WMJ 01 2005
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WorldMMeeddiiccaall JJoouurrnnaall
Vol. No.1,March200551
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall
Medical Professionalism 1
Tracing The Aetiology Of
Genetic Disorders In Children 1
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
Unesco’s proposed Declaration
on Bioethics and human rights 4
Medical Information and
Privacy in the Information Society 6
Advanced Medical Technology and Medical Ethics 14
Statement on healthcare in prisons
and other forms of detention 10
WWMMAA SSeeccrreettaarryy GGeenneerraall
From the Secretary General’s Desk 11
WWMMAA
The WMA Medical Ethics Manual 12
MMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
aanndd EEdduuccaattiioonn
Medical Implants For Higher
Performance And Longer Life 13
Modern Demands in Health Care 17
Coordination of Progress in Information
Technology with Health Care in the 21st Century 21
The Medical Liability System
in Germany – An Accepted System 23
Out Of Africa 25
WWHHOO
WHO Supports Global
Effort To Relieve Chronic Pain 25
Fight Childhood Obesity To Help
Prevent Diabetes, Say WHO & IDF 26
WHO Director-General Travels
To Indonesia And Sri Lanka 27
RReeggiioonnaall aanndd NNMMAA NNeewwss
Fiji Medical Association 27
European NMAs meet in Oslo 28
“UniversityHospitalCologne”Photo:EberhardHahne
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-elect President Immediate Past-President
Dr K. Letlape Dr Y.D. Coble Dr J. Appleyard
South African Med. Assn. 102 Magnolia Street Thimble Hall
P.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
Lynnwood Ridge 0040 USA Blean, Nr Canterbury
Pretoria 0153 Kent, CT2 9JJ
South Africa Great Britain
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. J.D. Hoppe Dr. Y Blachar Dr. T.J. Moon
Bundesärztekammer Israel Medical Association Korean Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
Germany P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721
Secretary General
Dr. Otmar Kloiber
World Medical Association
BP63, 01212 Ferney-Voltaire Cedex
France
Tel (33) 4 50 40 75 75
Fax (33) 4 50 40 59 37
E-mail: otmar.kloiber@wma.net
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
B.M.A House
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
Website: www.colmedbo.org
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868 00
Fax: (55-11) 317868 31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov
1431 Sofia
Tel: (359-2) 954 -11 69/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC E
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
UNITED STATES S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
ii
Association and address/Officers
iii
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores
Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24
00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@omsul.com
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Progresului 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: amr@amr.sfos.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA E
Russian Medical Society
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4
61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA E
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11
Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610
SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Medical Association
201, Shih-pai Rd., Sec. 2
P.O. Box 3043
Taipei 11217
Tel: (886-2) 2871-2121, ext 7358
Fax: (886-2) 28741097
E-mail: cma@vghtpe.gov.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
Editorial
Medical Professionalism
The problems facing the medical profession appear to be ever increasing. Some of the arti-
cles in the current issue of the World Medical Journal reflect this trend. The overview of
bioethical and other aspects of medical technological advances presented in Tokyo during
the scientific session of the WMA Assembly in Tokyo, analyse both the benefits and the
problems related to technological advance (see also Haddad’s article in WMJ50(4).
It even possible to detect the relegation of clinical skills in some clinical protocols to a
lower priority in the management of presenting disease ,which place the carrying out of
technological tests before clinical examination in the list of priorities.
The concerns of the European Forum of Medical Associations and WHO about the
Bologna Process, which proposes radical changes affecting the nature of basic medical
training, at a time when there has already been general agreement about the reform of the
basic medical curriculum, also express some feelings of serious disquiet. While welcom-
ing some aspects of the proposals, there is grave concern at the suggestion that the funda-
mental proposals for Bachelor / Master degrees for recognising academic studies should be
applied to medical basic studies. The apprehensions relate to the additional problems of
recognition which these will raise in an increasingly globalised world, where the problems
of recognition and increasing medical migration are significant problems already. It found
no evidence that the proposed two cycle Bachelor / Master process will improve anything
in the medical training process justifying the application of the Bologna proposals to med-
ical studies which are a specific training for a profession. Finally it expressed deep con-
cern, that such a move might undermine the positive integration of the theoretical and clin-
ical parts of medical education and then be harmful for the quality of patient care.”
Behind all of these problems is the increasing questioning of what constitutes profession-
alism in medicine. Dr. Mary Schramm ,President of the Fiji Medical Association, extracts
of whose address appear in the NMA news section, reinforces the importance of some of
the principles on which medical practice had been based for millenia. In the extracts from
her speech which appear in the NMA News section ,and she calls for their reinforcement.
Faced with the number of problems which individual doctors in their ordinary daily prac-
tice have to address, it is essential that, in a time of changing values and expectations, the
profession collectively also addresses the question of the professions’ role in today’s soci-
ety and whether or not this has any implications for the fundamental principles on which
the practice of medicine have been hitherto based.
Alan J. Rowe
Editorial
1
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At the Great Ormond Street Hospital for Children (GOSH) NHS Trust and the Institute
of Child Health (ICH), the new Dean, Professor Andrew Copp(i)
, reports that research
covers many aspects of child and developmental health, ranging from clinical genetics
to mental health. The goal is to make discoveries that can improve clinical practice for
the benefit of children locally, nationally and indeed internationally throughout the
world. Research and teaching opportunities are provided for ever broader clinical ques-
tions in child health – evidence-based disgnosis and cures for many common childhood
illnesses.
Tracing The Aetiology Of Genetic Disorders
In Children
The ‘Jeans for Genes’Appeal
Following the complete sequences of the
human genom, new ideas on genetic disor-
ders, the relation between structure and
function in the chromosomes, and the spon-
taneous occurrence of mutations, are being
investigated. An innovative piece of equip-
ment known as a pyrosequencer is at the
heart of numerous collaborations between
universities on the genes, development and
disease theme. For example, Dr James
Turton is researching the genetics of the
forebrain and pituitary gland development,
looking for mutations as transcription fac-
tor candidate genes in children with
endocrine growth disorders. The DNA
sequences in the genes will determine the
function and developmental processes of
each transcription factor, thus aiding disg-
nosis and treatment.
Pyrosequencing, using differential heat
processes to ‘melt’DNA chains, enables sci-
entists to study genes much more quickly
than was previously possible. Changes can
thus be detected in the genes that might be
relevant to disease causation. The system
identifies genetic mutations or variations in
a person’s DNA sequence known as ‘single
nucleotide polymorphisms’. Such SNPs act
like disease markers which identify people
who may be prone to a certain disease.
The problem lies in identifying the genes
that underlie childhood growth. Children
come into GOSH with all kinds of growth
problems, from relatively straightforward,
easily measurable hormone deficiencies that
can be treated by giving hormone replace-
ment, right through to those who have life-
threatening conditions in which their devel-
opment is severely restricted or abnormal.
Since the development of the pituitary gland
is closely linked to that of the forebrain,
some children may, for example, have very
serious central nervous system problems
such as blindness, autism and development
delay. Severely affected children may never
go on to develop normal brains, or in the
case of Duchenne muscular dystrophy boys
may become progressively weaker, result-
ing in death at a tragically young age.
The DNA pyrosequencer is used to screen
candidate genes – those which have already
been identified as playing a role in growth
problems. The pituitary development group
has identified many changes in both known
and novel genes implicated in normal devel-
opment of the pituitary and in control of
human growth. The skill of the biochemist
lies in being able to pick out genuine, dis-
ease-causing mutations from natural varia-
tions or polymorphisms found across the
normal population. Nevertheless, even these
variations may in time provide clues about
transcription factors that modify growth,
from DNA sequence to RNA (messenger,
transfer and ribosomal) to functional pro-
teins. Human growth hormone (HGH), via
adenyl cyclase, can stimulate normal devel-
opment and injections can be given to com-
bat pituitary dwarfism. Local hormones, the
cytokines, play their part in the growth and
development of specialised tissues in terms
of gene expression. Teams at GOSH are
working on the genes involved in asthma
connected with cystic fibrosis – where over
230 mutations have been found – juvenile
arthritis disorders and various genetic der-
matological diseases.
Gene therapy for cystic
fibrosis
It is 17 years since scientists first discovered
the gene responsible for cystic fibrosis, rais-
ing the prospect of a cure for a commonly
inherited life-threatening disease.
In a recent breakthrough, Dr Adam Jaffe and
his team at GOSH have discovered that,
given the correct conditions, children can
grow new and healthy lung tissue from stem
cells. The first trials of gene therapy for
patients with CF aimed to replace the abnor-
mal gene with a healthy copy administered
by a nasal spray. Despite initial optimism,
and even a temporary cure in some patients
who nevertheless reverted back to their
original condition, treatment has proved to
be elusive. This is partly because of the
nature of CF: the disease causes the lungs’
secretions to become thick and sticky. In the
absence of treatment death can follow at an
early age as these secretions clog up the
lungs, making breathing difficult, causing
recurrent infections and leading eventually
to respiratory failure.
In order to replace the abnormal gene in CF
sufferers, the healthy gene must be attached
to a ‘transfer agent’that will carry it into the
target cell. Although this has been achieved
using either a virus or a liposome (a fatty
substance that sticks naturally to cell sur-
faces), the presence of so much mucus
makes for great difficulty in penetrating the
cell. An additional problem is uncertainly
about exactly which cells within the air-
ways should act as a focus for the vector.
It has long been known that bone marrow
produces the cells that become blood cells.
More recently, scientists have proved that
bone marrow also produces stem cells with
the property of ‘plasticity’ ? that is, they are
capable of becoming other types of cell
entirely. Indeed, stem cells in the blood
could become lung cells, and so they could
offer an effective means of replacing dis-
eased lung cells affected by cystic fibrosis.
Dr Jaffe suggests that in the near future it
might be possible to cure babies of CF in
the womb. Treatment here may be less
problematic because unborn babies have
not yet developed their own independent
immune systems, and would therefore put
up less resistance to an incoming agent.
Gene therapy to tackle
blindness
The eye represents a fruitful area for gene
therapy according to Professor Robin Ali.
Clinical trials are being set up for a rare
inherited condition in the eye caused by a
single defect that causes blindness in chil-
dren, and age-related macular degeneration
(AMD) in the over 65s, a relatively com-
mon cause of blindness in the elderly that
has a complex mix of causes including dia-
betes. In both cases, a virus-derived vector
would be used to insert a gene into the cells
of the retina. For the inherited disorder, this
would involve replacing the missing or
defective gene. For AMD, genes would be
employed to treat major symptoms of the
condition, for example inhibiting the
growth of destructive, invasive blood ves-
sels into the retina.
Editorial
2
Genetics, development
and disease
According to Professor Peter Scambler, treat-
ing children with birth defects and inherited
conditions constitutes a major part of medical
practice in the West, America and Japan.
Although individually rare (the commonest,
CF, has a prevalence of carriers around 1 in
every 25 people), the 4,000 or so known
genetic disorders cause immense suffering
for affected children and their families.
Clinical management and genetic coun-
selling for these conditions depend on pre-
cise diagnoses, which are considerably
helped by having sophisticated computer
databases. The aim is to pick out the genes
that have been mutated causing malforma-
tions and cancers, using the new techniques
from biochemistry and molecular biology.
Once a gene involved in a disease syn-
drome is identified, the function of the pro-
tein it encodes for is elucidated. In order to
further our understanding of the fundamen-
tal mechanisms operating in embryology, it
is important to establish an axis in the inter-
nal architecture of the cell. In the develop-
ment of children’s diseases, and in the
expression of genetic mechanisms, rare dis-
orders may present at the same time as
common problems, for example in heart
conditions, diabetes and mental illness.
At GOSH/ICH, in addition to studying sin-
gle gene disorders, work is underway which
attempts to unravel more complex gene and
gene-environment interactions that may
underlie common conditions such as deaf-
ness, cleft lip and palate, obesity and aller-
gies in atopy. At the whole organ and cellu-
lar level, doctors are interested in disease
processes and how they might be modelled
effectively in the laboratory and on comput-
er. For instance, significant progress has
been made in understanding how malformed
duplex kidneys occur, and in bringing back
to life cells involved in ischaemic heart dis-
ease, the penumbra where they lack oxygen,
and in spinal and neuronal injuries which can
be treated with stem cells. Novel routes to
treatment are being discovered which impact
directly upon disease processes. Surgical
treatments at the micro-level, such as heart
valves delivered by catheter inside the heart,
or relief of kidney and bladder malfunctions,
are constantly being improved.
Making sense of Usher
syndrome
Dr Maria Bitner-Glindzicz reports that
Usher syndrome is a form of inherited deaf-
ness in which children also progressively
lose their sight. Restricted vision or night
blindness in Usher syndrome may first
become apparent around the age of 7 years ?
and this often progresses to severe visual
impairment in the teens. During the year
2000, her medical team saw two very unusu-
al families at GOSH and succeeded in iden-
tifying the gene responsible for their condi-
tion. Within these families, siblings or other
relatives such as cousins had not only devel-
oped deafness, but they also had hyperinsuli-
naemia problems with blood glucose con-
trol, which had not been previously linked to
Usher syndrome. It was established that the
genes causing these conditions were located
next to each other and that a stretch of DNA
was missing from the tip of chromosome 11.
On-going research has revealed that abnor-
malities associated with at least 13 genes can
underlie Usher syndrome. In most cases the
normal role of the gene is to control the
development of sensory hair cells of the
inner ear. In relation to the eye, their function
is less clear – young children with the condi-
tion develop normally until around 7–8 years
of age. Visual problems controlled by these
genes appear to be associated with maintain-
ing photoreceptor cells required for sight.
The severity of Usher syndrome together
with increasing knowledge of its genetic
basis means that more sensitive detection
and earlier treatment may become possible.
The responsible genes identified to date are
all recessive; hence a couple who are both
carriers of the abnormal gene have a 1 in 4
chance of their child being affected. The
condition is quite often diagnosed in a child
before the couple have completed their fam-
ily, and so this has very significant implica-
tions in terms of counselling. However, as
we don’t yet know all the genes that can
cause Usher syndrome, and those that we do
know are very large, accurate genetic testing
during pregnacy is not yet possible.
