Transport,
China Civil Aviation Administration, Chi-
na Railway Corporation and RCSC jointly
established a green channel mechanism
for organ transportation to ensure smooth
transfer of donated organs in 2016 [12].
A scientific allocation system through which
the organs donated could be allocated fairly
and transparently is key characteristics to
the scientific and ethical transplant system.
The China Organ Transplant Response
System (COTRS) was developed and put
into operation in 2011, by which advanced
international experience was referred to for
determining the allocation priority. The
Management Regulations for Acquisition and
Distribution of Human Donor Organs (Trial)
was issued in August 2013 as based on the
experience with operation of COTRS [13].
It is mandatory that all donor organs must
be allocated through the COTRS thereby
ensuring that the processes are just, open,
and traceable.
As coordinators are growing and matur-
ing with the construction and improve-
ment of the organ donation system, the
number of voluntary deceased organ dona-
tion has been increasing year by year, and
gradually occupying an important part of
­
transplant ­
organs [14]. Based on these facts,
The National Human Organ Donation and
Transplantation Commission (NHODT)
announced that executed prisoner organ
donation should be terminated from Janu-
ary  1, 2015. From then on, citizen organ
donation has become the only legitimate
source of transplantable organ in Chi-
na [15].
After 10 years of arduous reform, a fair,
transparent, and open climate of volun-
tary citizen organ donation movement has
gradually formed across the society. Organ
donation reached 6,302 cases in China
mainland in 2018. The number of organ
donors ranked second worldwide, and the
per-million-population (pmp) donation
rate rose to 4.53 (from 0.03 at the begin-
ning of the pilot in 2010), thereby laying a
solid foundation for high-speed develop-
ment of organ donation and transplantation
(Figure 1) [16]. More patients benefit from
transplant surgery with the promotion of
deceased organ donation. The quantity of
solid organ transplantation was rapidly es-
calating, a total of 20,201 organ transplants
were performed in 2018 (Figure 2). With
the rapid increasing of the quantity of the
solid organ transplantation recently, China
now turns to pursue quality management
and improvement in the transplantation
field [16]. At present, the development tar-
gets of organ transplantation is undergo-
ing a transition from fast growth of quan-
tity and scale to promoting improvement of
quality. China has set up organ transplant
quality control centers based on the original
transplant recipient clinical data registra-
tion systems in 2016, who are responsible
for the national medical quality monitor-
ing, supervision and inspection of specific
Figure 1.
Counts of Deceased Donor, Living Donor and PMP, 2015–2018. PMP was
calculated with the deceased donor.The Figure and data were obtained from
the Report on Organ Transplantation Development in China (2015–1018), and
authorized by the China Organ Transplantation Development Foundation
BACK TO CONTENTS
17
Organ Donation
transplant programs. The exploration of
the quality improvement program began in
2017 by the Kidney Transplantation Qual-
ity Control Center of National Health
commission [17], and it was introduced to
other transplantation program in the 2019
Annual Congress of Chinese Society of
Organ Transplantation [18]. The Chinese
organ transplantation quality improvement
program would establish statistic models
based on clinical outcomes data of the Chi-
nese recipients to set up scientific medical
quality evaluation methods, and through
refining of clinical practices guideline and
norms to promotion standardized diagnosis
and treatment procedures, thereby to pro-
motion the quality improvement in organ
transplantation. The establishment of stan-
dardized diagnosis and treatment system
was led by the Chinese Medical Associa-
tion, which organize the experts from Chi-
nese Society of Organ Transplantation to
update and revise the clinical guideline and
clinical norms for transplantation. Clini-
cal Guideline For Organ Transplantation in
China (2017 version) has been published in
2018, it has referred the latest clinical evi-
dence and incorporated with the local ex-
perience about the Chinese patient clinical
characteristics, a total of 27 guidelines had
been revised or establish [19].The updating
and revising of the clinical norms has been
ongoing since 2018, 57 clinical practice
norms have been completed and published
[20–22]. The publication of guidelines and
norms effectively improves the standard-
ization of organ transplant diagnosis and
treatment, and does promote the quality
improvement of clinical care.
The organ donation and transplantation
system in China was constructed with
long-term support and assistance of the
international transplant community. Since
2006, many international transplantation
experts have visited China to provide as-
sistance and guidance [8]. A jointly China-
European Union (EU) education program
named “knowledge Transfer and Leader-
ship in Organ Donation, from Europe to
China (KeTLOD)” has been carried out
Figure 2.
Counts of Transplantation Surgeries in China, 2015–2018. A: kidney Transplantation performed in china, and the annual
growth rate calculated with the deceased donor Transplantation. B: Liver Transplantation performed in china, and the annual
growth rate calculated with the deceased donor Transplantation. C: Heart Transplantation performed in china, and the annual
growth rate. D: Lung Transplantation performed in china, and the annual growth rate. All the data were obtained from the
Report on Organ Transplantation Development in China (2015–1018), and authorized by the China Organ Transplantation
Development Foundation
BACK TO CONTENTS
18
Organ Donation
since 2016. These efforts greatly increased
awareness of organ donation among Chi-
nese society [23, 24]. Since 2015, the China
has invited international experts to person-
ally witness the whole organ donation pro-
cesses to confirm the facts.The organ dona-
tion work is transparent and open in China,
and leaves a deep impression on the visiting
experts.It has also prompted experts skepti-
cal of the organ transplantation process to
acknowledge the construction and reform
of the organ transplantation system [2, 25].
The United Nations and the Vatican Pon-
tifical Academy of Sciences jointly held a
conference on “Ethics in Action” in March
2018  [26, 27]. For the first time, Huang
Jiefu introduced the experience with organ
transplantation reform and its practice to
the world. It was referred to as the “China
model” and well received by the participat-
ing experts [28]. it was concluded that the
organ donation and transplantation reform
experience in China may be adopted as a
reference for countries with similar social
and cultural backgrounds and socioeco-
nomic development status [26, 29].
The fourth China – International Confer-
ence on Organ Donation – ‘The Belt and
Road’ Organ Donation International Co-
operation Development Forum was held in
Kunming,Yunnan, from December 6, 2019,
to December 8, 2019 [30]. Representatives
from WHO, the International Associa-
tion of Organ Transplantation (TTS), and
transplant associations from 62 countries
across all continents attended the forum.
Experts at the conference praised China’s
achievements in organ donation and trans-
plantation reform, and they affirmed the
important role of the “Chinese Experience”
in the construction of the transplant system.
The forum follows the principles of “exten-
sive consultation, joint contribution, and
shared benefits.” The Kunming Consensus
on International Cooperation Development
of ‘The Belt and Road’ Organ Donation and
Transplantation was issued. China conveyed
to the world the belief of establishing an
ethical organ transplant system consistent
with the criteria of WHO. It also provided
the world transplant community with the
“Chinese experience.” China will actively
promote international exchanges and coop-
eration in the cause of organ donation and
transplantation in the field of humanities
and health organ among countries along
“The Belt and Road,” thereby jointly ad-
dressing problems and challenges in human
development [30].
We will make unremitting efforts to build
a perfect organ donation and transplanta-
tion system that is consistent with the ethics
and criteria of the WHO, thereby actively
promoting international cooperation of
“The Belt and Road” organ donation and
transplantation, presenting the image of a
responsible political power to the interna-
tional community,and making our due con-
tribution to the construction of the “human
destiny community”.
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sion). Chin J Neurosurg 2013; 46 (9): 637-640.
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of National Health and Family Planning Com-
mission. Criteria and practical guidance for de-
termination of brain death in children (BQCC
version). Chin J Pediatr 2014; 52 (10): 756-759.
12. National Health and Family Planning Commis-
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China Railway Corporation, China Red Cross
Federation. Notice on Establishing a Green
Channel for Human Organ Donation2016.
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AE%98%E8%BD%AC%E8%BF%90%E7%B
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00090&manuscriptId=206fb7d1c0014c48bd6a
76b8f155c935.
13. National Health and Family Planning Commis-
sion of the People’s Republic of China.Notice of
the Interim Provisions on Human Organ Pro-
curement and Allocation2013. Last accessed on
2020 February 20th.Available from:http://www.
nhc.gov.cn/yzygj/s3585u/201308/8f4ca932129
84722b51c4684569e9917.shtml.
14. Zhang Q. They gave their word, and more.
Global Times.2016. Last accessed on 2020 Feb-
ruary 20th. Available from:http://www.global-
times.cn/content/1001281.shtml.
15. Guo Y. The “Chinese Mode” of organ donation
and transplantation: moving towards the center
stage of the world. Hepatobiliary Surg Nutr
2018; 7 (1): 61-62.
BACK TO CONTENTS
19
Climate Change
16. China Organ Transplantation Development
Foundation. Report on Organ Transplantation
Development in China(2015-1018). Beijing:
2019 November 2019. Report No.
17. Shi B,Liu Z.Kidney transplantation: from qual-
ity control to quality improvement plan.Chinese
Journal of Transplantation (Electronic Edition)
2018; 12 (03): 7-11.
18. Shi B, Liu Z. To Construct of quality improve-
ment proram system and to promote the transi-
tion development of organ transplantation. Or-
gan Transplantation 2020; 10 (1): 1-7.
19. Chinese Society of Organ Transplanta-
tion of Chinese Medical Association. Clini-
cal Guideline For Organ Transplantation In
China. Beijing: People’s Medical Publishing
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20. Chinese Society of Organ Transplantation of
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operation specification of small bowel transplan-
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22. Chinese Society of Organ Transplantation
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82571c7c7.html.
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recognition. Global Times.2018. Last accessed
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and transplantation: moving towards the center
stage of the world. 2018;
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gan donation and transplantation2018. Last ac-
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nation and transplant applauded amid ru-
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China-s-effort-in-organ-donation-and-trans-
plant-applauded-amid-rumors-Mg2f9aG1X2/
index.html.
Bingyi Shi1, 2
,
Bingyi Shi, M.D, Chairman of Chinese
Society of Organ Transplantation
of Chinese Medical association.
The honorary Dean of the PLA Organ
Transplant Institute, The 8th
Medical
Centre of Chinese PLA General
Hospital, Beijing 100091, China
E-mail: shibingyi666@126.com
Zhijia Liu1, 2
,
E-mail: liuzhijia416@163.com
Tao Yu1, 2
,
E-mail: yutao197801@163.com
1
Chinese Society
of Organ Transplantation
of Chinese Medical Association,
Beijing 100091, China;
2
Organ Transplant Institute, The 8th
Medical Centre of Chinese PLA General
Hospital, Beijing 100091, China
Climate is a decisive social factor in basic
health. The climate system is fundamental
for life as a safe climate is needed to sus-
tain health,for which reason climate change
is a direct threat to health. It is also one of
humanity’s greatest challenges and protect-
ing the climate and environment is syn-
onymous with protecting health.To achieve
this objective, swift, efficient mitigation and
adaptation strategies that improve health
and reduce health vulnerability must be
implemented. These should incorporate
climate change and its risks within health
programmes, in addition to preparation and
response programmes for emergencies that
may occur.
Climate change is the global variation in
the Earth’s climate,mainly owed to human
activity through greenhouse gases that al-
ter the atmosphere’s composition, causing
global warming with detrimental effects
in many areas of the planet and with spe-
cific consequences for global health. The
latter is a priority for public health as it
may become progressively worse, creating
The Impact of Climate Change on Health
A question of survival
José Ramón Huerta Blanco
BACK TO CONTENTS
20
Climate Change
a world health crisis throughout the 21st
century. Being aware of this, preventing it
as far as possible, and acting to diminish
and temper its consequences are obliga-
tions for all of mankind, and the medical
profession in particular given its responsi-
bility and commitment to caring for hu-
man health.
According to the World Meteorologi-
cal Organisation (WMO) and the World
Health Organisation (WHO), at present
climate change makes a significant contri-
bution to increasing the global burden of
premature deaths and illnesses worldwide,
especially in terms of cardiovascular, respi-
ratory, allergic, digestive and neurological
diseases. In addition, it alters the distribu-
tion of numerous infectious diseases, caus-
ing continuous changes in some vectors
that expand important illnesses (malaria,
yellow fever, zika virus, chikungunya virus,
dengue fever, among others). It affects agri-
culture, food, air and water with disastrous
consequences for people’s health and qual-
ity of life. Climate change will heighten
inequality in health, especially in more vul-
nerable countries and populations who will
suffer more from its consequences.