To date there are three types of Usher syn-
drome which differ in severety and age at
onset. The severest form, type 1, presents
with profound deafness, balance problems,
failure to develop speech and the need to
learn sign language for communication
unless there is a cochlear implant. Children
with type 2 have moderate to severe deaf-
ness, normal balance, and they can learn to
speak if they have a hearing aid. Type 3 is a
recent category in which hearing is normal
at birth but progressively deteriorates. All
children suffering with Usher syndrome will
ultimately develop severe visual problems.
The relative rarity of the syndrome, as with
so many genetic diseases in children (1 in
1000 children are born deaf and about 5%
of these are thought to have Usher syn-
drome), does not make it an obvious candi-
date for the development of genetic tests.
Further knowledge about the genes
involved in disease causation would not
only allow pre-natal testing, but would also
bring closer the possibility of gene therapy
for the visual problems in affected children.
Genetic abnormalities under-
lying Bardet-Biedl syndrome
Infants with Bardet-Biedl syndrome (BBS)
are often born with extra fingers or toes, have
learning difficulties, and gradually develop
progressive blindness and obesity. In some
cases the latter can lead on to diabetes, heart
disease or kidney failure, causing early death
in about a third of those with BBS.
Dr Philip Beales, a Wellcome Trust Senior
Research Fellow, explains that his interest
in BBS started when he was working on
diabetes in children, which involves many
genes and gene interactions. When he saw
his first case of BBS (1 in 70,000 children
are affected), which has diabetes and obesi-
ty at its core, he realised that this condition
might help doctors understand more com-
mon problems in the population.
With access to genetic information for about
500 families, much of Dr Beales’ research
focusses on the genetic abnormalities that
Editorial
3
On January 28, 2005 the International
Bioethics Committee (IBC) of UNESCO
(United Nations Educational, Scientific and
Cultural Organization) finalized its pro-
posed Universal Declaration on Bioethics
and Human Rights2
According to the
timetable approved in April 2004 by
UNESCO’s Executive Board, the Decla-
ration will be presented to UNESCO’s
General Conference in October 2005 for
adoption. Before going to the General
Conference, the IBC final draft will be
examined, and is likely to be amended, by a
committee of government experts meeting
in April and June 2005.
Despite two major consultations on earlier
drafts of the Declaration and subsequent
revisions, the IBC’s final draft is seriously
flawed. At a conference held on 25–26
February 2005 in Paris to review this draft,
speaker after speaker pointed out ambigui-
ties, inconsistencies and omissions and
expressed major differences of opinion
regarding the aims and contents of the doc-
ument. Since no further consultation is
scheduled, it will be up to the government
experts and ultimately the government rep-
resentatives to the UNESCO General
Conference to determine the final form of
the document and to decide whether it
should be adopted.
Physicians and other health care profes-
sionals have good reason to be concerned
about the deficiencies of the draft
Declaration. Although it would not have
the binding legal status of a Convention, it
encourages nation states to “take all appro-
priate measures, whether of a legislative,
administrative or other character, to give
effect to the principles set out in this
Declaration3
”, and it contains provisions
for monitoring and evaluating its imple-
mentation by states. It would be far better
to correct the deficiencies of the document
before it is adopted rather than having to
deal with them afterwards.
Major Defects
Although the draft Declaration contains
much that is worthy of support, its scope
and aims are inappropriate and many of its
principles present problems in their inter-
pretation and application. In what follows,
only the most important shortcomings of
the Declaration will be discussed.
Scope – Contrary to the advice of the WMA
Ethics Unit4
and the World Health Orga-
nization (WHO)5
among others, the
Declaration defines ‘bioethics’ very broad-
ly as “the systematic, pluralistic and inter-
disciplinary study and resolution of ethical
underlie BBS. The condition is unusual in that
some of those affected have mutation not only
in both copies of the same gene (one paternal,
one maternal, the usual pattern in recessively
inherited conditions), but they may also have
a third mutation in another gene.
Eight genes involved in causing BBS have
been found and, with colleagues from the
USA and Canada, Dr Beales’ group is
investigating their function. Of particular
interest is the role that some or all of these
genes play in the motility of cilia. Ciliated
cells with motile, flexible tails based on
ATPase activity are widespread throughout
the human body.
Much work has involved a Birmingham-
based, Pakistani family in which all three
sons (but not the one daugther) are severely
affected by BBS. The protein encoded by the
BBS-8 gene is missing in all three boys in
this family. The researchers hope that these
studies will reveal more about the link
between ciliary and cellular function, and in
turn further elucidate the developmental and
cognitive patterns which occur in BBS.
Genes, sex, facial expression
and autism
Two striking features in studying childhood
to adult autism have been linked: the fre-
quent problems of those affected in under-
standing the meaning of expressions on
people’s faces, and records which show that
men are much more likely to have autism
than women.
Professor David Skuse has reported
progress in tracking these conditions. His
team have looked at the sex chromosomes,
XX for women and XY for men, and they
found that one of the clearest risk factors
for autism lies in possessing only one X
chromosome. Women suffering from
Turner’s syndrome (one X instead of two)
and men (XY) both have a much higher risk
of autism than women with two X chromo-
somes. Indeed, women with a specific dele-
tion of a particular section of the X chromo-
some cannot accurately process some facial
expressions. They behave in this respect
like autistic people.
This key section of the X chromosome is
linked to the amygdala part of the brain
involved in processing emotional expres-
sions on people’s faces. The data suggest
that having two fully functioning X chro-
mosomes definitely protects agains autism
— and would account for the traditional,
cooperative care so well developed
amongst women as compared to the com-
petitive, combative streak so often found in
men.
Ivan M. Gillibrand
(i)
Reference
Leading the way
Research Review 2003
Institute of Child Health and Great
Ormond Street Hospital for Children
NHS Trust
Medical Ethics and Human Rights
4
Medical Ethics and Human Rights
Unesco’s proposed Declaration on Bioethics and human rights1
issues raised by medicine, life and social
sciences as applied to human beings and
their relationship with the biosphere,
including issues related to the availability
and accessibility of scientific and techno-
logical developments and their application”
(article 1). By including ethical issues in
medicine in the scope of the document,
UNESCO is clearly overstepping its man-
date and encroaching on that of WHO.
More seriously, many of the document’s
principles are inappropriately applied to
clinical medical practice, as will be shown
below.
Aims – Article 3 of the draft Declaration lists
no less than seven aims. The first is the most
problematic because it includes two incom-
patible proposals: (1) “to provide a universal
framework of fundamental principles and
procedures to guide States in the formulation
of their legislation and policies in the field of
bioethics,” and (2) “to form the basis for
guidelines concerning bioethical issues for
the individuals, groups and institutions con-
cerned.” These statements demonstrate clear-
ly the confusion of law and ethics that perme-
ates the document. Given the definition of
bioethics as “the study and resolution of eth-
ical issues…,” how can bioethics be incorpo-
rated into laws? There can be laws regulating
the practice of medicine, medical research
and the organization and delivery of medical
care, but these should not be confused with
bioethics. The second part of this article is
appropriate for bioethics, insofar as it speaks
of guidelines for individuals, groups and
institutions. But these have a different status
to that of laws. They speak to how people
should act rather than how they must act.
Principles – The heart of the Declaration is a
set of 12 principles that, according to article
2, “apply as appropriate and relevant: (i) to
decisions or practices made or carried out in
the application of medicine, life and social
sciences to individuals, families, groups and
communities; and (ii) to those who make
such decisions or carry out such practices,
whether they are individuals, professional
groups, public or private institutions, corpo-
rations or States.” Whether a principle is
appropriate and relevant to a particular deci-
sion or practice will often be a matter of dis-
agreement, particularly between the two
main audiences to which the Declaration is
addressed, namely, States and individuals/
groups/institutions. Here again, the Docu-
ment confuses law and ethics.
The following principles are particularly
questionable for their application to med-
ical practice:
Article 5 – Equality, Justice and Equity:
“Any decision or practice shall respect the
fundamental equality of all human beings
in dignity and rights and ensure that they
are treated justly and equitably.” This prin-
ciple fails to take into account the multiple,
and incompatible, concepts of justice and
equity in health care6
. According to their
codes of ethics, physicians are not being
unjust when they give priority to their own
patients over others, but a State could inter-
pret this article in such a way as to require
physicians to practise in public facilities
open to all patients.
Article 7 – Respect for Cultural Diversity and
Pluralism: “Any decision or practice shall
take into account the cultural backgrounds,
schools of thought, value systems, traditions,
religious and spiritual beliefs and other rele-
vant features of society.” This is clearly
impractical, if not impossible, in most clinical
encounters between physicians and patients.
Article 10 – Informed Consent. This article is
divided into three parts, the first dealing with
research, the second with medical diagnosis
and treatment, and the third with persons lack-
ing the capacity to consent. Apart from the
fact that it is clearly impossible to summarize
the ethical principles relating to informed
consent in five sentences, the article makes no
provision for emergency treatment in situa-
tions where consent cannot be obtained.
Moreover, although the Declaration is sup-
posed to provide a universal framework of
fundamental principles and basic procedures
designed to guide States in the formulation of
their legislation and their policies in the field
of bioethics, the principle for consent to med-
ical diagnosis and treatment for incompetent
patients in this article is simply that existing
domestic law should be followed.
Article 11 – Privacy and Confidentiality:
“Any decision or practice shall be made or
carried out with respect for the privacy of
the persons concerned and the confidential-
ity of their personal information. Unless
irretrievably unlinked to an identifiable per-
son, such information shall not be used or
disclosed for purposes other than those for
which it was collected.” The second sen-
tence of this article is considerably more
restrictive than the WMA Declaration on
Ethical Considerations Regarding Health
Databases7
, as well as existing legislation in
many countries. If adopted, it could serious-
ly inhibit epidemiological research.
Article 12 – Solidarity and Cooperation:
“Any decision or practice shall pay due
regard to solidarity among human beings
and encourage international cooperation to
that end.” Depending on how “due regard”
is interpreted, this principle is inapplicable
to patient-physician encounters.
Article 13 – Social Responsibility: “Any
decision or practice shall ensure that progress
in science and technology contributes, wher-
ever possible, to the common good.” The
comment on article 12 applies equally here.
Article 15 – Responsibility towards the
Biosphere: “Any decision or practice shall
have regard to its impact on all forms of life
and their interconnections and to the special
responsibility of human beings for the pro-
tection of the environment, biodiversity and
the biosphere.” Here again, the Declaration
is far removed from the realities of clinical
medicine.
The next section of the Declaration is enti-
tled, “Conditions for Implementation.”
The eight articles here are just as problem-
atic as the above-mentioned principles.
For example:
Article 16 – Decision-Making. This article
requires that any decision or practice
should “be made following full and free
discussion and in accordance with fair pro-
cedures.” This may be appropriate for law
making but certainly cannot apply to emer-
gency medical procedures.
Article 17 – Honesty and Integrity: “Any
decision or practice should be made or car-
ried out with: (i) professionalism, honesty
and integrity; (ii) declaration of all conflicts
of interest; and (iii) due regard to the need
to share knowledge about such decisions
and practices with the persons affected, the
scientific community, relevant bodies and
civil society.” Since the Declaration is
Medical Ethics and Human Rights
5
addressed to every individual, the require-
ments of professionalism and of a declara-
tion of conflicts of interest are inappropri-
ate. The “due regard” of the last sentence is
open to multiple interpretations.
Conclusion
Despite its best efforts, the IBC was unable
to produce an adequate Declaration on
Bioethics and Human Rights in the nine
months allotted to it by the UNESCO
Executive Board. It is highly unlikely that
the committee of government experts in
two meetings will be able to succeed where
the IBC failed. This is not at all surprising,
given the nature of bioethics, its relatively
recent rapprochement with human rights,
and UNESCO’s desire to respect cultural
diversity and national sovereignty. The
World Medical Association, which deals
with similar challenges, took three years
(1997-2000) to revise the Declaration of
Helsinki. One reason for this delay that
could be a lesson for the UNESCO project
was the willingness of the WMA Council
to recognize that the process followed dur-
ing the first 18 months of the revision was
not the right one and that a different
approach was needed8.
The new approach
proved successful, despite many difficult
challenges. We can only hope that the
UNESCO Executive Board or General
Assembly will likewise realise that the
process followed to date to develop a
Declaration on Bioethics and Human
Rights has not been successful and will
authorize a new approach, one that will
include sufficient time for further consulta-
tion and consensus-building.
John R. Williams, Ph.D.
Director of Ethics
World Medical Association
1
The views expressed in this article are those
of the author, not necessarily of the World
Medical Association.
2
http://portal.unesco.org/shs/en/file_down
load.php/10d16a8d802caebf882673e
4443950fd Preliminary_Draft_EN.pdf
3
Proposed Universal Declaration on Bioethics
and Human Rights, paragraph 24
4
https://www.wma.net/e/ethicsunit/
unesco_project_bioethics.htm
5
http://portal.unesco.org/shs/en/file_down
load.php/e9d8dfce8497c221c4e620d11952
dde1Consultation_en.pdf
6
WMA Medical Ethics Manual
(https://www.wma.net/e/ethicsunit/re
sources.htm), 72
7
https://www.wma.net/e/policy/d1.htm
8
Williams JR: The Promise and Limits of In
ternational Bioethics: Lessons from the Re
cent Revision of the Declaration of Helsinki.
Journal international de bioéthique/Interna
tional Journal of Bioethics 2004; 15: 36-37
Medical Ethics and Human Rights
6
Medical Information and Privacy in the Information Society
Norio Higuchi
Professor of Law
University of Tokyo, Japan
Presented at the WMA General Assembly in
Tokyo 2004
It is truly a great honor and joy for me to be
here, given a chance to talk about one of the
most important and interesting topics which
is medical information and privacy in con-
temporary society. I have been teaching
comparative law and medicine for more
than ten years at the University of Tokyo
from the nnn in particular relating to the
U.S. and Japan and now I am chairing a
government committee for making guide-
lines on this subject.
I. Introduction: Two
metaphors to deal with
medical information
The importance of medical privacy in this
era
1) As all of you are aware, from the ancient
Hippocratic Oath to the present day, the most
basic duty of physicians is that of confiden-
tiality, or keeping the secrets of patients.