Climate change is an important risk fac-
tor for health given its repercussions that
impact many relevant aspects, ranging
from extreme events like torrential rains,
floods, droughts, hurricanes, tornadoes,
heat waves and cold snaps, to alterations in
the distribution of water and food. These
threaten food safety and cause diarrhoea
along with other problems, such as air pol-
lution, changes in pollination and ultravio-
let radiation, resulting in increased diseases
and deaths. Other consequences include
exoduses with mass emigration and cli-
mate refugees in a panorama that could act
as the trigger for armed conflicts, poverty,
hunger, and changes to oceans and fishing,
with fewer glaciers and more droughts that
threaten the entire rural environment and
agriculture, altering ecosystems and biodi-
versity.
According to the WHO, one in four deaths
in the world is owed to environmental fac-
tors and it warns that the impact of climate
change will be particularly serious in chil-
dren, old people, pregnant women, people
with chronic diseases in general, and es-
pecially those affected by respiratory and
cardiovascular diseases, considering that
diseases sensitive to the climate are among
the most lethal. For these reasons, the cru-
cial impact of climate change on health and
life must be emphasised. Although it is a
recognised fact, it appears to be of second-
ary importance when it should be a priority.
Climate change is a global issue that re-
quires solidarity and collaboration on all
aspects, with a comprehensive approach
covering prevention, mitigation, adapta-
tion to its consequences, and research in
all areas to reduce its impact on health.
Via their National Medical Associations
(NMAs), doctors must take climate change
into consideration and actively participate
in devising policies and initiatives that re-
duce its consequences on health, participat-
ing in the field of education in particular
to raise professional and social awareness
of the importance of the environment and
climate change on people’s health as well as
community health. Environmental educa-
tion constitutes a form of training in values
and, in order to fight climate change and
improve its impact on health, doctors and
their professional organisations (as well as
the entire health industry) must strive to
uphold and introduce new values in addi-
tion to an ethical and moral facet to address
the issue.
The World Medical Association (WMA)
and NMAs must act as the frontline when
defending against the health issues related
to climate change.They must also lead doc-
tors so they may help people to adapt to
its consequences, fight against the diseases
linked to climate change, and collaborate
with governments and other organisations
to tackle, mitigate and adapt to the effects
climate change has on health.
Climate change is a health emergency,an im-
mense crisis for humanity that is at a tipping
point. It destroys the economy and health
(and even health advances achieved over
time), thus reducing life expectancy. Con-
sequently, it constitutes a global challenge
given its repercussions, which are difficult to
reverse,and its impact on health results.Time
is short when it comes to stopping global
warming and protecting health, therefore,
our life model must be redefined to become
more sustainable and healthier because when
the climate changes, life also changes.
In this battle against the clock, public
health systems must be strengthened so
as to improve their health response capac-
ity and ability to adapt to climate change.
Funding must be increased to bolster pri-
mary health care (along with community
initiatives and risk prevention responses),
reduce greenhouse gases that cause global
warming, control vectors, protect environ-
mental health, and monitor the diseases cli-
mate change causes. Research in all areas of
health affected by climate change must be
encouraged in order to pinpoint solutions
and ameliorate the health consequences
for people and communities, strengthen
monitoring systems for the diseases caused
or altered as a result of climate change, and
make the medical community’s voice heard
as a significant party in the climate debate
such that climate change’s impact on health
is treated with the importance it requires.
The WMA must also join these efforts to
promote better environmental manage-
ment in addition to improved management
of water, farming, and industrial resources
as well as ecosystems. It must also call for
responsibility and professional commit-
ments in relation to a healthy environment
given that doctors, when protecting life and
health,have an ethical and professional duty
to protect the environment and report inci-
dents of environmental abuse that may be
potentially dangerous to health or life.
José Ramón Huerta Blanco. M.D.
Spanish Medical Council
BACK TO CONTENTS
21
Public Health
Globally, sedentary lifestyle has been a pub-
lic health burden [1, 2]. More people are
becoming sedentary due to modernization,
westernization and civilization, as well as
the advancement in technology. There have
been more devises invented that helps relief
manual labour and some of these newly de-
veloped household gargets that makes life
easier and expends less energy in operating
them. These are making people to be less
physically active. In public health, physical
inactivity has become an important research
topic [3]. Many people are becoming physi-
cally inactive in the changing world [4].
Worldwide, one in four adults is physically
inactive [5]. Movement of the human body
is linked to physical activity as the human
beings are designed for it. Physical activity
is necessary for maintaining physical and
mental wellbeing.
Physical activity can be defined as any
movement of the body produced by the
skeletal muscles that result in the expendi-
ture of energy [6]. Physical activity involves
all forms of activities which can be chores
done within and outside the home,activities
of daily living and also recreational activi-
ties [7, 8]. Examples of physical activity are
brisk walking, cycling, swimming, running,
dancing, shopping, exercise, jogging and ac-
tive sports [5, 7–10]. Being physical active
has some health benefits but they are done
with little concern of its importance on the
role it plays on physical fitness [11].
When physical activity is planned, it is exer-
cise, that is structured and it is used for the
improvement of health for the maintenance
of physical fitness [10]. Healthy lifestyle in-
volves physical activity [12]. Different forms
of physical activity have different intensities;
hence the World Health Organization rec-
ommends that the activity should be done
in episodes of at least ten minutes for it to
be beneficial to cardiorespiratory health [8].
There are several benefits of physical activity
[13] as it is important for staying healthy [7,
14,15].It helps in the prevention of diseases
as physical inactivity is a risk factor of most
non-communicable diseases such as hyper-
tension, obesity, cardiovascular diseases, cor-
onary heart disease, type 2 diabetes mellitus,
osteoporosis, colon cancer, depression, anxi-
ety, improves physical fitness and strength
[3, 5, 7–9, 11, 12, 16–19].The fourth leading
risk factor for mortality is physical inactivity
as globally about 3.2 million persons die be-
cause they are physically inactive [8]. There
is an increase in the number of people that
are becoming physically inactive worldwide
[8, 20,21].Therefore in global health,physi-
cal inactivity has become a burden [5,  9,
22, 23]. Healthcare professionals including
medical doctors are involved in counsel-
ling their clients and patients in the course
of their work. Advices are given by the
healthcare workers are usually held in high
esteem as most hospital clients and patients
will perceive that the healthcare worker as a
role model in health matters and maintain-
ing healthy lifestyle [3, 10, 24]. Hence this
study investigates physical activity amongst
medical doctors in Rivers State, Southern
Nigeria.
Method
This is a cross-sectional descriptive study
conducted during the 2018 annual general
meeting and scientific conference of the
Rivers State Branch of the Nigerian Medi-
cal Association. Respondents were medical
doctors and dentists and participation was
voluntary. A questionnaire was administered
to the research respondents. The question-
naire included questions related to demo-
graphics and the short form of the Inter-
national Physical Activity Questionnaire
(IPAQ-SF). The International Physical
Activity Questionnaire is a valid and reliable
instrument for measuring physical activity
which has been tested in different popula-
tions worldwide [1, 25–30]. The short form
which was used in this study is a recall of
physical activity of moderate and vigorous
activity and walking and sitting in the past
seven days and comprises of seven ques-
Dabota Yvonne Buowari Hope Ilanye Bellgam Obelebra Adebiyi Ufuoma Edewor Vetty Agala
Physical Activities of Doctors in Rivers State, Southern Nigeria
BACK TO CONTENTS
22
Public Health
tions [26, 31–33] The International Physi-
cal Activity Questionnaire was developed
in 1998 [27]. Data extracted from the In-
ternational Physical Activity Questionnaire
short form was analyzed using the scoring
protocol of the instrument [34]. The Meta-
bolic Equivalent Task was obtained from the
International Physical Activity Question-
naire scoring protocol and the total Meta-
bolic Equivalent Task (MET) calculated.
One Metabolic Equivalent Task was the en-
ergy that would be expended at rest and this
is approximately 3.5  ml O2
  kg-1min-1 in
adults [16, 35, 36] or 20 mlmin of oxygen is
used up in an average 70 kg adult [16].There
is a rise in the amount of oxygen consumed
where an increase in the intensity of the ac-
tivity hence the mean equivalent increase
with the intensity of physical activity [16].
The values of MET assigned to sitting,
walking,moderate and vigorous physical ac-
tivity intensity by the international physical
activity questionnaire protocol are [28, 30]:
• Walking: 3.3 MET
• Moderate physical activity: 4.0 MET
• Vigorous physical activity: 8.0 MET
For each activity as calculated by multiply-
ing the number of minutes the activity was
carried out by the number of days and the
constant assigned to that activity. The cal-
culated MET was compared with the stan-
dard MET
Using the MET, physical activity was cat-
egorized into low,moderate and high physi-
cal activity as shown below [1, 2]:
Category
MET – min-
utes/week
Low physical activity: <600
Moderate physical
activity:
≥600 to <3000
High physical activity: ≥3000
The MET – min-per week = : MET level X
events per week.
Activities lasting less than 10 minutes are
not counted [36].
Results
One hundred and six doctors participated
in this study; only 102 questionnaires were
filled completely while four questionnaires
where incomplete therefore they were not
included in the study. Table 1 shows the
social demographics characteristics of the
respondents while table 2 shows the re-
spondents place of work. Most 77 (80%) of
the respondents worked in a government
owned hospital. Table 3 shows the number
of days that is spent on physical activities.
Table 4 shows physical activities of respon-
dents using the metabolic equivalent task.
The highest physical activity was conducted
by 43 (42.16%) moderate physical activ-
ity, 40 (39.22%) low physical activity and
19 (18.63%). Table 4 shows the time spent
on various activities.
Measurement of physical activity is com-
plex as it can be measured directly or
indirectly using self-reported question-
naires  [4]. There are different methods of
measuring physical activity. Questionnaires
is the most commonly used and valuable
method [3]. Doctors spend a lot of time
sitting down as they have to sit down tak-
ing history from their patients except those
involved in surgeries or procedures in which
they have to stand. According to the World
Health Organization adults should have
150 minutes of moderate physical activity
per week or 75 minutes of activity of vigor-
ous intensity daily [8, 20]. Using the MET
43 (42.16%) had moderate physical activity
and 19 (18.63%) high physical activity. It
shows that some doctors are physically in-
active. Activities les that ten minutes were
not included in the study.
Doctors are involved in the counselling
and educating patients on been physically
active to help prevent some non-commu-
nicable diseases in which physical inactiv-
ity is a risk factor [2, 37, 38]. The result of
this study is in contrast to the study con-
ducted among healthcare professionals in
South-West Nigeria where only 20.8% met
Table 1. Social demographic characteristics
of the respondents
Variable
Frequency
(n)
Percentage
(%)
Age (n=102)
21–30 Years
26 25.5
31–40 Years 49 48
41–50 Years 18 17.6
51–60 Years 4 3.9
61–70 Years 4 3.9
71–80 Years 1 1
Sex (n=102)
Males 34 33.3
Females 68 66.7
Marital sta-
tus (n=102)
Separated 2 2
Single 35 33.3
Married 66 64.7
Rank
(n=100)
House of-
ficer
14 14
Senior
House of-
ficer
1 1
Registrar 22 22
Senior Reg-
istrar
9 9
Consultant 11 11
Professor 2 2
Medical of-
ficer
23 23
Senior
Medical Of-
ficer
12 12
Principal
Medical of-
ficer
2 2
Chief medi-
cal officer
3 3
Retired 1 1
BACK TO CONTENTS
23
Public Health
Table 4. Time spent on various activities amongst the respondents
(n=102)
Variable Frequency (n) Percent (%)
Time spent on Vigorous activities (minutes)
<= 60 94 92.2
91–120 4 3.9
121–150 1 1.0
151+ 3 2.9
Time spent on moderate vigorous activities (minutes)
<= 60 91 89.2
61–200 8 7.8
201–340 1 1.0
341+ 2 2.0
Time spent Walking (minutes)
<= 60 85 83.3
61–220 8 7.8
221–380 6 5.9
381+ 3 2.9
Total 102 100.0
Time spent sitting (minutes)
<= 60 53 52.0
61–440 31 30.4
441–820 14 13.7
821+ 4 3.9
Time spent sleeping (hours)
<= 3.0 73 71.6
3.1–6.0 18 17.6
6.1–9.0 7 6.9
9.1+ 4 3.9
Time spent watching TV (Hours)
<= 3.0 73 71.6
3.1–6.0 18 17.6
6.1–9.0 7 6.9
9.1+ 4 3.9
Table 2. Place of work of the respondents
Variable
Frequency
(n)
Percentage
(%)
Hospital Ownership (n=96)
Military Hospital 1 1
Company hospital 3 3.1
Non-Governmental Organization 3 3.1
Private 12 12.5
Government 77 80.2
Type of public facility (n=71)
General hospital 2 2.8
Management staff 4 5.6
Specialist hospital 9 12.7
Primary health care 11 15.5
University teaching hospital 45 63.4
Department (n=92)
No Department 26 28.3
Community Medicine 9 9.8
Family Medicine 6 6.5
Hematology 3 3.3
Internal medicine 7 7.6
Obstetrics and Gynaecology 19 20.7
Surgery 4 4.3
Paediatrics 3 3.3
Others 17 18.5
Table 3. Physical activity category
Physical category Metabolic equivalent task
Low 600–3000 43 (42.16%)
High >3000 19 (18.63%)
Total 102 (100%)
BACK TO CONTENTS
24
Public Health
the ­
recommendation for physical activity.