Medical information and privacy issues are
not new. No one, physicians, patients, or
general public, need or should worry about
it, since it has been a long established duty of
physicians. Nevertheless, this particular
issue is a major concern in most countries
worldwide in this 21st century. Why? There
should be some reason for it, and I believe
there are at least three.
First, we have come to make more and
more use of patients’ information in a
broader context. Medical information is
originally acquired and accumulated for the
care and cure of patients. It is nowadays,
however, used in a much broader context.
For instance, it is used for a variety of aims,
such as the oversight of medical institu-
tions, educational uses for young physi-
cians, nurses, or paramedics. Also in some
circumstances, physicians are legally oblig-
ed to disclose medical information to out-
side authorities. It is easy to imagine such
situations in public health area and also
child protection matters. At any rate, the
more use there is of medical information,
the more concern we should feel about it.
Second and related is the fact that we live in
the so called “information society”. This
medical information is not in a paper form,
but an electronic file. It could be transferred
instantly to the opposite side of the world.
Amazing it is, but it certainly increases fear
among us. Imagine that someone we do not
know at all or have never seen, knows
about my illness, diagnosis, family medical
history. it is really scary, isn’t it?
Third, it has something to do with the
increased distrust of physicians among the
general public. It is well known that bioethics
in the United States has grown from the big
scandals about medical research in 1950s and
60s. Also informed consent doctrine and
emphasis upon patient autonomy in that
country is a sort of indication that we cannot
rely upon paternalistic protection by physi-
cians any more, “in sum”, we could not
depent on medical professionals. In Japan,
during the last ten years, we have seen many
medical accidents in major hospitals,. Media
report a lot and we see almost daily some
reports of medical mishaps. Patient safety has
become a major policy issue for the govern-
ment, the Ministry of Health, Welfare and
Labor, who are planning to accumulate and
analyze the reports of medical accidents and
incidents nationwide. Patient safety in this
context means, as we should be aware, that
patients should be safe from physicians!
2) Two metaphors to protect medical priva-
cy in Japan: the metaphor of ownership
That is why we are now worrying about
medical information issues. To deal with
our concern, two metaphors are quite popu-
lar in Japan. I will show you what they are
and, although they are popular and easy to
understand or believe, they are wrong or
useless. I wonder if the same type of
metaphors is used in other countries. If it is,
my discussion will apply as well.
The first metaphor is that of ownership of
property or a thing. We see a number of
publications, books and articles, which are
titled “Who owns medical charts or medical
records?” This metaphor of ownership of
property is totally wrong.
In the first place, information is not a thing
at all. For instance let us compare informa-
tion with your paper material in your hand.
The paper is certainly a thing, but informa-
tion is not. Even though the paper includes
information, information is distinguishable
from the paper, which contains it.
Information cannot be seen, or cannot be
touched. It is intangible.
In the second place, the claim of ownership
emphasizes monopolizing something. It
means that this particular something is
exclusively mine or yours or his or hers.
Certainly, if you say this paper document is
yours, then, when you read it, others cannot
read it. Others can be completely excluded.
Information is, however, difficult to
monopolize. Rather, information can be
shared at the same time. You can enjoy
information without disturbing others’
enjoying it. That is the peculiar characteris-
tic of information.
In the third place and most importantly, it is
hard to earmark so that this particular infor-
mation is yours. With regard to the paper
document in your hand, you can write your
name on it to show your ownership. In the
case of information, it is really hard to do
so. Also, once information is disseminated
out of your control, it is extremely difficult
to recover and get back to the past. We
should recognize that information is so spe-
cial. It cannot be contained. It is not a thing.
You might say, however, that there is a legal
device for the ownership of information. It
is the scheme of intellectual property.
Patents and copyrights are famous exam-
ples by which inventors or authors enjoy
ownership over information they created,
and the law recognizes it.
Professor Nobuhiro Nakayama, an authori-
ty of intellectual property law in Japan, says
that if information can be successfully con-
tained, then we could think of private prop-
erty in it. There are two means for it. One is
literally to contain information, or to keep it
secret from any others. If you know some-
thing valuable, and also if you would like to
take advantage of it in financial terms, then
you can make it secret rigidly and share
with only few of those who would pay for
it. If you find someone who pays for it, the
information is your property, which would
bring money to you. However, this strategy
has its own limitations. The more valuable
the information is, then the more probable
the information will be leaked. You cannot
trace how it escapes and also it is hard to
get back to the past.
That is how most society develops the intel-
lectual property scheme. Through this device
of legal imagination, the law grants a sort of
ownership for a certain period to the inven-
tors, authors of other creators of information.
However, the important point is the fact that
those inventors or authors could not keep it
secret. Rather that the secrecy, the disclosure
is encouraged under the intellectual property
law. Well then, is there anything common
between the intellectual property idea and
our concern with medical information? Very
little, if any, is my answer.
When we talk about medical privacy, we
usually do not care about medical invention.
What we do discuss is patients’ concern
about their privacy. After all, the legal sys-
tem of intellectual property is a matter of
money. It is an artifical legal device to
encourage creative activities by giving
financial incentives. Most patients, however,
do not wish to keep their information pro-
tected for financial reasons. In other words,
the metaphor of ownership and property fits
very well with monetary interest, which has
nothing to do with patients’ concern.
3) The second metaphor: balance of interest
The second popular metaphor with regard
to medical privacy is balancing of interests.
Suppose there is a balance to judge what is
just. On the one side, we put medical priva-
cy and on the other, we put its uses for other
values than privacy. Let me quote one
example from what happened recently in
Japan.
Our Parliament enacted the Individual
ProtectionAct of 2003 which covers medical
information, and will take effect from April
2005. The first section of this important act
prescribes the main purpose of law, which is
to protect the privacy rights of individuals
while taking into consideration appropriate
uses of information. In sum, this Act orders
to make a good balance between protection
and use of information about citizens.
But the problem is how to make good bal-
ance. To tell the truth, the act itself is of lit-
tle help. Two points should be noted in par-
ticular.
First, in the process of enactement, a sort of
interim report was published in 1999 by an
advisory committee, which clearly empha-
sized the basic idea the coming Act should
be the right to control one’s own informa-
tion. But, it is gone from the face of the Act.
The idea of the right to control one’s own
information is close to the ownership
metaphor. It is now gone and has moved to
the balancing metaphor.
Second, Professor Yoshiharu Matsuura, a
legal philosopher at Nagoya University,
explains that the metaphor of balance
works well only if there is already an estab-
lished rule in a comparable situation. This
is totally different from our situation, where
we only say that both protection and use are
important to medical information. We can
see no related or established rule, and this
7
Medical Ethics and Human Rights
cannot make a good argument from the
comparison and analysis from it.
4) The failure of two metaphors
To sum up so far, we love metaphors that
are easy to understand and also to apply in
appearance. The metaphor of ownership
and balance are exactly those types. Yet,
they give us only dreams or illusions. They
do not help us much.
II Construction from the
basis: why we should pro-
tect medical information
1) Search for a way of solution
When we find that popular metaphors fail,
we need to get back to the starting point of
discussion, as to why we should protect
medical information.
The answers may appear so various that it
may sound a waste of time. An example of
balance metaphor comes from patient safe-
ty area in Japan. In April 2003, a govern-
ment committee within the Ministry of
Health, Welfare and Labour, issued a report
to make hospitals and medicine safer. The
core idea is that we should learn from mis-
takes. In order for us to do that, we need to
collect accident and incident reports, and
send back a proposal for deterrence and
prevention to each medical institution. To
realize and organize the scheme, the report
argues for the establishement of a profes-
sional institution for patient safety.
Our interest in this report is that it tries to
make uses of medical information of patient
safety, while it emphasizes as well the impor-
tance of patient privacy. We can see the
metaphor of balance.
For instance, when our Parliament enacted
the Information Protection Act, in 2003,
each House added a resolution requiring the
government to consider within two years
whether some additional special legislation
should be enacted in three important evi-
dences, to prove that our representatives
regarded medical information protection as
one of the highest policy issues.
But, if it is so crystal clear, we need not use
the metaphor of balance from the begin-
ning. We should protect patient informa-
tion, and that is the end of discussion. The
problem is, however, not so easy or not so
simple. We need to return to the most basic
question: why we should protect medical
information.
Consider then an example from the credit
and finance area, which includes sensitive,
information in the medical field according
to our Parliament. Suppose that you are a
creditor and that you lend money to some-
one. Under Japanese law and maybe in other
countries as well, you need not acquire con-
sent from your debtor when you transfer
your claim (chose in action against the
debtor) to a third party. After completing the
deal between you and the third party, the
debtor will have to pay the debt, not to you,
but to the third party. Under the Civil Code
in Japan, you need not get consent from the
debtor, but you have to give notice to the
debtor. Otherwise, the debtor will be at a
loss as to whom he or she should pay.
The Information Protection Act gave us an
opportunity to reconsider this rule. Suppose
that you want your claim cashed now, and
decide that you would transfer or sell your
claim to a third party. During the transac-
tion, you would be required to explain
about the debtor’s financial situation. The
potential assignee would ask: Is the debtor
reliable? Does he have a stable job and
position? Has he not made any defaults in
the past deals? The information you would
give to the third party is exactly credit
information of the debtor. If the new Act
protects credit and financial information
and prescribes a consent rule to transfer it to
the third party, you cannot enter a negotia-
tion without consent from the debtor.
It is quite strange if you can transfer your
claim without consent of the debtor under
law, but you cannot negotiate with the third
party without permission from the debtor. In
monetary transactions, debt transfer is much
more important than the information related
to it. Still if the new act says, “you can do
the principal part of transaction, but cannot
do the incidental part and therefore cannot
do the whole transaction,” it is clearly a
legal inconsistency. Also it would overthrow
the credit transaction system altogether.
2) A couple of lessons from the example of
credit area
Let us draw a few lessons from the example
above mentioned.
First, the example reminds us that there are
two parts of transaction, though they are
closely related with each other, which
should be definitely distinguished: transfer
of debt, the principal part, and flow of Infor-
mation, the incidental part. In the case of
claim transfer, the new act could not have
changed the fundamental rule of it. Even
after the passage of Information Protection
Act, therefore, any creditors could transfer
their claim freely without taking consent
from the debtor. It means that we should be
cautious about interpreting the new
Information Protection Act. While it appears
to say that the transfer of information
including credit status would always require
consent some exception should apply to this
case. One possibility is to look to a section
in the Act that the information transfer to a
third party is permissible without consent if
the transfer has some legitimate basis under
the law. Our Civil Code is exactly the law,
one of the most basic laws in our country,
and the Code allows the transfer of claims
without consent, which transaction
inevitably accompanies with information
transfer. Thus, creditors could discuss with a
potential buyer about debtor’s credit status
without his consent under the new law.
At any rate, the first lesson to learn from this
credit example is this. We should keep in
mind that we may be dealing with informa-
tion matters side by side with the principle
transaction, and the latter is more important
than the former in most cases. In the medical
context, the principal part of transaction
between physician and patient is physicians’
treatment of patients’ body and mind. In this
aspect, the ownership metaphor applies
without question. Patients own their body
and mind. It is not a metaphor, but a reality.
The bodily integrity or the right to decide on
one’s own body and mind should be most
highly respected. We should stricly apply the
informed consent rule to this principle part
of transaction, and that is for the better or
best treatment for patients. We should, how-
ever, make a distinction with regard to infor-
mation matters. Suppose, for instance, that a
8
Medical Ethics and Human Rights
physician hears that another physician has
medical information about you, which is rel-
evant and necessary for your treatment.
Should he wait for your visit next time when
he gets a consent from you authorizing the
release of information from that physician?
Should the same consent rule strictly apply?
My answer is no. The rule would only delay
your treatment, which is just a waste of time,
since any of you would give your consent
and the delay would not benefit you at all.
Also one more thing to note here is that the
medical information is much more useful in
a social context than credit information. It
is easy to prove it. Let us compare a person
who is bankrupt with another person who
has an infectious disease. From the view-
point of society as a whole, the latter infor-
mation is much more important than the
former. Thus, it is much harder for us to
stick to the consent principle in the medical
context.
A second lesson from the credit example is
that the individual Information Protection
Act has some significance, nevertheless.
Let us suppose that the creditor tells a third
party about the debtor in each of the follow-
ing ways.
(A) The third party happens to be the
employer of the debtor, and he decides to
make use of credit information for the
employment and promotion context. Or,
(B) The third party wants to know every-
thing about the debtor, and the creditor
informs the debtor’s family matters, med-
ical history, and the number of tickets he
got from the police in the past. Or,
(C) The creditor makes mistakes and wrong
information about the debtor’s credit status
is transferred to the third party, who makes
a misjudgment on it.
These hypos vividly show that free infor-
mation transfer should have its own limita-
tions. We need some rules against these
things happening for the protection of the
debtor. And that is the very reason for the
Information Protection Act.
In the medical context, these examples sug-
gest that patients’ concern about informa-
tion transfer is natural and justified in the
following cases.
(A) Information transferred may be used for
discrimination.
(B) Information transferred may be more
than necessary for the legitimate uses of
information.
(C) The information transferred may be
wrong and it may harm the patient’s interest
some way or other.
From the credit example, therefore, we
could draw a couple of important lessons.
The first one is that we should not believe
in the consent principle too much in the
information context. The second lesson is
that can we still find legitimate concern of
patients about information handling in
medical context. Also that improvement of
information protection would help not only
patients but also society as a whole. We
should think seriously about the strategy in
that direction without relying only on the
consent principle.
III A strategy for the better
future
1) From the wishes of patients
In order to make a good strategy for future
we need to get back to patients’ wishes and
ask what they want. They want at least the
following:
(A) Patients wish to see their own medical
record. Since medical information relates
their health condition, their interest is natur-
al. The rhetoric that they own the informa-
tion is unnecessary, and what they need is
“the right to know.” Thus section 25 of the
Information Protection Act prescribes the
duty of disclosure on the part of hospitals.
(B) Patients want physicians and hospitals to
take good care of their medical information.
They fear that it may be leaked to others, and
that they may receive some day those mail
ads which clearly show that others know
their illness.They fear discrimination by the
reason of illness in the context of insurance,
employment, or other social activities. Here
as well, the rhetoric of metaphor of informa-
tion ownership is not needed. What they
need is the reight to monitor or check han-
dling of information by medical experts.
Under the Japanese law, it prohibits hospitals
from making use of information for other
purpose than the specific ones appropriately
notified in advance. Also, disclosure of med-
ical information to a third party requires con-
sent by patients in principle.
(C) In some cases, patients’ main concern
may not be their information, but informa-
tion about their health and medical treat-
ment. That may be the precise reason for
claiming the right to know access or med-
ical records, by which they try to check the
medical treatment itself. Also it may be true
that those physicians, who manage medical
information well treat patients well and
take good care of them. In other words,
patients wish to trust towards physicians.
Second, although patients’ wish should be
always important, I would repeat again and
again that it is unnecessary and wrong for
them to claim ownership of medical infor-
mation. It is not logically correct, since
information is not subject to ownership in
most cases, but also it is not desirable for
policy reasons. Patients should not monop-
olize their information. Of course, physi-
cians should not monoplize it, either. It is
easy to understand this, when you imagine
a case in which a patient suffers from an
infectious disease, and also when a physi-
cian finds a new method of treatment and
tries to keep it secret. nnn The information
should be reported and responded to, and in
the case of new method of treatment, it
should be shared. In a word, medical infor-
mation is too precious and too valuable in
social terms to be monopolized by anyone.
2) A strategy for protection and uses of
medical information
We thus should seek for a new strategy to
pursue two aims at the same time: best
medical treatment for the individual patient
and also best uses for the benefit of entire
society. I have studied the so called
“HIPAA privacy rule”, which took effect in
2003 in the United States.
The most important characteristic of the
HIPAA privacy rule is the fact that it seeks
for two aims at the same time. It tried to
speed up the standardization of medical
information through electronic means and to
reduce the health costs to society. Since stan-
9
Medical Ethics and Human Rights
dardizing in the form of electronic data
increase the risk of privacy, they introduce a
comprehensive nation-wide rule to protect
medical information. Put another way, they
found the accumulation of medical informa-
tion in a standard form beneficial to society
as a whole, and, in order to realize its benefit,
found it necessary and indispensable to set up
a legal system to protect medical privacy.
The same reasoning should apply to Japan as
well. The first goal, then, is to set up a scheme
to gather as much useful information as possi-
ble. The goal can be justified in two ways.
First, it is beneficial to patients. As we saw,
the most basic and fundamental wish of
patients was and has been the best medical
treatment for them, and the best health care
could be realized on the maximum of rele-
vant information.
Second, accumulation of medical informa-
tion is beneficial to the society as well. It
can be used for variety of useful activities
such as public health, medical research
oversight of clinical practice etc.
Thus, we come to a conclusion that the first
basic goal is to accumulate medical informa-
tion. But the information to be gathered has a
peculiar character, quite different from things
or property we saw in the first part. Inaccurate
information is useless and harmful. Even
though it is accurate, if disseminated and used
for bad purposes, then patients would be
reluctant to share information, since it is
extremely hard to recover the original status.
The specific character and importance of
medical information requires us to be cau-
tious with making up a legal strategy to pro-
tect medical privacy. The system should be
equipped with three principles.
(1) Prevention principle to deter leakage of
information.
(2) Discovery principle to find out viola-
tions as fast as possible.
(3) Sanction principle to punish intentional
wrongdoings.
The first principle of prevention is realized
by setting clear and concrete rules to be fol-
lowed by both physicians and patients. The
privacy rule should be clear cut in content
and make no traps for those who deal with
medical information. Also patients should
understand, how their information is used,
disclosed, and kept secret. Each hospital
should publish a privacy statement or a priva-
cy policy. It should include how the patients’
“right to know” is respected and realized.
As to the second principle of discovery,
there are a couple of means to make it easi-
er to discover privacy violations. One is the
patient’s right to accounting, by which they
can claim for tha actual use and disclosure
of their inforamtion. More specifically, they
have the right to know how has made access
to their inforrmation has been used. Te
American HIPAA privacy rule recognizes
this right to accounting, but Japanes Act
does not. We should consider seriously
making use of monitoring incentives on the
part of patients to discover privacy viola-
tions. It would help to deter violations. The
other means for early discovery of viola-
tions is to give a privacy officer in medical
institutions a high status and strong power.
He or she should be responsible for compli-
ance with the privacy rules. Under the
Information Protection Act in Japan, every
entity is required to have a privacy officer,
but who it will be and what kind of expertise
and power will be given remains to be seen.
The third principle of sanction is the most
weak under Japanese law. The maximum
sanction against privacy violations is six
months imprisonment and 2,700 U.S. dol-
lars fine. Let me contrast this with U.S.
HIPAA privacy rules in which the maxi-
mum penalty is ten years imprisonment and
a fine up to 250,000 dollars. Of course,
criminal sanction is just a part of the whole
scene.We should not forget that other sanc-
tions could work well, but we should recon-
sider the comparatively lenient attitude
even in the case of intentional wrongdoing
when we think of the importance of medical
privacy.
10
Medical Ethics and Human Rights
European Forum of National Medical Associations
Statement on healthcare in prisons
and other forms of detention
The European Forum of Medical
Associations and WHO meeting in Oslo
on 11 – 12 March 2005,
Notes that healthcare in prisons, detention
centres and police institutions raises spe-
cific ethical and health issues;
Welcomes the activities and initiatives of
national medical associations to provide
support and education (such as the
Norwegian Medical Association/WMA
internet course) for doctors working in
custodial care;
URGES national medical associations to
address these issues, working to the fol-
lowing broad principles:
• Detained persons should receive a stan-
dard of medical care equal to that avail-
able within the general community.
• Healthcare in prisons should be struc-
tured to reflect the high level of men-
tal health and substance abuse prob-
lems within the detained population,
as well as its social, economic and
educational makeup.
• While recognizing that physicians
working in prison have dual loyalty,
the healthcare and confidentiality of
the patient should always be the doc-
tor’s primary concern.
• Healthcare policies should recognize
the financial benefit of effectively
treating health problems which, if left
untreated, will result in significant
overall additional cost to the commu-
nity.
• Patients in prison should have the nec-
essary access to secondary care ser-
vices.
• Investment in after-care and support
following release is essential.
11
WMA
IV Conclusion
Medical information and its protection are
important worldwide. The discussion about
it, is however sometimes surrounded by
misunderstandings or wrong metaphors.
Medical information is not a thing anyone
could or should own. Still, it may be critical-
ly important in some cases. Also it is bene-
ficial not only to patients but also to society
as a whole. We should seriously consider
both the best uses and best protection of it.
Discussion uses and protection in an adver-
sarial way would lead in a wrong direction.
Just to say that we should make good balance
of uses and protection is useless or helpless.
We should set up a goal and make up a legal
strategy to realize it. I know that Japan is just
beginning to start in that direction. The World
Medical Association would provide a good
opportunity to discuss, compare, and
improve the strategy each country should
adapt.And through the support and efforts by
the great Association, I hope that the wishes
of patients to trust physicians come true.
WMA Secretary General
From the Secretary General’s Desk
Some feel that Medical ethics nowadays is
more important than ever. And indeed many
ethical questions in medicine have had public
attention during the last ten years: Questions
concerning the beginning and end of life,
research on embryos, cloning, euthanasia and
assisted suicide, embryo transfer, substitute
motherhood, together with subjects such as
organ trade and doping, are just a few of
those ethical questions which tend to be most
visible in the public discussion. They all have
been on the agenda of the World Medical
Association and most likely they will return.
But the work of the WMAis much more than
the high profile and much disputed questions
with vibrant public attention: Patients’Rights
– especially concerning children, research on
humans, professional conduct – the questions
of every day medical life are the ones that
make the work of the WMA indispensable.
Since World War II the WMA has been the
voice of physicians on ethical and social
questions in medicine worldwide.
In times of change this role is becoming
more and more important. Our economical
and political world has changed and so does
our medical world. More and more people
and governments see or deal with medicine
as a commodity business. The work of
physicians and other professionals in the
field of health is under the threat of being
turned into a plain commercial activity,
ignoring the very special relationship
between patients and their physicians.
And with that change both market and gov-
ernment influence on medicine grow in prac-
tices and in hospitals alike. Economic inter-
ventions in medicine driven by managed care
organisations, insurers or governments
threaten the professional autonomy of physi-
cians. Our professional freedom – the free-
dom to provide care in the best interest of the
patient is threatened in most, if not in all
countries of this world regardless how differ-
ent the health care systems are structured.
In a survey among the members of the
World Medical Association during last
summer, health reforms and their effects on
medical practice got the highest attention.
In all parts of the world questions of struc-
ture and reform move and affect physicians
and patients alike. The WMA will tackle
these questions. We will analyse and speak
out on what health care reforms will do to
the care for patients. Our commitment was
and is to keep medicine as a free profession,
dedicated to people, committed to health,
demanding freedom from undue influence
both from market and from inappropriate
governmental influence.
Medicine is the unique combination of car-
ing for people and the ethical application of
science and art. The freedom it requires is
no “divine right” and no permission for
foolishness. It is rather a derivative of the
patients’right to good and accessible health
care and protection.
Higher cost and higher demands for medi-
cine and rapidly changing demographics in
many of our countries are only two of many
reasons pressing for change. The rapid
changes we are experiencing and their
influence on our ethics and the care we pro-
vide would be an important, if not the most
important global questions in medicine.
Whoever in this world uses scarce resources
should be prudent and should handle those
resources with regard to society at large,
especially if those resources are not renew-
able, critical for life or in the public domain.
Our work concerns all of these types of
resources and most of us are aware of that.
However, commercialisation or socialisa-
tion is no answer to the problem. Both limit
the freedom necessary to provide choices,
to allow confidentiality, to build trust. Both
come with the inherent threat of rationing.
The WMA gives us the platform to work
together on answers to these questions.
As our governments work closely together
on the international scene, exchange their
views and discuss their tools, we have to do
the same. Whoever believes that the inter-
national context is not important for medi-
cine and health care will find him or herself
in an isolated position very quickly.
The WMA consists of people with very dif-
ferent cultural backgrounds and traditions,
with different economic situations, with
different political views and different
beliefs. And yet it is the ideal ground for
the establishment and protection of com-
mon values and principles. The WMA is a
membership organisation and the members
are the heart and the brain of this organisa-
tion. It is their contribution and engage-
ment that counts. It is the Secretary
General’s duty and service to make that
work.
More than fifty years of very successful
work of the WMA are a solid basis to work
on, and to be a successor to the prominent
persons, who have served in this position is
an honour.
Otmar Kloiber
12
WMA
On 18 January 2005 the WMA released its
new Medical Ethics Manual. The Manual is
a concise introduction to ethics for medical
students and physicians worldwide. It deals
with the basic ethical concepts in clinical
medicine and research and related princi-
ples of human rights and medical profes-
sionalism, and it provides references to
more detailed treatments of specific issues
and other appropriate resources. It can be
viewed and downloaded free of charge on
the WMA web site (www.wma.net/e/ethic-
sunit/resources.htm) and a print version is
available in limited quantities. A Japanese
translation has been completed and French
and Spanish ones are in progress. Other lan-
guage versions will be produced as funds
permit.
The manual is a product of the WMA Ethics
Unit. It is an educational resource, not a
WMA policy document (although it pre-
dominantly cites WMA policies).
Background
The WMA has a long-standing interest in
medical ethics and medical education. In
1999 the WMA Assembly adopted the fol-
lowing Resolution on the Inclusion of
Medical Ethics and Human Rights in the
Curriculum of Medical Schools World-
Wide:
1. Whereas Medical Ethics and Human
Rights form an integral part of the
work and culture of the medical profession,
and
2. Whereas Medical Ethics and Human
Rights form an integral part of the his-
tory, structure and objectives of the
World Medical Association
3. It is hereby resolved that the WMA
strongly recommend to Medical
Schools world-wide that the teaching
of Medical Ethics and Human Rights
be included as an obligatory course in
their curricula.
To assist in the implementation of this resolu-
tion, the WMACouncil designated the devel-
opment of an ethics manual as the principal
activity of the WMA Ethics Unit, which was
launched in 2003. It is also a primary objec-
tive in the WMA Strategic Plan 2003-2007.
A preliminary survey of medical ethics cur-
riculum materials revealed that there are a
large number of textbooks and monographs
but these are generally written for a specif-
ic country and, moreover, are too expensive
for most medical students in developing
countries. The WMA Ethics Manual differs
from these by being international in scope
and available free of charge. Moreover, it
relates medical ethics to both medical pro-
fessionalism and human rights, three sub-
jects that are usually treated separately.
Development
Work on the Manual began in the autumn of
2003 following my appointment as Director
of the WMA Ethics Unit. I developed a pros-
pectus for the Manual and circulated it to an
international group of medical ethics teachers
for comment. Following revision of the
prospectus, I began writing the Manual early
in 2004 and completed a first draft in June.
That was sent to an expanded group of advi-
sors, including a number of medical students.
A second draft of the Manual that incorporat-
ed their comments and suggestions was com-
pleted by the end of September and that, too,
was circulated to the advisors and to members
of the WMA Council, along with a proposed
design of the covers and layout. The final ver-
sion of the text was completed in December
and the PDF version of the Manual was pre-
pared for its launch in January 2005.
Content
The Manual consists of an introduction,
five principal chapters, a conclusion, and
several appendices. Four of the five chap-
WMA
The WMA Medical Ethics Manual
ters begin with a paradigm case study that
illustrates the issues dealt with in the chap-
ter and end with suggestions for how the
case should be resolved.
The Introduction states the goals and scope
of the Manual and explains what medical
ethics is, why it is important, and how it is
related to medical professionalism, human
rights and law.
Chapter One presents the principal features
of medical ethics: its values of compassion,
competence and autonomy; its pluralistic
character; its gradual evolution over time;
its differences and similarities from one
country to another; and the role of the
WMA. The chapter also provides a brief
description of the different ways that indi-
viduals make ethical decisions.
Chapter Two, the longest in the Manual,
deals with the patient-physician relation-
ship. It discusses six topics that present chal-
lenges to physicians in their daily practice:
respect and equal treatment; communication
and consent; decision-making for incompe-
tent patients; confidentiality; beginning-of-
life issues; and end-of-life issues.