Though this study included all cadres of
healthcare workers, it did not specify the
different categories of healthcare profes-
sionals [24]. The long hours spent at the
workplace and the sedentary nature of
medical work are some of the causes of low
physical activity among healthcare workers
including doctors [24].
Physical inactivity is a risk factor for most
non-communicable diseases which are life
threatening and causes morbidity, mortality
and end organ damage. Doctors who know
all about the benefits of physical activity are
also physically inactive even though they
contribute so much to health education ad-
vising their clients and patients to increase
their physical activity and decrease physical
inactivity.
Limitation
Since this study was conducted during a
scientific and annual general meeting of the
Rivers State branch of the Nigerian Medi-
cal Association, only doctors that attended
the meeting participated in the study hence
the results may not reflect the true physical
activity of doctors in Rivers State,Nigeria as
doctors that did not attend the meeting did
not participate in the study.
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20. Akarolo-Anthony SN, Adebamowo CA. Preva-
lence and correlates of leisure-time physical ac-
tivity among Nigerians. BMC Public Health.
2014, 14:29. www.biomedcentral.com/1471-
2458/14/529
21. Craig CL, Marshall AL, Sjnostrom M, Bau-
man AE, Booth ML, Ainsworth BE, Pratt M,
Ekelundu et al. International Physical Activity
Questionnaire: 12-country reliability and valid-
ity. Med Sci Sports Exer. 2003, 1381-1395.
22. Pratt M, Norris J, Lobelo F, Ronx L, Wang G.
The cost of physical activity: moving into the
21st century. Bri J Sports Med. 2014, 48, 171-
173.
23. Momton JS, Ferment P, Khan K, Poirer P,
Fowles J, Wells GD, Frankorich RJ. Physical ac-
tivity prescription: a critical opportunity to ad-
dress a modifiable risk factor for the prevention
and management of chronic disease: a position
statement by the Canadian Academy of Sports
and Exercise Medicine. Bri J Sports Med. 2016,
6,1-6. doi.10:1136/bjsports.2016-696291.
24. Wuala SO, Sekoni AO, Olamoyegun MA,
Akanbi MA, Sadirr AA, Ayankogbe OO. Self-
reported physical activity among health care
professionals in South-West Nigeria. Nig J Clin
Pract. 2018, 18 (6), 790-795.
25. Hagstromer M, Oka P, Sjostrom M. The In-
ternational Physical Activity Questionnaire
(IPAQ): a study of concurrent and construct
validly. Public Health Nutrit. 9(6), 755-762.
doi.10.1079/PHN.2-58598.
26. Lee PH, McDowell L, Leung Ham TM,
Stewart SM. Performance of the International
Physical Activity Questionnaire (Short Form) in
subgroups of the Hong Kong Chinese popula-
tion. Inter J Behavioral Nutr Physical Activity.
2011.8.81. www.ijbnja.org/contents/811/81 as-
sessed january 2020.
27. Lee PH, MacFarlane DJ, Ham TH, Stewart
SM. Validity of the International Physical Ac-
tivity Questionnaire Short Form (IPAQ-SF): a
systematic review. Inter J Behavior Nutr Physi-
cal Activity. 2011. 8. 115. www.ijbnpa.org/con-
tent/18/1/15 assessed january 2020.
BACK TO CONTENTS
25
Paliative Care
28. Adeniyi AF, Ogwumike OO, John-Chu CG,
Fasanmade AA, Adeleya JO. Links among mo-
tivation, socio-demographic characteristics and
physical activity level among a group of Nigerian
patients with type 2 diabetes. J Med Biomed Sci.
2013, 2(2), 8-16.
29. Kim Y, Park L, Kang M. Convergent validity of
the International Physical Activity Question-
naire (IPAQ): meta-analysis. Public Health Nu-
tri. 2012, 16(3), 440-452.
30. Wolin KY,Heil DP,Askew S,Mathews CE,Ben-
nett GG. Validation of the international physical
activity questionnaire-short form among Blacks.J
Physical Activity Health. 2008, 5, 746-760.
31. Nang EEK, Ngunjiri SAG, Wu Y, Salim A, Tai
ES, Lee J, Dam RMV. Validity of the Interna-
tional Physical Activity Questionnaire and the
Singapore prospective study program physical ac-
tivity questionnaire in a multiethnic urban Asian
population. BMC Med Res Meth. 2011.11.141.
www.biomedcentral.com/1471-288/11/141.
32. Tran DV, Lee AH, Au TB, Nguyen CT, Hoang
DV. Reliability and validity of the International
Physical Activity Questionnaire-Short Form for
older adults in Vietnam. Health Promotion J
Australia. 2013, 24, 126-131.
33. Meeus M, Eupen IV, Willems J, Kos D, Nijs J.
Is the International Physical Activity Question-
naire – short form (IPAQ-SF) valid for assessing
physical activity in chronic fatigue syndrome?
Disability Rehabilitation. 2010, 1-8.
34. Guidelines for data processing and analysis of
the International Physical Activity Question-
naire (IPAQ) short and long forms. www.ipaq.
ki.se/scoringpdf
35. American College of Sports Medicine. Position
stand.The recommended quantity and quality of
exercise for developing and maintaining cardi-
orespiratory and muscular fitness and flexibil-
ity in healthy adults. Medicine and Science in
Sports and Exercise. 1998, 30, 975-91.
36. Forde C. Scoring International Physical Activity
Questionnaire (IPAQ). Trinity College of Dub-
lin. The University of Dublin exercise, prescrip-
tion for the prevention and treatment of disease.
37. Nomton JS, Ferment P, Khan K, Poirere P,
Fowles J, Well GD, Frankorich RI. Physical ac-
tivity prescription: a critical opportunity to ad-
dress a modifiable risk factors for the prevention
and management of chronic disease: a position
statement by the Canadian Academy of Sport
and Exercise Medicine. Bri J Sports Med. 2016,
6, 1-16. doi.10.1136/bjsports.2016-696291
38. Brannan M, Bernardotto M, Clarke N, Varney J.
Moving healthcare professionals – a whole sys-
tem approach to embed physical activity in clini-
cal practice. BMC Med Educ. 2019, 19, 84. doi.
org/10.1/86/s/2909-019.1517y
Dr. Dabota Yvonne Buowari,
Department of Accident and
Emergency, University of Port Harcourt
Teaching Hospital, Nigeria
E-mail: dabotabuowari@yahoo.com
Dr. Hope Ilanye Bellgam,
Department of Internal Medicine, Care of
Elderly Persons Unit, University of Port
Harcourt Teaching Hospital, Nigeria
Dr. Obelebra Adebiyi,
Medical Women’s Association of Nigeria,
Rivers State Branch, Port Harcourt, Nigeria
Dr. Ufuoma Edewor,
Medical Women’s Association of Nigeria,
Rivers State Branch, Port Harcourt, Nigeria
Dr. Vetty Agala,
Medical Women’s Association of Nigeria,
Rivers State Branch, Port Harcourt,
Department of Community Medicine,
University of Port Harcourt Teaching
Hospital, Rivers State Ministry of
Health, Port Harcourt, Nigeria
What and who?
Fifty years ago,palliative care was largely lim-
ited to comfort care at the end of life,and was
mainly provided in very few free-standing
hospices. Since then the scope of palliative
care has expanded considerably and probably
can best described as ‘care beyond cure’. It is:
• holistic: addressing physical, psychologi-
cal, social/family, and spiritual/existential
concerns
• focused on quality of life,but can be provided
in tandem with life-prolonging treatments
• based on need, not limited by diagnosis
or prognosis
• applicable across all age groups
• ideally provided by a multidisciplinary
healthcare team [1].
In other words, humane care for human
beings, not mechanical care for human
machines. However, shifting from cure-ori-
ented care to palliative care requires a tran-
sition by all involved – clinicians, patient
and family: an acceptance that cure is not
possible and a re-focusing on comfort [2],
and an avoidance of ‘therapeutic obstinacy’
not prolonging death and suffering by fu-
tile resuscitative interventions when death
is clearly inevitable and relatively imminent.
In 2014, the World Health Assembly called
on all health services to provide palliative
care within the context of universal health
coverage [3]. Thus, palliative care should be
integrated into primary health care in the
community, with back-up from specialist
palliative care – as with other medical spe-
cialties [4]. Centres of excellence, particu-
larly in tertiary care and university hospitals,
Palliative Care: What, Who, When, How?*
*Based on a lecture on October 24, 2019, at the World Medical Association General Assembly, Tbilisi, Georgia
Robert Twycross
BACK TO CONTENTS
26
Paliative Care
are necessary for the care of patients and
family with complex needs, and for training
both generalists and specialists. In practice,
most of such centres care for patients with
end-stage disease, most commonly cancer,
with their services embracing outpatients,
inpatients, ward consultations, day care,
home care support, and even more intensive
round-the-clock ‘hospice at home’in the fi-
nal few days,as well as bereavement support
if necessary.
When should family practitioners and other
hospital specialists refer to a specialist pal-
liative care service? In the USA, the Ameri-
can Society of Clinical Oncology suggests
that referral should be considered for any
patient with metastatic cancer and/or high
symptom burden [5].Other specialties will
need to make their own criteria for referral.
However, having a list of ‘Red Alerts’ could
allow more timely referral, for example:
• pain not responding to your analgesia
• nausea/vomiting not responding to anti-
emetics
• inoperable bowel obstruction
• constipation not responding to routine
measures
• breathlessness at rest
• insomnia/nocturnal distress
• anyone expressing distress that they are
dying
• anyone you think is dying badly.
In the UK and possibly elsewhere, there is
a shift towards ‘pro-active’ palliative care:
instead of waiting for a referral, all admis-
sions over the previous 24 hours are scru-
tinized from the hospital’s master-list.
Likely palliative care patients are visited by
the Support Team whether in a temporary
‘holding’ward or an Intensive Care Unit. In
addition there are regular pro-active visits
to Oncology and Renal Departments, and
other specialist wards depending on local
arrangements. This results in many patients
being transferred more swiftly to the pallia-
tive care inpatient unit or discharged home
with a care package in place. It is of value
not only to the patients concerned but also
to the hospital – with significant financial
savings being made.
There is also a tendency for palliative care to
fill the gaps in existing provision for long-
term (continuing) care. For example, in the
UK,many palliative care services in the 1980s
and 1990s established lymphoedema clinics,
caring for those with congenital lymphoede-
ma as well as patients with cancer (cured or
end-stage). In Moldova, the Angelus Hos-
pice in the capital Chisinau is the only ser-
vice in the country offering ostomy care; and,
in Moscow, long-term inpatient post-stroke
and long-term inpatient ventilation care has
been integrated into palliative care.
How?
According to a systematic review,in relation
to palliative care, the top four priorities for
patients and families are:
• effective communication, shared deci-
sion-making
• expert care
• respectful and compassionate care
• trust and confidence in clinicians [6].
Three of these four priorities relate to cli-
nician–patient/family relationships. Rela-
tionships are built on trust. Thus, the basic
question for the professional carer must
surely be: what can we do to increase trust?
A doctor in her mid-30s with end-stage
ovarian cancer wrote,‘Introductions [make]
a human connection… They begin thera-
peutic relationships and can instantly build
trust in difficult circumstances’. She began
a campaign for all those working within
health services called ‘Hello, my name is…’
because she knew from hard experience (as
I  do too!) how dehumanizing it is when
someone by-passes this common courtesy
and just says what they have come to do.
Thus, all health professionals (and support
staff) should begin by introducing them-
selves by name, and wear a clearly visible
and easily readable badge stating the per-
son’s name and position.
Palliative care should be seen as a partner-
ship between experts. In relation to the dis-
ease process, the clinicians are the experts
but, in relation to the impact of the illness,
the experts are the patient and family. It is
vital to recognize this because, through lis-
tening to their story and their problems, the
patient and family begin to shift from be-
ing passive victims to empowered persons.
An important first step is to let the patient
set the agenda, for example, by asking them
what is troubling them the most, or what
they hope will come out of the consultation.
In recent decades, much has been written
about‘person-centred care’.However,in prac-
tice much of it is about moving from a pater-
nalistic ‘covenantal’ relationship between pa-
tient and carer to a commodified ‘contractual’
one – akin to a typical business relationship
of client and contractor.In practice this tends
to downgrade the professional to a techni-
cian,and often leaves the patient uncertain of
the best way forward. For partnership, a ‘cov-
enantal’ (but non-paternalistic) relationship
is required [7]. Empathy, the cognitive abil-
ity to imagine what someone else is feeling,
is essential.Empathy is enhanced by listening
to people’s stories. For those not often caring
for palliative patients,reading stories can sub-
stitute for personal clinical experience [8, 9].
Susan Block, an American psycho-oncolo-
gist, has listed what she regards as impor-
tant to know when talking to someone with
advanced disease:
• What do you understand about your ill-
ness?
• What are your concerns about the future?
• If your health were to get worse, what
would you want to do in the time that’s left?
• What trade-offs are you willing to make?
• How much suffering are you prepared to
accept in order to gain added time?
• Who do you want to make decisions for
you if you cannot [10]?
Holistic care takes time. Data from a sys-
tematic review show that the median length
of the initial consultation is 55 minutes
BACK TO CONTENTS
27
Paliative Care
(range 20–120) [11]. The median time
devoted to symptom management was
20 minutes (range 0–75); coping 15 min-
utes (range 0–78); understanding 10 min-
utes (range 0–35). However, giving this
time initially results in better care – and
may well save time in the long-term.
Expert Care: symptom
management
Palliative care is generally ‘low-tech’ but
always ‘high-skill’. The general principles
underlying symptom management can be
summarized in the mnemonic ‘EEMMA’:
• Evaluation: diagnosis of each symptom
before treatment
• Explanation: explanation to the patient
before treatment
• Management: individualized treatment
• Monitoring: continuing review of the im-
pact of treatment
• Attention to detail: no unwarranted as-
sumptions.
To a large extent, evaluation is based on
probability and pattern recognition [12].
Symptoms may be caused by treatment, de-
bility or a concurrent second disorder rather
than the primary disorder. Symptoms are
often caused by multiple factors; pain can
occur at several sites have distinct causes.
Explanation by the doctor of the causes of a
symptom can do much to reduce its psycho-
logical impact on the sufferer (‘The doctor
understands what is going on…’).
Management falls into three categories:
correct the correctable, non-drug measures,
and drugs. By adopting a multimodal ap-
proach, it is generally possible to obtain
considerable, if not complete, relief. A list
of 20 relatively inexpensive essential drugs
is contained in the report of the Lancet
Commission on Global Access to Pallia-
tive Care [13] and updated guidelines for
the management of cancer pain in adults
and adolescents have been published by
the World Health Organization [14].
Drugs for persistent symptoms should be
prescribed regularly on a prophylactic (‘by
the clock’) basis; the use of drugs only ‘as
needed’ is the cause of much needless dis-
tress. For some symptoms, management
may mostly be helping the patient (and
family) accept the irreversible physical limi-
tations of advanced progressive disease, for
example anorexia, weakness and fatigue.
Monitoring is crucial. Patients vary and it is
not always possible to predict the optimum
dose of opioids, laxatives, and psychotropic
drugs. Particularly initially, doses may need
to be adjusted upwards (and sometimes
downwards). Adverse (side) effects may
jeopardize patient compliance. Attention
to detail is important at every stage, and is
equally important in relation to the non-
physical aspects of care. All symptoms are
exacerbated by anxiety and fear.
Death-accepting, but
Also Life-enhancing
‘Add life to days even when it is no longer
possible to add days to life’is a central tenet
of palliative care. An emphasis on ‘doing’
rather than ‘being done to’ helps the patient
to live and die with their self-respect main-
tained. In many cases, gentle and imagina-
tive encouragement is all that is needed to
entice a patient into an activity that leaves
him with an increased sense of well-being.
The concept of living with cancer (or other
advanced progressive disease) until death
comes is still foreign to many patients and
their families, and to many professionals as
well. Indeed, many terminally ill patients,
although capable of a greater degree of ac-
tivity and independence, are unnecessarily
restricted by well-meaning relatives.
Multidisciplinary Teamwork
and Community Involvement
‘Teamwork is the fuel that allows ordinary
people to achieve extraordinary results.’
Holistic care is generally best provided by
a multidisciplinary team.The ‘nuclear’ team
comprises a doctor and a nurse. To these
can be added a physiotherapist, occupa-
tional therapist, social worker, chaplain,
clinical psychologist, liaison psychiatrist,
and even music and art therapists. Volun-
teers are vital. Depending on their abilities,
they can do a wide range of tasks along-
side the professional staff. In addition, their
presence conveys the message to the patient
that they are still a valued member of the
community.
Incompatible Values
Regrettably, there are many factors that
work against the provision and delivery of
palliative care – and not only financial ones.
There will always be the need to contend
with the ‘distaste’many health professionals
feel when confronted with end-stage dis-
ease, and a reluctance to change the focus
of care from disease control to comfort.
Linked with this is the inability of many
professionals to engage sensitively and
skillfully in discussions about impending
death.
Further, the underlying values of most
healthcare systems are incompatible with
compassion and caring. The values of the
system tend to be competition, rational-
ization, productivity, efficiency, and even
profit­
 [15]. Healthcare has been ‘industri-
alized’ and there is little room for holistic
care. All too often this leads to emotional
exhaustion and cynicism in the profes-
sional carers. Thus, the long-term challenge
of providing high quality palliative care
should not be under-estimated. It requires
resilience, determination, high level clinical
skills, undergirded by the attitude verbal-
ized by Cicely Saunders, the founder of the
modern hospice and palliative care:
‘You matter because you are you. You matter to
the last moment of your life, and we will do all
we can, not only to help you die peacefully, but
to live until you die.’
BACK TO CONTENTS
28
Euthanasia
In June 2016, Canada legalized euthanasia
and assisted suicide, which legislators re-
ferred to collectively as “Medical Assistance
in Dying” (MAiD). In Sept 2018, an article
was published in this journal summarizing
the early impacts of legalized euthanasia on
Canadian medicine [1]. In October 2019,
the World Medical Association (WMA)
reaffirmed its opposition to euthanasia and
assisted suicide [2]. We propose in this ar-
ticle to update colleagues around the globe
on consequences of the rapid expansion and
References
1. Pastrana T, Junger S, Ostgathe C, Elsner F &
Radbruch L. A matter of definition: key ele-
ments identified in a discourse analysis of defi-
nitions of palliative care. Pall Med, 2008; 22:
222-232.
2. Meeker MA, McGinley JM & Jezewski MA.
Metasynthesis: dying adults’ transition process
from cure-focused to comfort-focused care. J
Adv Nurs, 2019; 75: 2059-2071.
3. World Health Assembly. Strengthening of pal-
liative care as a component of integrated treat-
ment throughout the life course. 67th World
Health Assembly, 2014.
4. Gomez-Batiste X & Connor S. Building Inte-
grated Palliative Care Programs and Services.
Worldwide Hospice and Palliative Care Alli-
ance,2017.https://www.thewhpca.org/resources
5. Smith TJ, Temin S, Alesi ER, Abernethy AP,
Balboni TA,Basch EM,Ferrell BR,Loscalzo M,
Meier DE, Paice JA, Peppercorn JM, Somerfield
M, Stovall E & Von Roenn JH. American So-
ciety of Clinical Oncology Provisional Clinical
Opinion: The Integration of Palliative Care into
Standard Oncology Care. J Clin Oncol, 2012;
30: 880-887.
6. Virdun C, Luckett T, Davidson PM & Phillips
J. Dying in the hospital setting: a systrmatic re-
view of quantitative studies identifying the ele-
ments of end-of-life care that patients and their
families rank as being most important.Pall Med,
2015; 29: 774-796.
7. Beach MC, Inui T & the Relationship-Cen-
tered Care Research Network. Relationship-
centered care: a constructive reframing. J Gen
Intern Med, 2006; 21: S3-8.
8. Byock I. Dying Well: peace and possibilities at
the end of life.Riverside Books,New York,1997.
pp. 299.
9. Mannix K. With the End in Mind: how to live
and die well.William Collins,London,2017.pp.
342.
10. Block S. in: Gawande Atul. Being Mortal: ill-
ness,medicine and what matters in the end.Pro-
file Books, London. 2014, pp. 182-183.
11. Jacobsen J, Jackson V, Dahlin C, Greer J, Perez-
Cruz P, Billings JA, Pirl W & Temel J. Compo-
nents of early outpatient palliative care consul-
tation in patients with metastatic nonsmall cell
lung cancer. J Pall Med, 2011; 14: 459–464.
12. Twycross R. Factors involved in difficult-to-
manage pain. lnd J Pall Care, 2004; 10(2):21-32.
13. Knaul FM, Farmer PE, Krakauer EL, De Lima
L, Bhadelia A, Kwete XJ et al. Alleviating the
access abyss in palliative care and pain relief:
an imperative of universal health coverage: the
Lancet Commission report. Lancet, 2018; 391:
1391-1454 (Panel 2).http://dx.doi.org/10.1016/
S0140-6736(17)32513-8ing the n alliative care
14. World Health Organization. WHO guidelines
for the pharmacological and radiotherapeutic
management of cancer pain in adults and ado-
lescents.WHO: ISBN 978 92 4 155039 0 (avail-
able on-line).
15. Youngson R & Blennerhassett M. Humanising
healthcare. Brit Med J, 2016; 355: 466–467.
Robert Twycross DM Oxon, FRCP Lond.
Emeritus Clinical Reader in Palliative
Medicine, Oxford University, UK
E-mail: rob.twycross@spc.ox.ac.uk
The “Normalization” of Euthanasia in Canada:
the Cautionary Tale Continues
Leonie Herx Margaret Cottle John Scott
BACK TO CONTENTS
29
Euthanasia
cultural normalization of the practice of in-
tentional termination of life in Canada.
This paper will balance recent portrayals in
the popular and medical media that imply
only a positive impact as a result of the intro-
duction of euthanasia into Canada’s health
system [3–4]. Evidence will be presented to
demonstrate that there are significant nega-
tive and dangerous consequences of this
radical shift for medicine, and particularly
for palliative medicine. These include the
widening and loosening of already ambigu-
ous eligibility criteria, the lack of adequate
and appropriate safeguards, the ­
erosion of
conscience protection for health care pro-
fessionals, and the failure of adequate over-
sight, review and prosecution for non-com-
pliance with the legislation. Indeed, what
we have seen over the past four years is that
“the slope has in fact proved every bit as
slippery as the critics had warned” [5]. We
also seek to reaffirm the vision of the physi-
cian’s role “to cure sometimes, to relieve of-
ten and to comfort always.”