Chapter Three is concerned with the rela-
tionship of physicians and society, includ-
ing those situations where there is an
apparent or real conflict between the needs
of patients and the demands of third parties
(governments, employers, police, family
members, etc.). The chapter also deals with
the difficult matter of resource allocation or
rationing and the role of physicians in pub-
lic health and global health.
Chapter Four discusses the relationship of
physicians and their colleagues in patient
care, both other physicians and non-physi-
cians. It describes what medical profes-
sionalism requires of physicians in their
behaviour towards their physician col-
leagues, teachers and students, including
reporting unsafe or unethical practices. It
also stresses the need for cooperation with
non-physician health professionals to pro-
vide optimal care for patients, and it sug-
gests guidelines for dealing with conflicts
about patient care.
Chapter Five focuses on the ethical
requirements for medical research on
human subjects, as set out in the WMA
13
Medical Science, Professional Practice and Education
Medical Science, Professional Practice and Education
Medical Implants For Higher Performance
And Longer Life
Long-lifecycle MICS architecture ideal for
pacemakers, defibrillators, remote tele-
monitors, orthopaedic devices, pump con-
trollers, nerve stimulators and swallowable
imaging systems
Cambridge UK and Boston MA, January
18, 2004 – Cambridge Consultants has
designed a new ‘control and communica-
tions’ radio architecture for in-body med-
ical diagnostic and therapeutic applications.
Called SubQuore, it supports medical
device manufacturers’drive for implantable
devices which combine very low power
requirements with robust wireless commu-
nications.
Cambridge Consultants’ design combines
exceptional power economy with great
flexibility. In a typical pacemaker for exam-
ple, SubQuore would deliver more than 10
years of activity from a lithium cell, but it is
equally capable of meeting short term
requirements for high volumes of data, in a
swallowable video imaging device for
example.
The implantable device market is current-
ly growing at double digit rates: wireless
communications have added a valuable
new dimension to in-body therapeutic
devices, and enabled a whole new gener-
ation of diagnostic aids. For device
designers, the challenge is to exploit
these new capacities within extreme size
contraints, and with minimal power
requirements. SubQuore is designed for
implementation on system-on-chip (SoC)
solutions, to provide a tiny control and
communications platform suitable for
devices using Medical Implant
Communications Services (MICS) fre-
quencies, the medical band now emerging
as a global standard.
“Advances in electronics technology are
enabling a host of new implantable applica-
tions, and this design draws on three of
Declaration of Helsinki. These include
ethics review committee approval, scientif-
ic merit, social value, acceptable manage-
ment of risks, informed consent, confiden-
tiality, avoiding conflict of roles (physician
vs. researcher), honest reporting of results,
and dealing with unethical research.
The Conclusion calls attention to the fact
that medical ethics should address the rights
of physicians as well as their duties. It also
deals with the responsibilities of physicians
to themselves, and it concludes with some
reflections on the future of medical ethics.
Five Appendices complete the Manual: a
glossary; a list of resources that are avail-
able on the Internet; WMA and World
Federation of Medical Education statements
on medical ethics education; suggestions for
strengthening ethics teaching in medical
schools; and additional case studies.
Next Steps
An intensive communication program is
underway to make the Manual known to
teachers of medical ethics, medical students
and practising physicians throughout the
world.
The WMA Ethics Unit is developing a pro-
posal to link teachers of medical ethics in a
virtual network using the WMA website.
The network could serve as a means of
communication and exchange of experi-
ences and suggestions for the teaching of
ethics.
The Ethics Unit may also develop an online
CME/CPD course based on the Manual.
John R. Williams, Ph.D.
Director of Ethics
those trends: ultra low power consumption
technology, more intelligent radio perfor-
mance and extreme miniaturization” says
Richard Traherne, head of Cambridge
Consultants” wireless business unit.
“Combined with the opportunities offered
by the MICS frequency allocation —
which is emerging as a worldwide standard
endorsed by the FCC and ETSI — we see
great demand for an optimized single-chip
wireless platform that delivers the econo-
my required for mass-volume medical
applications”.
The new implantable transceiver design
leverages Cambridge Consultants’ portfo-
lio of field-proven intellectual property for
ultra-low power radio, as well as the con-
sultancy’s lean RISC processor core, XAP.
Extreme attention to power economy has
been applied throughout the design, both to
consumption in the transceiver architec-
ture, as well as the power-saving algo-
rithms that are employed to wake up and
control the device. The architecture would
consume an average current of less than
1µA, and less than 1.7mA peak, for a
0.05% duty-cycle, 400 kbits/second bi-
directional communications application.
Although the range of implantable medical
applications is expanding exponentially,
each application is different and requires a
particular mix of control, monitoring and
communications facilites – and Cambridge
Consultants expects to fine-tune the IC
core for individual applications.
The SubQuore radio operates in the 402-
405 MHz “MICS” frequency band – com-
patible with new FCC and ETSI standards
– and offers a communications range of 6
feet/2 metres when implanted under the
skin. The only other use of this band is for
meteorological equipment, minimizing the
potential for interference and providing an
excellent platform for economy of scale
through standardization.
Among the applications foreseen are for
high-performance/long-lifecycle an MICS
devices implantable pacemakers, defibril-
lators, remote telemonitors, orthopaedic
devices, pump controllers, nerve stimula-
tors and swallowable imaging and diagnos-
tic systems.
Advanced medical technologies include
organ transplants, reproductive medicine,
genetic diagnosis, gene therapy and regener-
ative medicine. Among others, this presenta-
tion will primarily focus on genetic diagno-
sis and regenerative medicine and outline
related bioethical issues.
First, in regard to genetic diagnosis, global
collaborative research on human genome
analysis (Human Genome Project) that start-
ed in 1990 advanced faster than was initially
expected. The draft sequence of the human
DNA base pairs was elucidated ten years
later in June 2000, and further relate details
were uncovered in February 2003. Many
will remember that a variety of events cele-
brating this accomplishment together with
the commemorative events celebrating the
fiftieth anniversary of the discovery of the
DNA helical structure by Dr. Watson and Dr.
Crick, were held worldwide. It can be said
that the elucidation of draft sequences of the
human genome has finally led us to the age
of new medical science and medical care
that is identified as the “post-genome era”
It goes without saying that elucidating the
draft sequence of human DNA itself has
extremely great scientific significance.
Furthermore, the global consensus is that the
biggest goal of medical studies in the post-
genome era is to elucidate the functions of
each respective human genome for which the
draft sequences were made clear as mentioned
earlier, as well as to apply the results of such
studies to medical science and medical care.
With regard to genetic disorders caused by a
single abnormal gene, almost 1,000 kinds of
abnormal genes, including notably less com-
mon genetic diseases, have already become
clear, and the results of the studies concern-
ing some of the genetic diseases have been
widely used clinically for genetic diagnosis.
In addition, with regard to acquired diseases,
genetic diagnosis along with prognostic
expectation etc., based on the results of such
diagnosis, have been widely used clinically
for many infectious diseases and some
tumors. Moreover, in accordance with the
recent elucidation of the complete base
sequence of human DNA, further studies on
the relationship between the results of DNA
analyses and certain diseases have rapidly
developed. Thus, it is expected that the stud-
ies will not only contribute to genetic diagno-
sis of congenital diseases, infectious diseases
and specific tumors caused by a single abnor-
mal gene, but also successively clarify the
correlation between symptoms of a range of
diseases that are classified as lifestyle-related
diseases such as hypertension, diabetes, can-
cer, arteriosclerosis and Alzheimer’s disease,
which are considered to be caused by multi-
Medical Science, Professional Practice and Education
14
Background In Freedonia report
“Implantable Medical Devices” of October
2003, US demand for implantable medical
devices is projected to increase nearly 11%
annually to $24.4 billion by 2007.
Cambridge Consultants Inc., 451 D
Street, Boston MA 02210, USA. Tel: +1
617 532 4700; Fax: +1 617 737 9889;
www.cambridgeconsultants.com
Cambridge Consultants Ltd, Science
Park, Milton Rod, Cambridge, CB4
0DW, UK. Tel: +44 (0) 1223 420024; Fax:
+44 (0)1223 423373; www.cambridge-
consultants.com
Advanced Medical Technology and Medical
Ethics
Fumimaro Takaku, M.D., Ph.D.
President, Japanese Association of Medical Sciences
Presented at the WMA General Assembly in Tokyo 2004
ple gene-mutations. As a matter of fact, in
Japan, studies on the correlation between
mutations in genes including single
nucleotide polymorphism (SNP) with regard
to the five diseases; hypertension, diabetes,
dementia, cancer and bronchial asthma, and
clinical conditions of these diseases have
been conducted with a unified national effort
as the Millennium Genome Project since
2001. Development of these studies has
every expectation of providing numerous
benefits to all mankind through prevention of
diseases, determination of diagnosis, choice
of treatment method, prediction of sensitivi-
ty to specific medical agents and the emer-
gence of side effects caused by medical
agents for each individual patient – the indi-
vidualized medical indication. On the other
hand, there is also a big possibility that we
must anticipate a large number of bioethical
issues, which are presently being raised in
connection with genetic diagnosis of con-
genital diseases, will be raised in a more
magnified form in the future.
While genetic diagnosis has been conducted
for a great number of congenital and
acquired diseases, as mentioned earlier, the
main characteristics of genetic diagnosis are
summarized in the following three points:
(1) More definitive diagnosis is possible
compared to traditional diagnostic methods,
(2) Diagnosis is possible with an extremely
small amount of samples, and (3) Diagnosis
before symptoms develop (presymptomatic
diagnosis) is possible. Of these, the most
controversial issue from the perspective of
bioethics is (3), the possibility of presympto-
matic diagnosis. This kind of problem does
not exist in genetic diagnosis for congenital
diseases, where abnormality is diagnosed by
clinical symptoms and the results of labora-
tory examinations, or acquired diseases such
as cancer and infectious diseases.
Presymptomatic diagnosis
However, it has been pointed out that a wide
range of bioethical issues will arise due to
genetic diagnosis for diseases, for which
diagnosis can be determined using genetic
diagnosis long before symptoms emerge.
Patients suffer from serious conditions and
no treatment exists for congenital diseases
such as familial amyloidosis, Huntington’s
disease, etc. For example, according to the
research by the University of British
Colombia in Canada announced in 1999, of
4,527 patients that were diagnosed with
Huntington’s disease, 44 people (0.97%)
either committed suicide, attempted suicide
or were hospitalized in a mental institution.
Of these, half of those who had attempted
suicide or were hospitalized in mental insti-
tutions were reported to have not at the time
developed any symptoms. This suicide rate
is more than times that of the average.
Another example of such problem as this is
genetic diagnosis of breast cancer that clusters
within a family. As it is confirmed that abnor-
mal genes related to the development of
breast cancer are identified as abnormalities
of BRCA-1 and BRCA-2 genes, when a
mother or sister was affected with breast can-
cer and abnormalities are found in BRCA-1
and BRCA-2 genes of the patient concerned,
it is naturally understood that a healthy female
in the family often desires to have the exami-
nation to check for the presence of abnormal
BRCA-1 and BRCA-2 genes. Although the
expensive cost of this examination of 2,000
US dollars or more is a problem, the psycho-
logical burden stemming from the test results
is deemed to be a more serious problem. In
other words, although there is no problem if
the test result proves that genes are normal,
there is no doubt that the person who took the
test will suffer serious psychological damage
if abnormal genes are found. The responses of
healthy females with abnormal BRCA genes
who have recovered from such psychological
damage to some extent are assumed to be the
following three:
(1) Cancer screening tests conducted by a
doctor,
(2) Starting to take medicines that are recog-
nized as preventing breast cancer devel-
opment, including Tamoxifen, and
(3) Removing a normal breast in which an
abnormality is not found in advance. It is
reported that a considerable number of
women choose to remove their normal
breast and then undergo artificial breast
reconstruction rather than being forever
concerned with the fear of breast cancer
developing in the future. However, since
they have to go through much internal
conflict before reaching such a conclu-
sion, it is needless to say that counseling
with specialists is regarded to be neces-
sary during such a period. Since the fre-
quency of breast cancer patients with an
abnormal BRCA gene is 5% or less in
Japan, (which is remarkably low com-
pared to European countries and the
U.S)., it rarely becomes subject of dis-
cussion at present, but similar issues are
obviously expected to become a problem
in the future.
Apart from the aforementioned issues, with
respect to presymptomatic genetic diagnosis,
it is questionable whether an individual
needs to claim insurance for genetic diag-
noses when the person is covered by health
insurance and life insurance. Although, in
Japan where all people are covered by pub-
lic health insurance, this kind of situation is
unlikely become a problem, genetic testing
when taking out a life insurance plan has
been studied for an extended period of time
and a conclusion has not yet been reached.
However, even in Japan, there is an undeni-
able possibility that an increased burden for
the general public due to people with gene
defects taking out insurance will come into
question in the future.
Guidelines
Without posing the above mentioned exam-
ples, you are probably already aware that var-
ious bioethical issues arise in the research of
human genes, and as a measure to cope with
such problems, ethical guidelines concerning
the study on human genome analysis and
research were publicized as a common guide-
line by three ministries ,the Ministry of
Education, Culture, Sports, Science and
Technology; the Ministry of Health, Labor
and Welfare; and the Ministry of Economy,
Trade and Industry, in March 2001. While
these guidelines are exclusively focused on
basic studies on human genes, the ethical
guidelines concerning genetic testing of clini-
cal test samples were also publicized in April
2001. It was Japan Registered Clinical
Laboratories Association that created these
guidelines. In many instances, testing compa-
nies perform genetic tests as part of daily clin-
ical examinations, based on the request from
hospitals. This is the basic process in which
the said guidelines were created by the associ-
ation comprising these testing companies
gathered together. Further, when conducting
genetic tests in medical facilities, protection
of privacy of patients who had had the test,
counseling for patients and other issues will
be an important issue to be addressed. To
respond to these issues, ten societies including
the Japan Society of Human Genetics, Japan
Society of Obstetrics and Gynecology and
Japan Society of Genetic Counseling pre-
pared the guidelines concerning genetic test-
ing in 2003. Furthermore, the subject of these
guidelines is limited to genetic tests for muta-
tions in genes of the generative cell system,
and thus body cell gene analysis targeting
cancer cells and such is not referred to.
Furthermore, in Japan, the Ministry of
Health, Labor and Welfare publicized
“Ethical Guidelines for Clinical Studies” in
2003. These are the guidelines dealing with
clinical studies in general created basically
in line with the “Helsinki Declaration,”
adopted at the World Medical Association in
1964, which has been modified and added to
six times.
As presented above, regulations on genetic
tests are distinctively placed in the format of
guidelines. Despite differences in the detail
of these guidelines according to the respec-
tive objectives and targets, the common
points among them are as follows:
Protection of the rights of patients, their fam-
ilies and relatives,
Protection of personal information,
Legislation prohibiting genetic discrimina-
tion
Acquisition of written informed consent
from search objectives,
Approval of facility chief after screening at
Institutional Review Board (IRB), and
Preparation of mandatory genetic counseling
system at testing facilities.
It is highly predictable that the research on
the correlation between gene abnormality
and diseases caused by multiple gene defects
such as lifestyle-related diseases, which is
competitively conducted on a global scale at
present, will be developed, the correlation
between the results of DNA analysis of each
individual and the development of these dis-
Medical Science, Professional Practice and Education
15
eases will be manifested, and checking
mutation in genes will enable the diagnosis
of whether or not each individual is likely to
be affected by these diseases. If such a situa-
tion is realized, it can easily be presumed
that, in addition to the aforementioned issue
of taking out insurance, a broad range of
social issues including the possibility of
genetic diagnoses in connection with finding
employment, marriage and other daily
issues; the issue of protecting confidentiality
of personal data on genes etc. will be raised
due to a great many more patients with
lifestyle-related diseases being different
from traditional cases of genetic diagnosis of
congenital diseases. The pace of progress in
bioscience is beyond our imagination and
thus, we need to use this chance to discuss
these issues, to a satisfactory extent, in
preparation for the advent of such situations.
Diagnosis in the Fertilised
Ovum
Further, diagnosis of fertilized ovum is
what arouses concern in Japan as genetic
tests related to reproductive medicine.
Fertilized ovum diagnosis is among med-
ical technologies for reproduction, in which
“in vitro” fertilization is performed; one of
the fertilized eggs is taken out for genetic
testing when the division of the fertilized
ovum proceeds and it is returned into uterus
only when the results prove it is normal. In
its bulletin, the Japan Society of Obstetrics
and Gynecology approves fertilized ovum
diagnosis only in the event of serious con-
genital diseases. However, the bulletin of
the society has no legal force. On the other
hand, there are some organizations that
strongly oppose fertilized ovum diagnosis.
Japanese law does not permit induced abor-
tions on the grounds of genetic abnormali-
ties. This is because of strong opposition
insisting that approval of induced abortion
of children with gene defects means dis-
crimination towards disabled people, and I
think opposition against fertilized ovum
diagnosis stems from this same reason.
However, in effect, it is estimated that
induced abortions of fetuses with congeni-
tal diseases has been conducted for differ-
ent reasons in Japan.
“Regenerative Medicine”
I would like to change the subject to bioeth-
ical issues related to “regenerative medi-
cine” as in the case of genetic analysis. It
was reported that Dolly, the sheep clone,
was successfully generated by Dr. Wilmut
of Roslin Institute in Britain in 1997 and
became a worldwide topic of discussion.. It
is not surprising that the mass media devot-
ed much space to concerns over the possi-
bility that the same technology may lead to
human cloning. Later, there actually
appeared doctors who attempted the cre-
ation of cloned human beings and there was
some publicity given to those claiming to
have been successful.
In Japan, “The Law Concerning Regulation
Relating to Human Cloning Techniques and
Other Similar Techniques” was enforced in
June 2001 and the creation of humans uti-
lizing cloning techniques has been prohibit-
ed by law. For your information, offenders
of this law are to be fined up to 10 million
yen or 100,000 US dollars and receive
prison terms of up to ten years.
On the other hand with respect to human
embryonic stem cells (ES cells) that are
capable o being differentiated into a variety
of cells, two American research groups
reported the establishment of the ES cell
line in 1998. ES cells can be differentiated
into every kind of cell and consequently, it
is natural that the application of this to med-
ical transplantation is expected, especially
for neurological disorders, severe cases of
diabetes and critical hematological disor-
ders that require bone marrow cell trans-
plants. On the other hand, it is true that
strong opposition is expressed, because cre-
ation of ES cells is accompanied by the
destruction of blastocyte generated from
human fertilized ovum. In Japan, the
review at the Office for Bioethics and
Biosafety, Lifescience Division of the
Ministry of Education, Culture, Sports,
Science and Technology led to the publica-
tion of “Guidelines for Derivation and
Utilization of Human Embryonic Stem
Cells”. Consequently, both the production
and use of human ES cells have become
possible. However, when doing so, a dual
screening system is employed in which the
research plan submitted by the head of the
institution after undergoing review by IRB
of the respective facilities are to be
reviewed again by the governmental review
board. In Japan, the production of the
human ES cell line as well as research using
human ES cells has already been conducted
at about ten research facilities.
When using the cell differentiated from
human ES cells for medical transplantation,
it is no wonder that the difference of HLA
between the original ES cells and a patient
will become an issue. It is because, needless
to say, transplanted cells will be rejected
despite the hard work of transplantation
unless HLAs between ES cells and a patient
match. The most effective method of solv-
ing this problem at the present stage is ther-
apeutic cloning technology.This is to create
cloned embryos by placing nuclei taken
from a patient’s somatic cells into donated
ovum after denucleation and then creating
ES cells from the cloned embryo. In addi-
tion, as for this technology, It has been
recently proposed to use the term “nuclear
transfer” since the term, cloning, is easily
mixed up with reproductive cloning to cre-
ate cloned human beings. The countries that
admit the creation of ES cells created by
using the patient’s own nucleus, produced
in the aforementioned manner, that is
autochtonous ES cells, are the U.K.,
Belgium, Sweden, South Korea and China.
South Korea attracted attention worldwide
since Prof. Hwang, et al. in Seoul National
University disclosed the successful creation
of autochtonous ES cells on the on-line
Science magazine in February 2004. After
that, some people, centering on opponents
of human cloned embryo, criticized the ori-
gin of donated ovum.
In Japan, the pros and cons of research on
therapeutic cloning has been debated for
over two and a half years by the Expert
Committee on Bioethics of the Council for
Science and Technology Policy in the
Cabinet Office and it was finally decided in
July 2004 to approve therapeutic cloning
only in cases of basic research and to pro-
mote the preparation for a system for this.
The reason behind the fact that it took a
long time of two and a half years for the
discussion to reach this conclusion was that
diverse opinions concerning the pros and
Medical Science, Professional Practice and Education
16
cons of promoting the studies on therapeu-
tic cloning among committee members of
the said Expert Committee prevented a
consensus from being reached.
I myself participated in the government-affil-
iated committee as a committee member
with regard to bioethics to deal with the
issues including reproductive medicine, gene
therapy, human ES cells and studies on ther-
apeutic cloning. The impression I got from
the meeting was that the Japanese committee
had only a few opportunities to hear patients’
opinions. Actually, an open symposium con-
cerning therapeutic cloning was the limited
opportunity for me to directly listen to
patients’ opinions. In addition, I received the
impression that media coverage was prone to
bring up more negative opinions on the sub-
ject of the advanced medical technology
mentioned above even if they were minority
opinions. Furthermore, probably due to few
opportunities to hear opinions from patients
and their related parties at the hearings of the
committee, I thought there were only a few
situations when news reports raised patients’
voices. On the other hand, partly because
regulations on genetic diagnosis and regener-
ative medicine are executed as guidelines
instead of laws, except for the Law
Concerning Regulation Relating to Human
Cloning Techniques and Other Similar
Techniques in Japan, it appears to be one of
the characteristics in Japan that a big politi-
cal impact has not been made to date.
Medical care is certainly embarking on an
age of globalization. The latest information
on advanced medical technologies can easily
be obtained via the Internet and it leads to the
era when the most advanced medical care is
available everywhere around the world as
long as the expenses are not brought into
question. Although the “Brain-Dead
Transplant Bill” proposed in Japan does not
permit the transplantation of organs from
brain-dead children, families constantly go
overseas to have their children undergo
transplantation despite the substantial
expenses. I also hear that many couples
obtain fertilized ovum diagnosis overseas,
which as I described can only rarely be con-
ducted in Japan.. I suppose other countries
probably have similar situations.
To overcome such conditions, I am looking
forward to seeing the World Medical
Medical Science, Professional Practice and Education
17
Association create universal ethical guide-
lines concerning advanced medical tech-
nologies. With admiration for the World
Medical Association’s formulation of the
Helsinki Declaration that has been revised
several times, I would venture to insist on
the need to add universal ethical guidelines
with regards to advanced medical technolo-
gies. As the perspectives concerning
bioethics of advanced medical technologies
vary widely depending on cultural and reli-
gious background of the respective coun-
tries, it is needless to say that difficulties
generated when creating such universal
guidelines could well be foreseen. However,
advanced medical technologies have been
developed and put into practical use not for
the special benefit of us, medical experts, but
for the benefit of patients whoreceive diag-
nosis and treatment utilizing such technolo-
gies. Given this fact, I regard it to be an
important role that the World Medical
Association should play to make an appeal
so that people throughout the world may get
equal benefit of all medical care including
advanced medical technologies.
Modern Demands in Health Care
Haruo Uematsu, MD
President, Japan Medical Association
Presented at the WMA General Assembly in Tokyo 2004
In looking back on the past century, the
20th century is noteworthy for achieving
scientific progress that is unprecedented in
the history of mankind. In conjunction with
developments attained in medical science,
physics, chemistry, biology, and other
fields, great strides have been made
through interdisciplinary exchanges.
Especially noteworthy is the progress made
in antibiotics, beginning with the discovery
of penicillin, that has especially been very
effective in controlling the foremost cause
of mortality—the spread of infectious dis-
eases. So effective was this control, that for
a short period of time, many people were
lulled into the belief that it was possible for
infectious diseases to be completely con-
trolled. However, the manifestation of
drug-resistant strains of bacteria, the emer-
gence and re-emergence of infectious dis-
eases has shown that numerous problems
will arise in tandem with future develop-
ments. In recent years, the focal point of the
disease structure has shifted from infectious
diseases to cancer, cerebrovascular dis-
eases, diabetes, and other diseases that stem
from lifestyle habits. This has led to a
review of lifestyle habits and it has greatly
affected the focus of medical care.
Another notable point is the progress that
has been made in clinical imaging technol-
ogy. The discovery of X-rays was a land-
mark discovery, but the development of the
CT, MRI, PET in recent years has epito-
mized the fruits of interdisciplinary
research, and the contributions to medical
diagnosis made by these imaging tech-
niques have been immeasurable. This has
also been true for biochemical tests.
Although progress in diagnostic technology
that precedes medical treatment has
incurred criticisms of excessiveness or the
waste of financial resources earmarked for
medical costs, progress in medical care is a
foregone conclusion.
The twentieth century has been called the
century of wars as attested to by the numer-
ous wars that were fought in the last centu-
ry. In the field of physics, fission phenome-
non developed by nuclear science was not
utilized for peaceful purposes, but to pro-
duce nuclear weapons; and tragically, there
is a history of its actual use, which provides
us with an unforgettable moral lesson about
what occurs when the scientific achieve-
ments are mistakenly utilized to fulfill
human or national greed.
Although with the passing years the growth
of various industries led by scientific devel-
opments has made our lives much more
convenient, it has also left us with a burden-
some legacy of serious environmental pol-
lution and the destruction of the natural
order of things. Moreover, it will require
additional years and enormous effort to
recover from these damages.
In Japan, the onset of the Minamata disease
caused by seawater pollution is a tragic case
example, as well as the large number of
patients with respiratory disorders stem-
ming from air pollution. The yin and yang
results of scientific development often
become apparent only after a fairly long
period of time. Thus, the effort to acquire
the wisdom to anticipate numerous phe-
nomena that may occur over a wide spec-
trum of situations must not be neglected.
Since medical science and medical care are
directly linked to life and death issues, its
impact on the future must be constantly
taken into consideration. In our review
about medical care and its ideal form, an
important point to consider is the relation-
ship between medical science and medical
care and recognition of their differences.
The late Dr. Taro Takemi, former JMA pres-
ident and the president of the WMA, de-
fined medical care as “the social application
of medical science”. As to whether this is
the best definition of medical care can be
debated from a myriad of differing perspec-
tives, but I believe that it is the most appro-
priate in explanations about medical care.
There is a relatively common perception
about medical science that is shared among
all countries. But, its social application is
tempered by a panorama of factors that
range from the natural environment, histo-
ry, culture, politics, to the economy of each
country. These exceedingly diverse condi-
tions that surround medical science con-
tribute to the complexity of medical care.
Cold climate and tropical regions, moun-
tainous and sea level regions, wet and dry
regions the climactic and geographical dif-
ferences lead to disparate diseases and the
medical care that is needed to treat them
also differs. A prime example is endemic
diseases. Due to developments in trans-
portation, infectious diseases that were
once confined to a specific region have
begun to spread rapidly and globally over a
wide geographical area forcing each nation
to be prepared to cope with these diseases.
The most recent example of this phenome-
non is SARS.
Diseases that are linked to the dietary habits
in each country or region are effectively
treated through lifestyle guidance measures
rather than by medical care. In the northern,
cold climate regions of Japan, studies have
shown that there was a high incidence of
hypertension due to a high dietary salt
intake by the population, and lifestyle guid-
ance measures have effectively helped to
control salt intake levels.
However, medical care issues in countries
that face political and economic hardships
are the most difficult to resolve. Due to
extremely poor public and environmental
health conditions, many people are unable
to receive needed medical care despite the
high incidence of diseases. The WMA has a
role to fulfill in such countries where the
population is unable to receive proper med-
ical care due to existing economic condi-
tions.
Currently, organ transplants, genetic test-
ing, gene therapy, reproductive medicine,
regenerative medicine and other forms of
advanced medical technology are being
successively and practically applied. The
advent of medical care that was once con-
sidered impossible or the development of
minimally invasive treatment methods has
raised the fervent expectations of many
and has pushed advanced medical technol-
ogy into the public limelight. Meanwhile,
bioethical issues, professional ethical
issues that confront physicians, and issues
that question the very essence of medical
care have come to the fore, as attested to
by the ethical issues seen in reproductive
medicine.