How Many People Undergo
Euthanasia in Canada?
In just under four years, the number of
euthanasia deaths has rapidly increased in
Canada. New statistics released by the fed-
eral government on February 24,2020,show
that 13,000 people have died by euthanasia
since the legalization of the practice, which
represents approximately 2% of all deaths
in Canada. The government estimated
that there were 5,444 deaths in 2019 and
4,438 deaths in 2018 from euthanasia [6].
In comparison, Statistics Canada reported
1,922 deaths in motor vehicle accidents for
2018, the latest year for which statistics are
available [7]. Euthanasia proponents argue
that the Canadian death rate should stabi-
lize at a level comparable to other jurisdic-
tions with equivalent legislation, such as
the Netherlands where euthanasia now ac-
counts for 4.9% of deaths [8]. However, it
is troubling that Canada’s rate has increased
more rapidly than other permissive jurisdic-
tions over a similar initial time period, and
that our rates are quickly approaching cur-
rent rates in the Netherlands and Belgium,
where euthanasia has been legal for almost
20 years.
Expansion of Euthanasia
Practice and Legislative
Changes
In addition to the increasing numbers of
cases, there is also an expanding range of
indications approved for euthanasia. In four
years, Canada has moved from approving
euthanasia for so-called “exceptional” cases
to euthanasia being treated as a normalized,
almost routine, option for death.
Ongoing court challenges to legislative re-
quirements for euthanasia have resulted in
its approval for individuals with chronic ill-
nesses such as osteoarthritis, dementia, and
physical disability [9, 10, 11, 12]. Media
reports point to less restrictive interpreta-
tions of eligibility criteria by assessors and
providers of euthanasia without interven-
tion from the courts [13, 14]. These prec-
edent-setting cases have produced what
euthanasia providers themselves call “not an
expansion of our law”but “a maturing of the
understanding of what we’re doing” [12].
This, in turn, has led providers to approve
cases they would not have previously ap-
proved due to earlier fears of criminal pros-
ecution [15]. Although reports of criminal
code and regulatory body violations have
been well documented [16, 17], no charges
have ever been laid.
In September 2019, a Quebec Superior
Court ruling on the Truchon case [11]
struck down a central euthanasia criterion
for “reasonably foreseeable natural death”
(RFND) which may soon open up eutha-
nasia to those with chronic conditions, dis-
abilities and mental health issues as a pri-
mary diagnosis. The Federal Government
is committed to expanding the legislation
and, on February 24, 2020, tabled a new bill
in Parliament to respond to the Truchon
case ruling to remove the requirement for
RFND [18]. In the near future, euthanasia
in Canada will almost certainly be open to
any person who feels their suffering cannot
be addressed except through intentional
termination of life. As mandated by the
2016 legislation, the Canadian government
is continuing to explore the additional in-
clusion of those with mental health issues
as a primary diagnosis, “mature minors” (i.e.
children), and euthanasia by advance direc-
tive (for those who may lose decisional ca-
pacity at some point in the future) as part of
a parliamentary review expected to begin by
June 2020 [19].
Even those who support euthanasia in some
circumstances are voicing concerns over
the rapid expansion of the procedure in
Canada, and a problematic lack of proper,
robust analysis of its utilization [20]. Many
who care for citizens with mental health
issues are extremely concerned, not only
that psychiatric conditions may be consid-
ered “irremediable” by some, but also that
if psychiatric indications are permitted as
the sole reason for euthanasia, these pa-
tients could possibly have euthanasia per-
formed almost immediately, whereas the
wait time can be years for specialized, life-
saving psychiatric interventions and care
[21]. The lack of access to psychiatric care
in Canada is also putting patients who are
facing an end of life diagnosis in an even
more dire situation [22], given the high
risk for suicide in this population [23, 24].
Euthanasia deaths are now serving as a
growing source of organ and tissue dona-
tions in Canada [25]. Unlike other coun-
tries, Canada is the first jurisdiction to allow
non-patient-initiated discussion of organ
donation for those approved for euthana-
sia. In other jurisdictions where euthanasia
is legalized, including the Netherlands and
Belgium, only patient-initiated organ do-
nation discussion is allowed, while in some
BACK TO CONTENTS
30
­
jurisdictions, including Switzerland and
some U.S. states, subsequent organ donation
is not possible following assisted suicide.
Having the potential to alleviate the suffer-
ing of another person in need or to leave a
legacy appears to be a powerful motivator
in the decision for organ donation as part
of death by euthanasia [25]. One individual
who donated her organs after euthanasia
stated, “I thought the knowledge of having
full autonomy by way of MAiD was com-
forting, but, when the possibility of organ
donation was added to it,the sense of elation
is the only appropriate word for me.” [25].
Given that most requests for euthanasia
are due to existential suffering, in particular
feeling a burden to others and loss of mean-
ing and purpose in life [26], the potential
“good” of organ donation may be a persua-
sive incentive for some who may otherwise
not have chosen to hasten their death.
Euthanasia providers are now making rec-
ommendations to add drugs (e.g., potassi-
um chloride) to the existing regimen which
will cause rapid cessation of cardiac activity
and reduce the potential for ischemic dam-
age to organs to be transplanted. The ratio-
nale for the change is that it “allows organs
to be donated in the best condition possible”
[27]. Questions are also being raised about
starting organ procurement processes prior
to death being determined which would
also allow organs to be donated in “the best
condition possible”[28].There are a number
of difficult issues that arise when consider-
ing organ donation in these circumstances,
including conscientious objection of team
members involved in transplantation, the
“dead donor” rule, and informing potential
recipients of the source of the organs to be
transplanted.
More evidence of the normalization of eu-
thanasia can be seen in the recent set of tips
published on how to prepare children for a
euthanasia death of a loved one.The author,
Co-Chair of the Ontario College of Family
Physicians Palliative/End of Life Care and
MAiD Collaborative Mentoring Network,
recommends, “if the adults surrounding
them normalize MAID [sic], so will the
children” [29]. Medical literature regarding
children, death and grieving was used to ex-
trapolate approaches to the euthanasia con-
text. Tip #5 states that these conversations
can easily be had with children as young as
four years old. Tip #6 suggests that eutha-
nasia providers should offer to show your
equipment (syringes, stethoscope, IV  sup-
plies). For example: “I have a tray with the
things I will use to help your loved one die.
These include medications and syringes.
I am going to leave them on the table and if
you would like to take a look you can. I will
stand beside the table and you can ask me
any questions” [29].
Euthanasia Due to Lack of
Access to Care or Lack of
Perceived Quality of Life
Examples are mounting of Canadians re-
questing euthanasia because of lack of access
to care, such as long-term care or disability
supports [30, 31]. A significant number of
reports have documented cases in which in-
dividuals have been told by health care pro-
fessionals and others to consider euthanasia
as an “answer”to a perceived poor quality of
life or a lack of health care resources to meet
their needs. Motivation for these decisions
and suggestions appears to include the cost
of care or specialized supports [32, 33].
Following the Quebec Superior Court rul-
ing on the Truchon case [11], over seventy
Canadian disability allied organizations
came together out of concern for the equal-
ity rights of vulnerable Canadians, and
signed an open letter asking the federal gov-
ernment to appeal the court ruling to the
Supreme Court of Canada [34]. A similar
open letter [35], urging an appeal in the
same case, was signed by over 350 physi-
cians from all specialties across Canada. No
appeal was made. These disability experts
and physicians argued that the removal of
the end of life criterion (RFND) means that
disability-related suffering, largely caused
by lack of support and societal inequality,
justifies the termination of a person’s life.
When the legislation is amended, this will
effectively enshrine in Canadian law the
principle that a person’s life can be ended
based on disability alone, further stigmatiz-
ing and devaluing the lives of those living
with disabilities.
Disability advocates continue to express
alarm at the evolving situation in Canada,
and Catherine Frazee (former Human
Rights Commissioner in Ontario and re-
tired professor in Disability Studies) points
to the hidden message being conveyed by
government, that “expanding medically as-
sisted death so that it is not only for those
who are dying,but also,exclusively,for those
who have some illness, disease or disability,
makes us a ‘special case’for ending a difficult
life. This categorically sends one and only
one message: we are not needed. Whatever
gifts we bring to the world, gifts of mind
and heart and body, are not of such value
that Canada will fight for us to live” [36].
International attention was garnered last
year when the UN’s Special Rapporteur on
the Rights of Persons with Disabilities trav-
eled to Canada in the spring of 2019. In her
end-of-mission statement, Ms. Devandas-
Aguilar stated that she is “extremely con-
cerned about the implementation of the
legislation on medical assistance in dying
from a disability perspective…” and she
urged Canada to do more to “…ensure that
persons with disabilities do not request as-
sistive [sic] dying simply because of the ab-
sence of community-based alternatives and
palliative care” [37].
“Safeguards” for Euthanasia
The Supreme Court of Canada, in the case
of Carter v. Canada (2015), that originally
led to the decriminalization and subsequent
legalization of euthanasia, stated that a
Euthanasia
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31
“carefully designed and monitored system
of safeguards” would limit risks to vulner-
able persons [38]. The safeguards in the
subsequent 2016 legislation [39] include
a mandatory ten-day reflection period be-
tween the request and the euthanasia pro-
cedure, the independent nature of the two
eligibility assessors, the requirement for
decisional capacity of the patient at the
time of the request and at the time of the
procedure, protection against coercion by
requiring two independent witnesses, and a
rigorous system of monitoring and review.
Currently, the ten-day reflection period is
often waived, and the newly proposed leg-
islation would formally repeal this require-
ment [18].In one cohort study of euthanasia
deaths in Ontario,26% of euthanasia deaths
had the ten-day reflection period expedited
[40]. In Quebec, it has been reported that
60% of euthanasia cases had the ten-day re-
flection period waived and, of these cases,
48% did not meet the criminal code criteria
for removal (i.e., imminent risk of death or
imminent loss of decisional capacity) and
26% had no documented reason for waiving
the reflection period [41].
Compliance reports from Quebec have also
documented concerns about the “indepen-
dent nature” of assessors [17]. In our per-
sonal experience, the assessors are in reality
not always independent. Assessors are often
colleagues belonging to a small community
of providers who practice euthanasia. The
second assessor can see the first assessor’s
report prior to seeing the patient or writ-
ing their own report. There are also no data
about how often a second assessor disagrees
with a first assessor, or how many different
assessors an individual seeks out, since there
is no limit to the number of assessments that
can be obtained. An individual patient only
needs two approved assessments. A study
from Belgium, which deals with euthanasia
for psychiatric reasons, suggested that 24%
of cases involved disagreement amongst
consultants, highlighting the challenge of
discordant assessments [42]. Although the
current and proposed initial amendments
to the euthanasia legislation in Canada (re-
sponse to the Truchon case) do not permit
euthanasia for psychiatric reasons alone,this
indication is under formal review [19] and
there is considerable public pressure for its
legalization from those who wish to see this
expansion [43].
We also note that it is difficult, even in
person, to determine decisional capacity
or possible coercion, especially if a case is
complicated. In Canada, both telemedicine
(video) and telephone (voice) are allowed
to be used for euthanasia assessments. De-
termination of a person’s decisional capac-
ity is not straightforward and may require
advanced skills and tools [44], but there are
no formal requirements for training to as-
sess decisional capacity and no requirement
for psychiatric consultation in complex
cases. Many physician colleagues, ourselves
included, report personal experiences with
patients who, in their opinion, lacked deci-
sional capacity at the time of the euthanasia
assessment and/or at the time of the pro-
cedure, and still received euthanasia even
though formal documented concerns had
been raised with the euthanasia providers.
Monitoring requirements include only basic
demographic information and are reviewed
in retrospect [45]. Information about race,
education, socioeconomic status, and lan-
guage abilities is not collected, and there is
no direct oversight or mechanism to stop
the procedure if red flags are raised.
A group representing euthanasia provid-
ers, the Canadian Association of MAiD
Assessors and Providers (CAMAP) has
been calling for the abandonment of the
requirement for two independent witnesses
(established to ensure protection against co-
ercion). They contend that this requirement
is a bureaucratic frustration that blocks
patient access. New legislation proposes
to reduce the number of witnesses to one
and would make it legal for that witness to
be the patient’s paid personal care worker
or health care provider [18]. There is also a
reasonable concern that the blanket misap-
plication of the so-called “duty to inform”
may soon suggest to all physicians that they
are required to offer euthanasia as an option
in every serious illness. If this is the case,
it will be impossible for physicians to avoid
the appearance,if not the reality,of coercion
for vulnerable patients who may already
feel they are a burden to others. Even sup-
porters of euthanasia have already acknowl-
edged there is no reliable way to measure
coercion [46].
Concerned Canadians continue to work
together to address the issue of safety for
vulnerable citizens. The Vulnerable Persons
Standard (VPS), initially developed in re-
sponse to the Carter v. Canada decision,
is an internationally recognized evidence-
based framework “that provides clear and
comprehensive guidance to law-makers
by identifying the safeguards necessary to
protect vulnerable persons within a regu-
latory environment that permits medical-
assistance in dying” [47]. The VPS was
developed by a large body of advisors with
expertise in medicine, ethics, law, public
policy and the needs of vulnerable persons.
Despite the fact that the VPS has received
strong, broad-based, continuing support, it
has been completely ignored by every level
of government.
It is also important to note that, during the
legalization process, access to palliative care
was positioned as a “safeguard”for euthana-
sia.However,in reality,less than 30% of Ca-
nadians have access to any form of palliative
care and less than 15% have access to spe-
cialized palliative care [48].Many,including
Shariff and Gingerich, have questioned if
euthanasia can truly be an informed choice
if there is no meaningful access to palliative
care [49].
Although economic considerations may
not currently be driving the normalization
and expansion of euthanasia in Canada, it
cannot be denied that the procedure is sig-
Euthanasia
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32
nificantly cheaper than rigorous, traditional
palliative care. The financial savings of eu-
thanasia for the health care system in Cana-
da have already been reported [50] and with
an aging demographic and diminishing fis-
cal resources, the option to save money in
this way may become increasingly accept-
able to health care decision makers.
Confusion Between Palliative
Care and Euthanasia
Another ongoing issue is the confusion
and conflation of euthanasia with palliative
care. The use of the euphemistic terminol-
ogy of Medical Assistance in Dying to refer
to euthanasia in Canada has exacerbated this
confusion in both the public and health care
spheres. Canadian palliative care organiza-
tions have argued against the use of such
language, affirming that palliative care pro-
vides support or “assistance» in dying to help
people live as fully as possible until their nat-
ural death, but does not intentionally hasten
death [51]. This assertion is also supported
by the longstanding World Health Organi-
zation definition of palliative care [52].
In spite of clear and repeated distinctions
made by national palliative care organiza-
tions and the Canadian Medical Associa-
tion [53–56], there are ongoing efforts by
some euthanasia providers to incorporate
euthanasia within the scope of practice of
palliative care, and to co-opt palliative care
language to describe their euthanasia prac-
tice, “as one of the many items in the pal-
liative care basket” [57, 58]. Linking the
two practices in this way misleads other
health care professionals and the public re-
garding palliative care. The 2019 Canadian
Guideline for Parkinson Disease is a recent
example [59].Palliative care was commend-
ably presented as one of the five key recom-
mendations for the approach to care for
persons with Parkinson Disease. However,
euthanasia (as “MAiD“) was listed directly
under the banner of palliative care support
and was the only specific measure listed!
National Canadian palliative care orga-
nizations have expressed concern that
this confusion and conflation of eutha-
nasia and palliative care perpetuates the
myth that palliative care hastens death
and that misconception may prevent pa-
tients from seeking timely palliative care
interventions which improve quality of
life and, in some cases, enable people to
live longer [60]. The Canadian Society
of Palliative Care Physicians has stated
that “patients and families must be able
to trust that the principles of palliative
care remain focused on effective symp-
tom management and psychological, so-
cial, and spiritual interventions to help
people live as well as they can until their
natural death.” [53].
Dr. Balfour Mount, the “father”of palliative
care in Canada, recently stated that
Canadian legislation utilizes the euphe-
mism ‘medical assistance in dying’ (MAiD)
to define euthanasia/assisted suicide and
that language has caused confusion con-
cerning its distinction from Palliative Care.
For over four decades, Palliative Care has
been providing expert medical management
to assist and support those who are dying
without hastening death or administering a
lethal dose of drugs to end life. The MAiD
euphemism confuses and causes fear in our
patients and the general public regarding
the practice of Palliative Care and the na-
ture of Palliative Medicine [61].
Impact on Palliative Care
The 2016 Federal legislation positioned eu-
thanasia (MAiD) as a health care right un-
der the Canada Health Act, and so it must
be publicly funded and accessible to all Ca-
nadians [39]. Palliative care, however, is not
afforded such status and there is no similar
requirement for it to be funded and accessi-
ble to Canadians. This is highly inequitable
since almost 98% of deaths in Canada are
not through euthanasia [6].
Euthanasia proponents continue to co-opt
the vocabulary and tools of palliative care
to create a new discipline of “end of life
medicine” with a radically different phi-
losophy, intention and approach that em-
braces hastened death as the “most beautiful
death” [3]. Under this banner of “end of life
care,” existing palliative care resources are
being used in some jurisdictions to provide
euthanasia, effectively reducing already lim-
ited resources for palliative care. This is the
case in Ontario where, in some regions, the
community Hospice Palliative Care Nurse
Practitioners were given the additional role
of providing euthanasia [62–63]. The as-
sessment for and provision of euthanasia by
physicians in Ontario are billed to the Min-
istry of Health using palliative care billing
codes, despite the objections of palliative
care physicians [64]. The very distinct and
disparate goals and procedures followed by
euthanasia teams and palliative care teams
make it reasonable and advisable to separate
the two practices.This separation should be
accepted without acrimony or contention as
it is in the best interests of patients, their
families and the teams themselves.
The impact of normalized euthanasia on
our day-to-day clinical work in palliative
care has been profound. When someone
expresses a desire to die or a desire for has-
tened death (for example, “I just want this
to be over…”), there can now be a knee-jerk
reaction to consult the euthanasia team as
a first response and neglect what palliative
care has to offer. Until now, the standard of
care has been to engage the patient in seri-
ous dialogue, to try to understand the nature
of their suffering and grief expression more
fully, and to determine what supports might
be helpful. In palliative care, it is universally
accepted that expressing a desire to die and
talking about hastening death are most of-
ten normal expressions of grief, loss and
coming to terms with one’s mortality in the
face of a life-threatening condition.Such ex-
pressions of distress need to be explored and
supported with skilled palliative care inter-
ventions to better understand the nature of
Euthanasia
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33
the suffering and how to address this,and/or
to accompany the person in their suffering.
There are many holistic, dignity-conserving
palliative care interventions such as Dignity
Therapy [65],developed by renowned Cana-
dian palliative care psychiatrist Dr. Harvey
Chochinov, which are aimed at restoring
purpose, meaning, and reframing hope in
the face of the losses that accompany life-
threatening illnesses. Such therapies help a
person and their loved ones to focus on liv-
ing, even while dying, and provide support
to accompany people on their journey, so
they do not feel abandoned or alone.
There is no mandatory palliative care con-
sultation prior to euthanasia. The only re-
quirement is that a patient is aware of all
options for care (informed of all means to
relieve suffering, including palliative care).
Awareness is not the same thing as mean-
ingful access,and what a person understands
palliative care to be may influence the per-
son’s understanding of what palliative care
has to offer. The Chief Coroner of Ontario,
who receives all reports of euthanasia cases
in the province, has identified that it is very
difficult to evaluate the quality/suitability of
the palliative care being offered to patients
who receive euthanasia [66]. Our own per-
sonal experience is that many patients and
health care professionals, including some
euthanasia providers, do not fully under-
stand palliative care and its extensive array
of therapeutic interventions.
It is also our experience that, although pal-
liative care teams offer to provide ongoing
palliative care for patients who request a eu-
thanasia death, a number of these patients
reject palliative care involvement. These
patients often refuse many of the medica-
tions offered for optimizing symptom man-
agement, citing fear that the medications
will cause them to lose decisional capacity
and therefore their eligibility to receive eu-
thanasia. Tragically and paradoxically, this
may result in the last days of life await-
ing a euthanasia death being more highly
symptomatic, and patients may have eu-
thanasia without ever having a proper trial
of excellent palliative care, even where it is
available. A Quebec study found that in pa-
tients requesting euthanasia, 32% of those
who received a palliative care consultation
had it requested less than seven days be-
fore euthanasia provision and another 25%
of palliative care consults were requested
the day of or the day after the euthana-
sia request [41]. With the removal of the
ten-day reflection period from euthanasia
request to delivery of the procedure in the
proposed revision for euthanasia legislation
[18], the reality of a meaningful palliative
care consultation seems even less likely.
Downar et al (2020) state that 74% of eu-
thanasia cases in Ontario had palliative care
involved, however, the reporting measures
used during the study period do not allow
for a detailed evaluation of the quality of
medical care provided, including palliative
care, as it is not within the legislated re-
quirements for oversight by the Office of
the Chief Coroner to review or collect this
information [66].    It is thus not possible
to delineate or evaluate either the quality
or quantity of palliative care involvement,
when it occurred in relation to the request
for euthanasia (the study only documented
that there was involvement at the time of
request), which palliative care team mem-
ber provided it (e.g. physician, nurse, or
social worker, etc.) or whether there was
any meaningful involvement by a specialist
palliative care team. A number of detailed
responses outlining the significant problems
with the conclusions made in this paper
have already been published online [40].
Strong lobbies are pushing for euthanasia to
be available in every palliative care unit and
hospice in the country [67]. In many areas,
euthanasia is required to be provided in all
settings of care in order to avoid the with-
drawal of public funding. Hospice societies
who fundraise to build the buildings and
co-support the day-to-day costs of special-
ized hospice care are also being mandated
to provide euthanasia on site or face closure.
Hospices and faith-based institutions are
criticized for “blocking access” to euthana-
sia, even where access is documented to be
excellent [68].
Protection of Conscience
for Physicians
Participation in euthanasia is also a great
concern for physicians who are profession-
ally and/or morally opposed to it. Some
physician regulatory bodies require partici-
pation via a mandatory referral for eutha-
nasia by physicians unwilling to provide the
procedure themselves. For some physicians,
such an obligation makes them complicit
in an act they find not clinically indicated,
unethical, or immoral. This happens in
Ontario, Canada’s largest province, where
the College of Physicians and Surgeons of
Ontario has mandated such an “effective
referral” requirement [69]. Physicians who
decline to do this could face disciplinary ac-
tion such as the loss of the license to practice
medicine. The Ontario courts have agreed
that the requirement for referral violates
the conscience/religious rights of physicians
(which are protected under the Canadian
Charter of Rights and Freedoms) but justi-
fies the referral requirement to “ensure ac-
cess» to euthanasia for patients, despite no
documented lack of access in Ontario [70].
This is the very first time in Canada that the
burden of ensuring access to other parts of
the health care system has rested on the in-
dividual physician.
As previously discussed, euthanasia pro-
ponents are now suggesting that doctors
must introduce euthanasia as an option to
all potentially eligible patients as a so-called
“duty to inform” [71]. However, in no other
clinical situations are physicians required to
discuss all potential options and procedures
if they determine that those options are not
medically indicated [72–74].
Some euthanasia providers are now re-
fusing to become the “Most Responsible
Euthanasia
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34
­
Physician” (MRP) via a transfer of care
prior to or during the euthanasia procedure.
One of the authors on this paper has direct-
ly experienced this at their local hospital.
Personal written communications have also
reported this practice happening at other
hospitals across Canada. In addition, some
euthanasia providers are refusing to accept
patient transfers from palliative care units
and hospices. These strategies profoundly
damage collegiality and may force physi-
cians unwilling to collaborate in euthanasia
(professionally or morally) into an ethical
crisis, compelling them either to remain the
MRP, formally approving euthanasia and
responsible for all aspects of care for the
patient and family, or to refuse to approve
it and face contrived accusations of having
obstructed patient access.