As a science, medicine has pursued
progress in the treatment of diseases and it
has sought to illuminate the phenomenon of
life. The fruits of these endeavors have
made advanced medical technology and
medical care possible. Medicine as a sci-
ence seeks to achieve the potential and to
attain progress through cumulative
research, but in order to apply the fruits of
medical science in medical care, the impact
of social factors mentioned earlier becomes
crucial. Even the understanding of bioethi-
cal issues that are perceived as being analo-
gous throughout the global community, will
differ according to the history, culture, and
religion of each country, as well as the ethos
of the times.
In Japan, laws that govern brain death and
organ transplants were not legislated for a
long period of time. In truth, one of the
underlying reasons for this delay was pub-
lic distrust of medical care, as well as dis-
satisfaction with the traditional system of
paternalism, an inadequate understanding
of informed consent, compounded by
Japan’s own unique religious beliefs and
perceptions about death. Thus, it took time
to achieve public consensus. In view of the
lessons that were learned from this experi-
ence, there must be adequate public disclo-
sure of information and sufficient public
dialogue with regard to highly advanced
medical technology.
If there was even one physician who
attempted to utilize advanced medical tech-
nology without the consensus of society for
personal fame or to satisfy academic curios-
ity, public distrust of the entire medical
field would be generated that would greatly
damage progress and development. As pro-
fessionals working in medical science and
medical care, this is an issue that precedes
ethics. However, advanced medical tech-
nology does contribute to human happiness
and well being. It is essential that society
recognizes that it is safe and there is an
extremely high probability of success.
Therefore, ethics, IT, physician qualifica-
tions, professional autonomy, and other
issues have been included in the program
for the Scientific Session with the main
theme of advanced medical technology. I
will leave detailed discussions about these
issues to the respective speakers who will
be discussing them in the special lectures
and symposium that have been planned.
In viewing the situation from a different
perspective, advanced medical care has
made it possible to provide treatments for
diseases that were unavailable in the past.
Simultaneously, it has forced physicians to
specialize in order to provide this treatment.
The curriculum in medical education has
become excessively concentrated and seg-
mented, and medical students are trained in
the partial and individual treatment of dis-
Medical Science, Professional Practice and Education
18
eases. But this education does not adequate-
ly address issues such as patient QOL, does
not consider what is truly beneficial for the
well-being of the patient, and what mea-
sures should be taken to achieve this well-
being from a broader perspective of med-
ical care. In an increasingly aging society,
these are issues that call for a reaffirmation
of the importance of holistic medicine by
all medical care providers. It is important to
note that the perspectives about life and
death that prevail in each country are also
important contributing factors.
The greatest demand that is being made on
medical care today, is to provide safe and
high quality medical care that is accessible
equally to all people. In Japan, as in other
countries, Japanese society and its citizens
have recently begun to stress the need for
safe medical care due to the frequent occur-
rence of medical errors. Consequently, spe-
cific measures and results are being
demanded of medical care providers.
The three causes of medical errors are peo-
ple, equipment, and organization. Of these
three causes, the foremost cause is people.
In other words, measures must be taken to
improve the professional qualifications of
medical care personnel and to raise physi-
cian ethics. Although this is the responsi-
bility of each individual physician, medical
associations also have a major responsibil-
ity to fulfill as professional academic orga-
nizations for physicians. Likewise, society
also has great expectations of medical
associations in helping to address this
issue. To meet these expectations, medical
associations must actively pursue measures
to raise the professional ethics of physi-
cians and to promote CME programs for its
members.
In the past, the physician was the focal tar-
get of responsibility for medical errors, but
it is more important to clarify the cause of
the error, to take measures to prevent its
reoccurrence, to reeducate the responsible
physician in lieu of punitive actions, and
to pursue measures that allow physicians
to provide a higher quality of medical
care. Latent high-risk cases should not be
simply compiled as potential medical error
cases. This task should be actively carried
out as a means of preventing medical
errors. Although error-proof equipment,
improved pharmaceutical packaging,
improved usage, and other improvements
have been targeted and implemented, ulti-
mately, the responsibility returns full cir-
cle on shoulders of the physician-in-
charge (the foremost cause of medical
errors).
In the area of organization, there are a vari-
ety of issues that must be investigated such
as the process of providing medical care
and other factors; and many medical insti-
tutions have created review committees to
address these issues. But, coordination
between the different medical occupations
within the medical institution becomes
important and we return again to the fore-
most cause of people.
Presently, every nation is faced with the dif-
ficulties of securing financial resources to
pay for medical care and with efforts to
control medical costs. It is vital that each
NMA actively stresses the importance of
the need to inject funds to cover medical
costs in order to secure safe medical care. It
is also important for the WMA to publicly
proclaim its viewpoint on this issue.
As of 1961, all residents in Japan have
equal access to safe and high quality med-
ical care at all times under the universal
health insurance system. Consequently,
according to a WHO report, Japan has the
longest healthy life expectancy and the
highest health record in the world.
Moreover, national medical costs are
ranked 17th in the world denoting the
achievement of effective health care at low
costs.
However, the universal insurance system in
its current form was achieved after many
trials and tribulations—nationwide strikes
by medical personnel, mass resignations by
health insurance physicians, political strug-
gles against the government over health
insurance measures, and many other activ-
ities. Medical payments are decided
according to a nationwide, uniform point
system for medical service fees. In Japan,
all medical services that are provided, from
consultation and examination fees, tests,
treatment, surgery, injections, medication,
to hospitalizations, are calculated and paid
according to the medical fee schedule. This
schedule is applied nationwide, and allows
all residents to receive medical care at all
times throughout the country under a uni-
form pricing structure. A breakdown of
national medical cost coverage shows that
30 percent is funded by public expenditure,
50 percent by health insurance, and about
20 percent by individual patients. It is dif-
ficult to inject national taxes to pay for
medical costs due to national economic
conditions, and the government’s recogni-
tion that medical care is part of social secu-
rity also plays a great role. We are endeav-
oring to maintain this system amidst suc-
cessive applications of costly, advanced
medical technology within a rapidly aging
society.
Each NMA is also undoubtedly striving to
achieve a system that will provide equal,
high quality medical care for all citizens,
and it is hoped that Japan’s universal health
insurance system as well as the activities of
the JMA will serve as an example.
Currently, the number of beds in proportion
to the total population is high in Japan and
the hospitalization period is lengthy.
Consequently, hospitals have been criti-
cized for allowing social hospitalizations or
long hospital stays by patients who can be
discharged. This has been toted as a prime
example of wasteful medical costs. As a
result, hospital beds have begun to be cate-
gorized as general hospital beds (for
patients hospitalized for medical care) and
convalescent beds (for convalescent
patients with minimal medical care needs)
and there is a move to reduce the number of
hospital days.
The foremost problem with regard to out-
patient services is the tendency of patients
to go to large hospitals, which has con-
tributed to extremely long waiting hours
and reduced examination periods. This is a
serious problem for many patients, that
simultaneously places excessive demands
on the physician. Thus, immediate counter-
measures are needed. This is one of the
inherent flaws of this universal insurance
system since it allows patients to receive
treatment at any medical institution with
only a relatively low, initial co-payment
fee.
Medical Science, Professional Practice and Education
19
To compensate for this flaw, to eliminate
wasted medical resources, and to provide
effective health care, a system of medical
provision has been created. In order to pro-
vide medical care, including advanced
medical technology, appropriately to those
in need, the functions of medical institu-
tions have been divided and coordinated. In
addition, information about the functions
of each medical institution are openly dis-
closed and measures to provide informa-
tion that allow patients easy access have
been pursued as an important means of
improving the system.
In Japan, a community health and medical
care plan has been created for communi-
ties with a population of about 300,000
that have been designated as medical
zones with all required medical facilities.
One of the focal aims of this plan is to
allow community residents to live in secu-
rity with regard to their medical care
needs, which are mainly taken care of by a
system of primary care physicians who are
supported by a network of hospitals. The
objective is to create a comprehensive
community health and medical care sys-
tem within a designated medical zone.
This is not a system that simply provides
medical care. The aim is to build commu-
nities where residents are able to live out
their lives in relative security within a sys-
tem that provides wide-ranging health
insurance and medical care services.
Medical association activities also include
maternal and child health, school health,
community health, industrial health insur-
ance, health insurance for the elderly, as
well as activities for health insurance for
all ages, vaccinations, emergency medical
care, and nursing care for the elderly. The
perspective has shifted from medical care
providers, who have traditionally been
responsible for creating health services
and providing medical care, to that of com-
munity residents, in order to establish
active local communities and to carry out
activities that will allow residents to live in
security. It is a significant means of renew-
ing public trust in medical care.
Long-term care or nursing care has become
an important issue as Japanese society con-
tinues to age. In tandem with the national
health insurance system, a long-term care
Medical Science, Professional Practice and Education
20
insurance system was created. Initially, nur-
sing care for the elderly was covered under
the national health insurance scheme as
social hospitalization. But, the focus of nur-
sing care has begun to shift increasingly to
in-home nursing care services. The idea is
to support the independence and self-
reliance of the elderly and to enable them to
live at home in familiar surroundings. The
amount of financial support that is provided
for nursing care costs is divided into six
levels, and a ceiling has been placed on the
maximum amount of assistance that will be
provided at each level.
Unlike the national health insurance, appli-
cants must be certified as being in need of
long-term nursing care in order to qualify
for long-term care insurance. The appli-
cant’s primary physician must submit an
accurate assessment of the applicant’s need
for nursing care and must follow-up on the
patient to ascertain that proper care has
been provided. Additionally, proper med-
ical care must also be provided. Therefore,
flaws in the system must be corrected and
the physician’s awareness must be
reformed. In this respect, these measures
can be included within the comprehensive
community health and medical care sys-
tem.
In thinking about societies that provide
medical care, the political and economic
conditions as well as the structure of the
diseases that exist in each country differ.
Thus, the issues that medical care faces are
myriad. There are economically rich coun-
tries, countries beset by poverty, population
growth, a declining birth rate, and there are
countries that face problems that are com-
pletely contrary to these issues.
The major theme of advanced medical care
that have been addressed at the Scientific
Session of the WMA Tokyo General
Assembly will discuss the fact that there are
countries where ethical concepts and per-
ceptions have been unable to keep up with
the ever increasing pace of advanced med-
ical technology and countries that desire to
have access to advanced medical care, but
cannot because of economic reasons, attest-
ing to the complexity of the issues that are
involved. It is difficult to come up with
expedient proposals that address these
issues and many must be addressed as polit-
ical problems.
However, if medical care exists to further
the well being and security of the human
community, each nation is obligated to pro-
mote medical care with in the various con-
ditions that exist despite the disparities
between countries. It is important to contin-
uously stress the fact that medical care is an
investment in health and consequently, an
investment in national strength to govern-
ments that try to control medical costs by
defining medical care as simply consump-
tion.
The medical care delivery system and the
concept of a comprehensive community
health and medical care system that is being
promoted in Japan does not generate inordi-
nate costs to implement, and they can be
immediately adopted and implemented in
countries that are economically burdened.
Hopefully, this plan will also serve to assist
such countries. I will be reporting periodi-
cally on how this system progresses in
Japan and hope that the information may be
of some assistance.
I have attempted to discuss the conditions
that surround medical science and medical
care, and the medical care issues that are
being demanded by the public. In conclu-
sion, what is being demanded today, is
safe, progressive, and “quality” medical
care that can be effectively and fairly
accessed by all. Each physician and med-
ical association must steadily strive to meet
these demands supported by governments
through national policies and financial
measures.
Lastly, I would like to state that we, physi-
cians who are entrusted with the task of
protecting the health of humanity through
daily medical care activities and the WMA,
a major organization of medical associa-
tions, must take action and courageously
voice their viewpoints on events that threat-
en human life, notably regional conflicts,
starvation, and other hardships that accom-
pany poverty.
Medical Science, Professional Practice and Education
21
1. Characteristics of
Information Technology (IT)
in the 21st
Century
To summarize the advancement of informa-
tion technology (IT) in the 21st
century, we
could say, “IT was utilized by health care
providers at medical institutions in the 20th
century. But with advancements in the IT
world, IT has been disseminated not only to
health care providers but also to patients in
the 21st
century, producing a great impact on
health care.” Today, I would like to speak
about the harmonization of IT progress and
health care, focusing on care provider and
patient utilization of IT. The next speaker
will discuss the great impact IT has had on
medical research, so I will talk mainly about
the impact of IT on medical practice.
First, let me summarize the characteristics
of IT in the century. The advancement of IT
in the century can be represented by 1) per-
sonal use of IT, 2) advanced communica-
tion, 3) multimedia, 4) large-scale database,
and 5) robotics.
Personal use of IT means that IT is utilized
by individuals. As of 2002, more than 70%
of households in Japan had personal com-
puters, and more than 80% of them are
using the Internet. It has become easy for
ordinary people to utilize information tech-
nology. Many people are using the Internet
via cellular phones in Japan; 79% of cellular
phones available in Japan are web-ready.
At home personal computers are connected to
the Internet, and users can obtain a variety of
information from around the world in no
time. For example, national university hospi-
tals can transmit high-resolution images using
the satellite communication system, making it
possible to exchange lectures such as live
surgeries among universities. It is noteworthy
that the broadband service fees in Japan are
lower than in any other area in the world.
Multimedia technology has created new
images such as the three-dimensional
image and made it possible to accumulate
and store high-resolution moving images
for a long time.
In large-scale databases, life-long medical
information of patients or the latest medical
literatures can be compiled and stored. For
example, it is widely known that the data-
base of the National Library of Medicine in
the U.S., on which some millions of litera-
tures are compiled, is open to the world as
a service called MEDLINE.
Robotics is also one of the characteristics of
IT in the 21st century. How the humanoid
robot technology will be applied is yet to be
seen.
2. Impact of IT on Health
Care
Each characteristic of IT is quite useful. We
are witnessing the tremendous influence of
modern science in our daily lives. But the
latest advanced technology has disadvan-
tages as well, even though the technology
itself is wonderful. Although some technol-
ogy is directly applied to human beings in
health care, great technology does not sim-
ply result in good health care.
In fact, health care in the 21st
century has
been changing under the influence of IT.