Palliative care clinicians have a high level of
burnout [75–76], and the perceived lack of
control over the scope of practice and forced
participation in something that goes against
their convictions about the very core of their
vocation may be contributing to increas-
ing moral distress and moral injury. This is
reflected in colleagues who come to us on a
daily basis to share experiences of repeated
distress from euthanasia cases. Even col-
leagues who support euthanasia in some cir-
cumstances have reported experiencing this
serious distress at times. Moral distress and
moral injury manifest as early retirements,
leaves of absence,and career changes by phy-
sicians who will no longer provide palliative
care due to the expectation that euthanasia is
included in the scope of practice. Additional
moral distress is experienced by some pallia-
tive care leaders when health region admin-
istrators arbitrarily put euthanasia admin-
istration and oversight into the “end of life
care”portfolio.The probable loss of palliative
care physicians from the workforce at a time
when even more clinicians are needed is in
part a direct consequence of such stressful
situations and heavy-handed measures.
Proponents of euthanasia use the phrase
“my life, my death, my choice,” which calls
solely on the principle of autonomy as justi-
fication for euthanasia [77]. But, in Canada,
the delivery of euthanasia is anything but an
autonomous act. By design, it involves one
or more other individuals. Many individu-
als and health care and community services
commonly participate in each death, some-
times against their better judgment and
possibly even against their will.
While palliative care has so far been on the
forefront of the euthanasia experience, the
coming expansion of the legislation that will
allow euthanasia for suffering due to any ill-
ness,condition or disability,will have a much
broader impact on physicians from all medi-
cal disciplines, as well as on other health care
professionals. There will be very few areas
of medicine that euthanasia does not touch.
In less than four years since the legalization
of euthanasia in Canada we have witnessed
• rapid increase in rate of death by euthana-
sia (now estimated to be 2% of all deaths
and expected to rise further) – a rate of
growth over 3 years that has surpassed all
other permissive jurisdictions
• the loosening of eligibility criteria by asses-
sors and courts and the weakening of safe-
guard mechanisms in existing legislation
• the imminent expansion of euthana-
sia through legislative revision, despite
strong opposition from citizens in the
disability community, mental health pro-
fessionals, palliative care clinicians and
public policy leaders
• the failure of federal and provincial gov-
ernments to designate palliative care as a
right and to provide access to palliative
care that is at least as robust as access to
euthanasia
• the confusion and conflation of palliative
care with euthanasia; and
• the erosion of conscience protection for
physicians and other health care profes-
sionals leading to coerced participation
and demoralization.
These formidable challenges faced by physi-
cians and patients in our difficult Canadian
experience should not lead to discourage-
ment but should instead inspire a reaffir-
mation of the commitment to traditional,
whole-person medicine. Patients, loved
ones, clinicians, and even society in gen-
eral are all deeply enriched when palliative
teams use our expertise to show compas-
sion through excellent clinical care in an
on-going, committed relationship with
each patient, no matter how difficult the
circumstances or how complicated the is-
sues. Suffering — pain, fear, loss of control,
sense of burden—is not solved by hastened
death, but by this excellent care, delivered
in a community and a society that honours
and protects our most vulnerable citizens at
the most difficult times in their lives. Eu-
thanasia is not the panacea that proponents
promise. Its legalization and subsequent
rapid normalization have had serious nega-
tive effects on Canadian medicine and on
Canadian society as a whole. We urge the
WMA and our colleagues around the world
to look beyond the simplistic media reports
and to monitor developments in Canada
carefully and wisely before making any
changes in their own country’s legal frame-
work for medical practice.
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Euthanasia
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37
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Authors’ Affiliations
(Institutional affiliation are provided for
identification purposes only and do not im-
ply endorsement by the institution)
Leonie Herx MD PhD CCFP (PC) FCFP
Chair, Division of Palliative Medicine
Associate Professor, Department of Medicine
Queen’s University
Kingston, Ontario, Canada
Margaret Cottle MD CCFP (PC)
Assistant Professor, Division
of Palliative Care
Faculty of Medicine, University
of British Columbia
Vancouver, British Columbia, Canada
John F. Scott MD MDiv
Associate Professor, Division
of Palliative Care,
Department of Medicine,
University of Ottawa
Ottawa, Ontario, Canada
Acknowledgements
and Endorsements
The authors want to express our deepest
thanks to our dear colleagues for their in-
sights, edits and support.
The article has been explicitly endorsed by
the following Canadian physicians:
Balfour M Mount, OC, OQ,
MD, FRCSC, LLD
Canadian Pioneer in Palliative Care and
Founding Director of Palliative Care, McGill
& McGill Programs in Whole Person Care
Emeritus Professor of Medicine,
McGill University,
Montreal, Quebec, Canada
Rebecca Adams, Lubomir Alexov,
Tommy Aumond-Beaupre, Stephanie Austin,
Jason Bailey, Pascal Bastien,
Thomas Bouchard, Ralf Buhrmann,
Myra Butler, Julia Cataudella,
Joseph Cavanagh, Cyril Chan,
David Chan, Sherry Chan, Srini Chary,
Martin Chasen, Luke Chen, Riley Chen-
Mack, Sylvia Cheng, Samantha Chittick,
Joyce Choi, Eileen Cochien, Ramona Coelho,
Alana Cormier, Robin W. Cottle,
Rita Dahlke, Julie E. Dermarkar,
Paola Diadori, Bryan Dias, Marisa Derman,
Jane Dobson, Ugo Dodd, Anne Doig,
Christopher J. Doig , Rosaria Domenicone,
David P. D’Souza, Ed Dubland, Sherif Emil,
Duncan Etches, Hao Ian Anita Fan,
Elizabeth Feeley, Theodore Karl Fenske,
Natasha Fernandes, Nisha Fernandes,
Catherine Ferrier, Michael Fielden,
Alanna Fitzpatrick, George M. Francis,
Geoff Friderichs, Remedios T. Fu,
Abraham Fuks, Romayne Gallagher,
Dominique Garrel, Stan P. George,
Gabriella Gobbi, Pamela Gold,
Ewan Goligher, Rudy Hamm,
Sheila Rutledge Harding, Pippa Hawley,
David Henderson, Amy Hendricks,
Neil Hilliard, Zoltan Horvath, Ann Hoskin-
Mott, Lawrence F. Jardine, Andre Jakubow,
Will Johnston, Stephanie M. Kafie,
Ebru Kaya, Lynn Kealey, Timothy J. Kelton,
Nuala Kenny, Anthony Kerigan,
Pongrac Kocsis, Michelle Korvemaker,
Tim Kostamo, Jaro Kotalik, Judith Kwok,
Joseph M.C. Lam, Jim Lane, Michael Lane,
Tim Lau, Mireille Lecours, Keith Lee,
Renata Leong, Andrea Loewen,
David Loewen, Constant H. Leung,
Iris Liu, Cindy Lou, Karen MacDonald,
Maria MacDonald, Jean-Noel Mahy,
Lauren M. Mai, Giuseppe Maiolo,
Karen Mason, Loraine Mazzella,
Brandon McIlmoyle, John R. McLeod,
Terence McQuiston, Amy Megyesi,
Randy Montag, Alisha Montes, Jose Morais,
Louis Morissette, David Neima,
Nicholas Newman, Natalia Novosedlik,
Michael J. Passmore, John Patrick,
Cameron W. Pierce, Jose Pereira,
Francois Primeau, Mimitha Puthuparampil,
Geoffrey Purdell-Lewis, Roger Roberge,
Cameron Ross, Christopher J. Ryan,
Paul Saba, Rafael Sumalinog, Luke Savage,
Kevin Sclater, Valerie Schulz, Elvira Smuts,
Beverly Spring, Nathan Stefani,
Sephora Tang, Philippe Violette, Lucas Vivas,
Lilian Lee Yan Vivas, Esther Warkentin,
James Warkentin, Eric Wasylenko,
Richard Welsh, Kiely Williams, Ryan Wilson,
Maria Wolfs, Artur Wozniak, Paul Yong,
Roman Zyla, Nathan Schneidereit
Euthanasia
BACK TO CONTENTS
38
Dear colleagues,I was a co-author of the ar-
ticle Euthanasia in Canada – a Cautionary
Tale, published in the World Medical As-
sociation Journal September 2018, Vol. 64
#3 pp. 17-23, although today I am writing
only on my own behalf.
I am writing to you to plead for a fresh
start by the WMA leadership to promote
the WMA’s vision of medical care without
euthanasia.
To this end, I  believe that in addition to
maintaining its prohibition of euthanasia by
physicians, the WMA needs now to explain
publicly its reasons for this, and these rea-
sons need to be on the WMA website along
with a prominent display of the policy.
My patients live in retirement residences
and therefore include many who think
about euthanasia for themselves now that in
Canada it is legal, increasingly frequent, and
increasingly seen as normal in the health
care system and in society in general. (I per-
sonally never suggest euthanasia to a patient,
and I counsel against it when the subject arises.
Rather, I try to discover the reasons underlying
my patient’s request, in order to see how I can
ethically help them with these.) In conversa-
tion with them, I have found it very helpful
to point out that the World Medical Asso-
ciation has repeatedly stated that physician
involvement in euthanasia is unethical, and
that since the WMA has over 100 con-
stituent national medical associations, we in
Canada are “the odd man out”of the world-
wide medical profession.
In light of the continuing creep of euthana-
sia in the Western World, I feel an urgency
to present to you a proposal to promote the
WMA’s wise policy and ethics statements
on the subject. I  believe we need to ac-
tively promote the WMA policy not only
in countries such as my own whose medical
associations have already succumbed to the
euthanasia activists, but also in other coun-
tries where cultural and political pressures
are mounting to make euthanasia both legal
and expected of the medical profession.The
WMA’s existing policy statements prohib-
iting euthanasia are valuable, but would be
more effective if the reasons for them were
explained. If explained, I  think that the
WMA’s policy could have much more trac-
tion in Western countries.
Why do we say that euthanasia
by physicians is unethical?
Regrettably, when I  searched through
the WMA website’s policies and archives
I found nothing on this question. The re-
action of many people, especially the well-
educated, if they hear about the WMA’s
policy will be to say, “That’s interesting, but
why does the WMA say that?”The WMA’s
reasons are not obvious to them, and that
is so with many of my medical colleagues
as well. They perceive the WMA’s position
as merely conservative, and the WMA as
a milieu in which Hippocrates is strug-
gling to catch up to the twenty-first cen-
tury. Personally, I think they are tragically
mistaken. I think there are good reasons for
physicians to abstain from euthanasia, and
that these reasons are just as pressing to-
day as they were twenty-four centuries ago.
I gather that suicide assistance did occur in
the Greece of Hippocrates’day, but we have
no evidence that he or his disciples were
political reformers. Rather, their position
seems to have been that suicide assistance
was not their role, that it was inconsistent
with medical care. As in Hippocrates’ day,
there are reasons for the medical profes-
sion to abstain from euthanasia that apply
no matter whether the larger society wants
it. While there are reasonable concerns that
the option of euthanasia in our clinical work
harms the doctor-patient relationship, I be-
lieve there are also reasons for concern that
euthanasia in the health care system harms
society as a whole.
I would therefore submit for the WMA’s
consideration the following as reasons that
society, even if it has decided to approve eu-
thanasia for its citizens, should not delegate
the adjudication or execution of euthanasia
requests to its physicians.
Euthanasia in the Health Care System
Even if Society has Decided that it
Wants Euthanasia, why Should it Keep
its Health Care Workers, Especially
its Physicians, out of Euthanasia?
First – Magistrates would do a better job
than physicians in adjudicating euthanasia
applications.
Unless society decides to legalize euthanasia
on demand, any legalization of euthanasia
will try to define some restrictions on the
practice. Therefore, as a practical necessity
the legislation will need to construct an ap-
plication process and to appoint someone to
Appeal for Policy Promotion
To our President
Terence McQuiston
Medical Ethics
BACK TO CONTENTS
39
adjudicate the applications. So far all eutha-
nasia laws in whatever jurisdiction have as-
signed the job of adjudication to physicians.
However, I would contend that physicians
are a poor choice for this role. It involves
legal decision-making, which is different
from clinical decision-making. We, phy-
sicians, are trained for and experienced in
the latter, but not the former. There are no
medical indications for euthanasia. Eutha-
nasia is not at its base a medical act. Rather,
it uses simple medical technology to ac-
complish a non-medical end. Euthanasia is
a new activity for our societies and needs to
be framed uniquely, distinct from all other
activities such as health care.
Predictably we are seeing a great variation
in physicians’ responses to euthanasia ap-
plication. This variation looks arbitrary to
the public,so it breeds disrespect for the law
and emboldens both patients and physi-
cians to skirt the law.
In 2009, the Human Rights Committee of
the United Nations Covenant on Civil and
Political Rights investigated Dutch eutha-
nasia practice and expressed concern “at the
extent of euthanasia and assisted suicides
……. a physician can terminate a patient’s
life without any independent review by a
judge or magistrate to guarantee that this
decision was not the subject of undue influ-
ence or misapprehension.” Evidently, they
did not consider review by a second physi-
cian to be an adequate safeguard.
Second – Execution of approved euthanasia
applications does not need a physician.
Instead, other individuals can be licensed
to perform euthanasia. The knowledge and
skill set needed to kill someone painlessly is
remarkably simple. A High School gradu-
ate could easily be trained for this in two to
four weeks.
Third – The effectiveness of the health care
system suffers when euthanasia is intro-
duced in it.
A – The presence of euthanasia in the health
care system erodes public confidence in
the health care system, especially in its phy-
sicians, that they can be trusted to care in
all circumstances, and never to harm. We
have seen evidence of this problem in the
Dutch experience. Indeed, this came out at
the WMA General Assembly in Reykjavik,
where it was reported that Dutch patients
receiving health care in Germany often car-
ry cards saying, “I do not wish to be killed.”
In a fiduciary doctor-patient relationship,
the patient’s trust in the physician is vital to
the relationship’s optimum function. How
can patients receive maximum benefit from
their doctors if they don’t trust them not to
kill them?
B – The presence of euthanasia in the health
care system impairs the morale of health
care providers including, but not limited
to, physicians and nurses. We are human
beings, not robots. Quality clinical care
necessitates a caring, personal relationship
between care-giver and patient. To kill our
patient necessitates a certain hardening of
ourselves to cope with this horrible real-
ity. Such hardening cannot be restricted to
the immediate euthanasia act. In our clini-
cal work with other suffering or “hopeless”
patients we will inevitably be weighing in
our minds the question of whether killing
the patient would be in their best interest.
It is very difficult to be continually mov-
ing between the vision of classical medical
care (to cure sometimes, relieve often, and
console always) and the idea of killing this
person.It’s like continually shifting our car’s
gears back and forth, between forward and
reverse.This severely grinds the gears.It cre-
ates too much stress in us to cope with, so
we have to reduce the gear-shifting. We can
do this either by suppressing the “reverse”to
euthanasia, thus failing our society in its de-
sire for euthanasia, or else by restraining the
“forward”, namely our professional calling
to give of ourselves to the maximum care
for patients in dire circumstances. Society
will therefore suffer in the quality of care it
gets from its physicians. Anecdotally I am
already seeing this in Canada, with physi-
cians leaving palliative care, and difficulties
in recruiting new medical graduates for pal-
liative care.
Perhaps you know of other reasons why
physicians should not involve themselves in
euthanasia. Unfortunately, although our eth-
ics code includes “the utmost respect for human
life”, I don’t think this consideration will reso-
nate strongly in our increasingly secular West-
ern societies, but perhaps you are aware of other
reasons that might resonate with them.
Euthanasia in Society as a Whole
is this a Public Health Issue?
Should the WMA Address it as
Such that in the Public Square?
So far, I have written only about euthana-
sia’s effects on the health care system.
However, it can be argued that euthanasia is
also a public health issue (People do die from
it), and the WMA quite properly involves
itself in other public health issues.
Does the presence of euthanasia in a so-
ciety’s culture result in significantly more
deaths than the euthanasia advocates origi-
nally anticipated or advocated for? Have we
“let a genie out of its bottle” in the words
of the Dutch Ethics Professor Theo Boer?
That is certainly what has been happening
in Canada, and in the Netherlands also,
I think. To quote from the then Professor
of medical ethics at the Free University of
Amsterdam, Dr. Henk Jochemsen, in an
open letter to Canadians in 2010 when our
parliament was first considering legalizing
euthanasia, “the practice of euthanasia in
the Netherlands is changing the doctor-pa-
tient relationship and the attitudes of soci-
ety toward the severely disabled,elderly,and
terminally ill.”I see similar changes now oc-
curring in Canada.
It should not come as a surprise that the
presence of euthanasia in a society’s culture
Medical Ethics
BACK TO CONTENTS
40
Green Doctor
Most of us are spending more time indoors
this month. Many people do not know that
the air inside is usually dirtier than the air
outside, contributing to asthma and other
pulmonary complaints. The World Medi-
cal Association’s My Green Doctor pro-
gram has a short guide to help your patients
improve indoor air quality, “Go Green at
Home to Prevent Asthma and Breathing
Problems” (Reading Time: five minutes).
You might print copies to share with your
office colleagues and for the waiting room,
or consider emailing it to all of your pa-
tients, either as a PDF (we provide the file)
or as a link: https://www.mygreendoctor.
org/go-green-at-home-to-prevent-asthma-
breathing-problems/. There’s also a link to a
free waiting room poster on this topic.
My Green Doctor is a free membership
benefit from the World Medical Associa-
tion that is saving clinics and offices money
as they adopt wise environmental practices
and share these ideas with their patients.
Hundreds of offices use My Green Doc-
tor. It adds just five minutes to each regular
office staff meeting. My Green Doctor ex-
plains what to say and do at each meeting
so there is nothing for the office manager
to study or prepare. This is how we prepare
our communities for the health threats of
climate change. Ask your clinic or office
manager to register: https://www.MyGreen-
Doctor.org/.
If you are a leader in your national medical
association, please add this message to your
organization’s newsletter so that your doc-
tors can enjoy this free membership benefit.
To receive this e-newsletter announcement
in a language other than English, simply
contact My Green Doctor’s Editor: tsack8@
gmail.com.
This Month Consider Indoor Air Health
will result in people being euthanized be-
cause they are sick, disabled, elderly, men-
tally ill,or in the last phase of their lives (i.e.,
“terminally ill”). Requests for euthanasia
from our patients and their families don’t
arise only from dispassionate philosophy
about end-of-life questions, but also from a
number of extra-rational factors including
suffering in many forms (physical, men-
tal, and social – they’re lonely), fear of the
future, shame (“I’m just a burden to my
family”), and existential despair (“My life
has no meaning anymore.”) As euthanasia
becomes more public and commonplace in
society, cultural pressure to conform to its
ideology will inevitably increase.
Let us not imagine that we of the WMA
will succeed on the battlefront of medical
ethics while ignoring this issue of public
health. Therefore I  ask, what should the
WMA be saying in the public square about
the effects of euthanasia in the broader cul-
ture of society, as an issue of public health?
The WMA has worldwide prestige. Its
messages become part of the cultural brew
and can make a difference. People still do
listen to what they hear their doctors say-
ing. However, such a statement would need
to be supported by more data than I have
ready access to.Drawing from our networks,
who can supply us with the necessary stud-
ies and statistics on the WMA approach, as
you work on a statement about the ramifi-
cations of euthanasia on public health?
I plead with the WMA’s leadership to con-
sider what I have written.
Please elaborate publicly your reasons for
declaring euthanasia by physicians to be
unethical.
If we really want credibility for our eutha-
nasia policy with physicians in the West,
let alone adherence to it, we must “unpack”
it. (Perhaps the WMA Workgroups on the
Patient-Physician Relationship and on the In-
ternational Code of Medical Ethics could work
on this.)
Please also form a committee to look into
the public health ramifications of eu-
thanasia, and develop an adequately re-
searched statement on this matter. (Sooner
rather than later – the need is urgent.)
Terence McQuiston M.D.
Associate Member, WMA
Toronto, Canada
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NMA News
Singapore Medical Association (SMA)
has been the voice of the medical profes-
sion in Singapore since its establishment in
1959, representing the majority of medical
practitioners in both the public and pri-
vate sectors.The objectives of SMA include
fostering and maintaining the honour, in-
terest and unity of the medical profession
as a whole. This is in conjunction with ac-
quainting the government and regulatory
bodies with the policies and attitudes of
the profession. SMA has participated in
numerous consultations with various minis-
tries and government organisations to voice
members’ opinions on matters such as the
National Electronic Health Records, the
Healthcare Services Bill, telemedicine and
the local residency training programme.
SMA plays a key role in professional de-
velopment through the setting up of Cen-
tre for Medical Ethics and Professionalism
(CMEP) in 2000. CMEP hopes to provide
doctors with a platform for life-long learning
in the area of medical ethics, professionalism
and health law.This was driven by the change
in medical landscape in the late 1990s, when
there was a move from social capital-based
healthcare financing towards economic
capital-based healthcare financing. This
transition posed challenges of answering
healthcare problems with innovative investi-
gations versus rising
healthcare costs, and
increasing demand
that doctors follow
guidelines of care
versus being liable
for medical incom-
petence. Till today,
CMEP constantly
engages with the
current generation of
doctors to promote
the art and science
of medical ethics and
medical practice, as
well as their application, for the betterment
of patient care and public health in the con-
text of changing social norms.
The global epidemic of Severe Acute Re-
spiratory Syndrome (SARS) in 2003 tested
Singapore’s healthcare preparedness in out-
break management. The sudden and swift
spread of the virus, which we had little
knowledge of at that time, almost paralysed
the community healthcare services – Gen-
eral Practitioners (GP) did not have enough
N95 masks. In response to members’ feed-
back on the difficulties in obtaining the
N95 masks, SMA purchased 5,000 pieces
of N95 masks from the Singapore General
Hospital and sold them to the GPs. Due to
the overwhelming response, all 5,000 pieces
were sold out on the same day. SMA subse-
quently sought support from the Ministry
of Health and received a second shipment
of 5,000 pieces of N95 masks, which were
sold to the GP clinics who were unable
to obtain masks earlier. This collaborated
move provided GPs with protection from
the deadly virus and hence allowed them to
continue the care of their patients safely.
SMA strongly believes in investing in the
future of healthcare and the recent SMA
Lectureship and the National Medical Stu-
dents’Convention are evident of our support
in the next generation of medical doctors.
Inaugurated in 1963, the SMA Lectureship
is a prestigious annual lecture delivered by
a distinguished speaker on medical ethics
and related topics that are pertinent in the
day. The 2018 SMA Lectureship was de-
livered by A/Prof Yeoh Khay Guan (Dean
of Yong Loo Lin School of Medicine, Na-
tional University of Singapore and Deputy
Chief Executive of National University
Health System) on “The Future of Medi-
cal Education”. The lecture explored the
implications of shifting trends in Singapore
healthcare and its impact on medical educa-
tion. The event drew an audience of more
than 150, comprising doctors, educators,
medical students, even A-Level students
and their parents. The 2017 SMA National
Medical Students’ Convention provided an
opportunity for students of all three local
medical schools to come together for a day
of learning and networking. Through the
discussion of important issues pertinent to
medical education, the convention sought
to provide clarity on students’ roles as fu-
ture doctors in an evolving medical training
and practice landscape. In its first run, A/
Prof. Benjamin Ong (Director of Medical
Services, Ministry of Health) delivered the
keynote address “The Future of Singapore
Healthcare and What It Means to Medical
Students Today”.
Celebrating our 60th
anniversary this year,
SMA will continue to work towards being
a stronger representative voice of the medi-
cal profession in Singapore – for doctors,for
patients.
Acknowledgement:
We would like to thank Dr Tan Yia Swam
(1st
Vice President), Dr Daniel Lee (2nd
Vice
President), Ms Sylvia Thay and Ms Jo-Ann
Teo (SMA News Team) for their assistance
and support towards the writing of this article.
Dr. Benny Loo – Honorary Assistant
Secretary (60th
SMA Council)
Dr. Lee Yik Voon – President
(60th
SMA Council)
Singapore Medical Association – sixty years on
Lee Yik Voon
Benny Loo
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