Human well-being could be enhanced if IT
is utilized correctly, but may degenerate if
IT is misused.
The changes in health care brought about by
IT can be described in a number of ways,
but I think the following four changes are
symbolic of them in general: (1) scientifica-
tion of health care, or dissemination of evi-
dence based medicine, (2) decentralization
of medical practice, (3) merger of public
Coordination of Progress in Information Tech-
nology with Health Care in the 21st
Century
Shigekoto KAIHARA, MD
Vice President, International University of Health and Welfare
Presented at the WMA General Assembly in Tokyo 2004
health, medical administration and clinical
medicine, and (4) expansion of the active
role of patients, or patient empowerment. I
would like to talk about each of these sym-
bolic changes in detail.
Scientification of health care
First, I will consider the scientification of
health care, or dissemination of evidence
based medicine. Various clinical trial meth-
ods have been established, and all clinical
procedures are now required to be per-
formed based on scientific evidence. Results
of clinical trials are published as medical lit-
erature, compiled to establish clinical guide-
lines, and made available to physicians on
the Internet. Physicians are expected to prac-
tice medicine following these guidelines.
Results of such clinical practice are fed back
to researchers, serving as cues for new
research. In this cycle, the results of clinical
studies are shared with clinicians in no time,
and new medical knowledge is quickly dis-
seminated all over the world. For example,
reports on significant adverse drug reactions
are made available to physicians in the
world within a few days. Such speedy dis-
semination of important information would
not have been possible without IT.
While this trend yields benefits for both
physicians and patients, we should consider
the availability of treatments recommended
in clinical guidelines to patients in the world.
There are numerous reasons for not being
able to receive such treatments. No matter
how advanced the information technology is,
it takes time to disseminate information to
each individual physician, and clinical guide-
lines are not necessarily put into practice
immediately. There are more serious reasons
for not being able to put guidelines into prac-
tice, however. One is not being able to obtain
the medical resources necessary to provide
recommended treatments for patients no mat-
ter how much such treatments are desired.
For example, there may not be any physician
who can perform the procedure, drugs may
not be available in the area, or drugs may be
available but cannot be obtained due to high
costs. When talking about medicine on a
global basis, it would not be exagerating to
say that there are only a few countries where
medicine can be practiced by following clini-
cal guidelines. As long as medicine is practi-
cal science, the constant presence of a gap
between medical knowledge and medical
practice is unavoidable.
Therefore, we should not criticize it as
unscientific if medicine cannot be practiced
by following clinical guidelines. Physicians
should have more interest in bridging the
gap between scientific medicine and actual
health care. It is more difficult to close this
gap compared with discovering new knowl-
edge. In some cases, you may have to use
alternative medicine (or traditional medi-
cine) that has a long history. We should
emphasize that the best medical practice is
to do our best with whatever resources are
available in the given environment.
Decentralization of medical
practice
Secondly, IT has brought about decentraliza-
tion of medical practice. Health care has been
provided to patients who visit certain places
where medical resources are centralized as
much as possible. Since it is impossible for a
physician to treat a lot of patients by visiting
each of them with medical and testing
devices, patients have to visit clinics, hospi-
tals or health care centres to seek treatment.
However, this may be undesirable for some
patients. Needless to say, it is most desirable
if they could receive the best treatment in the
places where they live with their families.
In the advanced information-telecommuni-
cation society, even if decentralization of
“tangible” medical resources cannot be
achieved, the decentralization of medical
“information” is now possible. With the
advanced information-telecommunication
system, information can be delivered any-
where in the world in no time. It is quite
interesting that a large part of medical prac-
tice is receiving or providing information.
Diagnosis, for the most part, means informa-
tion processing by a physician, with infor-
mation provided by a patient. The same can
be said for determining a treatment strategy.
In some treatment, physicians only provide
information to patients who “act out” what
they have learned. Moreover, in some cases
what used to be done by physicians may be
done by nurses instead. Taking into account
these perspectives, medical practices, to a
certain extent, could be given to patients at
home by combining information exchange
systems and a medical team of nurses.
Changes toward decentralization of medical
practice can be seen in a variety of areas. In
Japan, the value of home health care has
been reconsidered. Advanced medicine can
now be practiced on a ship in the Pacific
Ocean or on a spaceship. Jacque Marescaux
of IRCAD/EITS in Strasbourg, France, has
successfully performed a heart operation
through the intercontinental remote opera-
tion of a robot between Strasbourg and New
York; it is called “Lindbergh operation”
after the man who achieved the first trans-
Atlantic flight. Such medical practice is
called “distance medicine”.
These are wonderful achievements in med-
icine brought about by IT. However, we
should think about the disadvantages of the
technology once again. First, we must
never rely on information tools too much;
humane health care must not be forgotten.
No matter how the information technology
advances, it is essential for physicians and
patients to face each other as human beings.
We should remember that information
exchange through IT is one of complemen-
tary tools for medical practice.
Secondly, there is an issue of the cost of the
systems. In other words, it is an issue of med-
ical efficiency. Being efficient means being
more economical. Patients have been required
to visit medical institutions because health
care can be provided more efficiently that way.
In this sense, it is quite interesting to examine
if distance medicine is more efficient than cen-
tralization of health care. The advanced coun-
tries are taking different approaches regarding
this issue. In Canada andAustralia where peo-
ple live scattered across large land areas,
depopulated areas in the U.S. and in the moun-
tains in France, distance medicine is consid-
ered more efficient. The national or the state
governments in such countries have already
instituted policies promoting distance medi-
cine. In densely-populated Japan, there is no
consensus on whether health care can be pro-
vided more efficiently with distance medicine
compared with the centralization of medical
resources. When we think about harmonizing
IT and medicine, we should consider the eco-
nomical aspect of the harmonization.
Merger of clinical medicine
and public health/medical
administration
IT has also had an impact on public health
and medical administration. Such an impact
is associated with the construction of large-
scale databases. Public health and medical
administration services are provided for a
large number of people in a certain area or in
the whole country. It used to be impossible to
handle data on hundreds of thousands of indi-
viduals; decisions on what services to pro-
vide and how to provide them were always
made based on compiled data. In other
words, clinical medicine and public health
were totally different forms of health care.
However, to stretch the point, the technology
for constructing these databases enabled us to
build reservoirs with medical data on each
individual. For example, the technology
changed infection control measures. When
there is an outbreak of a certain infection, the
measures to control the infection are estab-
lished based on the analysis of data on infect-
ed individuals compiled in the database.
Medical institutions and administrative agen-
cies work closely with each other, and analy-
sis results are provided for physicians in the
clinical sites in real time. Such information
delivery was quite effective in the recent out-
break of severe acute respiratory syndrome
(SARS), as well as the spread of E. coli O-
157 infection in Japan several years ago.
Not only infection data but also the entire
medical data in a certain area or a country
could be retained, accumulated, and analyzed
in a database if they are electronically stored.
In countries where health care insurance is
disseminated, data are usually digitized in the
process of claiming medical fees. If these
digitized data are compiled to build a data-
base, the current situation of health care in
that country can be completely grasped. Such
databases are already available in some of the
advanced Western countries. Although elec-
tronic data on the health care insurance has
been promoted in Japan, a database does not
Medical Science, Professional Practice and Education
22
exist because such data have not been stan-
dardized. I am concerned that there may be a
lack of data that could serve as a basis for the
revision of medical fees.
Compilation of accurate medical data on the
entire nation is quite useful for the efficient
provision of health care. However, there are
some issues to be considered.Two of the major
issues are protection of privacy in the process
of handling medical information and autho-
rization to access the database. I will skip the
privacy issue because Dr. Higuchi will talk
about it in detail later. Here I would like to refer
to authorization to access the database.
Analyzing medical data of individual persons
in the database will reveal many facts; there-
fore, who will be authorized to access the
database is a big issue. If the government has
sole authority to analyze the data, the govern-
ment gains tremendous power and may force
a variety of policies on its people. Since this is
surely undesirable, the medical database for
analysis should be widely available to those
who are interested in such analysis, while
medical data containing personal information
should be handled with caution. All nations
should share their experiences in considering
how to resolve these conflicting issues. The
most important thing, I believe, is to establish
rules for using the database, to make it public,
and to authorize anybody who is willing to
obey the rules. The present guideline for the
medical database established by the World
MedicalAssociation puts emphasis on the pri-
vacy issue; however, I wish more considera-
tion had been given to the access issue.
Patient empowerment
The most important impact of IT is that
patients can now play a proactive role in health
care. We can call it patient empowerment.
Now that patients can easily obtain health care
information on the Internet, they will be able to
choose medical institutions according to the
obtained information and discuss treatment
options with physicians on equal terms. For
example, patients can review their medical
records kept at the hospital at home with their
families via the Internet. Although the number
is still small, some hospitals and clinics offer
such services for their patients in Japan.
Medical Science, Professional Practice and Education
23
While this is a welcome change, we should
keep in mind that much of the information
available on the Internet could be wrong or
exaggerated. The quality of information post-
ed on the Internet may be questionable, and
this is a common and serious problem, not
limited to health care, in the modern, advanced
IT world. It is almost impossible to totally
eliminate bad quality information from the
Internet. However, the influence of bad quali-
ty information can be minimized if medical
professionals provide high quality information
themselves. A group of physicians may evalu-
ate the medical information on the Internet to
set aside reliable information and give it an
approval mark. It will be meaningful if volun-
tarily done by people with conscience in the
private sector; it will be censorship and unde-
sirable if done by the government. Physicians
now should consider methods of quality assur-
ance in providing information to their patients.
Contrary to reducing the trusting relationship
between physicians and patients, patients’
proactive role in health care should enhance
such a relationship. Some say the number of
medical lawsuits will increase if patients
obtain health-related information; however,
there is no evidence to support such a notion.
In the 21st
century, patients should proactive-
ly obtain information to enhance the trustful
physician-patient relationship and improve
the quality of health care.
Robotics
Lastly, I will talk about robotics. Robotics has
only recently been put to practical use.
Nursing robots and transportation robots are
available now. There has been a growing inter-
est in using robots to comfort people. One type
of nursing robot will sense a slight movement
of the hand of a paralyzed patient and put food
into the patient’s mouth with a spoon.
All the roles robots will have in health care
is yet to be seen. There was a time when peo-
ple considered using robots in health care to
be totally inhumane and unacceptable.
However, if we carefully choose where to
apply robotics in health care, robots will be
useful. I will stop here because I do not have
enough data to further discuss this issue. We
will have to observe the development and
application of robotics in health care with
interest as medical professionals.
3. Conclusion
I have spoken about the necessity of harmo-
nizing IT and health care in the above-men-
tioned five areas. Needless to say, IT is a
wonderful technology that will make great
contributions to health care. In order to make
such contributions worthwhile, it is impor-
tant for all physicians to be interested in the
technology and use it correctly. Health care
will not improve just because IT is used; the
quality of health care will improve only if IT
is used correctly. Every physician should
understand the technology and use it as his
or her own tool in the 21st
century.I hope we
will all make efforts to enhance harmoniza-
tion of IT and health care.
The Medical Liability System in Germany –
An Accepted System
Dr. Suzanne Katelhön, Auslanddienst, Bundesärztekammer, Germany
Astronomical claims for damages and esca-
lating premiums for medical professional
liability insurance, a growing number of
court cases against doctors – not least
because of the high profits made by the
lawyers and the possibility of aggressively
soliciting suing patients – the snapshot pre-
sented by Dr. Palmisano in his article in the
latest issue of the World Medical Journal
(WMJ 50 (4)110 is alarming.
Worthy of note are the roughly 70% of
medical liability cases that end up before a
court and are closed without damages being
paid.
Medical Science, Professional Practice and Education
24
The USA are not exceptional in this con-
text. Comparable figures can also be found
in Germany, the difference being, however,
that the cost of litigation remains within
reasonable limits, since many of these cases
can be settled out of court.
The decisive factor behind this situation
was the introduction of Expert
Commissions and Arbitration Boards at the
State Medical Chambers in 1975. They are
independent bodies that examine differ-
ences of opinion between doctors and
patients to objectively establish whether
health-related complications are attribut-
able to medical treatment giving rise to lia-
bility. The aim is to reach an out-of-court
settlement between the doctor and the
patient. The Expert Commission draws up a
written expertise on the question of whether
the doctor can be accused of medical mal-
practice, as a result of which the patient has
suffered, or will suffer, damage to his
health. The Expert Commissions are head-
ed by a chairman qualified to hold judicial
office, who is usually assisted by two mem-
bers from the medical profession, at least
one of whom is active in the same field as
the doctor in question.
In agreement with the parties involved,
meaning the patient, the doctor or hospital,
and the liability insurer, the Arbitration
Boards clarify the facts and circumstances
of the case and then make a proposal for
settlement of the dispute.
The members of the Arbitration Board are a
doctor as chairman, a lawyer qualified to
hold judicial office, and other members
from the medical profession.
In this context, the statements of the
Arbitration Boards globally judge compen-
sation claims, while the Expert
Commissions appraise the activity of the
doctor as such. The decisions of the Expert
Commissions and Arbitration Boards are
determinations or recommendations. If the
doctor or the patient disagrees with the deci-
sion, he can resort to the ordinary courts of
law. According to an evaluation by the
Expert Commission of the North Rhine
Medical Chamber, only 13% of the petition-
ers in all appraisal procedures concluded in
the year 2000 (133 out of a total of 1,032)
decided to take such action. The fact that
only 10% of petitioners (63 out of 637)
resort to further litigation if medical mal-
practice cannot be established, is indicative
of the high degree of acceptance of the
expertises. Insofar as the proceedings had
already been concluded, the court and the
Expert Commission reached the same ver-
dict in the vast majority of cases. Only on
six occasions did the court decision differ
from the result of the appraisal procedure.
There is no statistical recording of medical
liability lawsuits in Germany. Conse-
quently, there are likewise no data as
regards the decline in the cost of litigation
following the introduction of Arbitration
Boards. Figures from the Arbitration Board
of the Northern German Medical Chambers
at least give an indication of the proportion
of expensive litigation proceedings that it
was possible to avoid: Of 4,000 petitions
filed in 2004, only 70% (2,813) were
accepted for a substantive decision at all.
1,208 petitions (30%) were not dealt with
further, either because they had been with-
drawn again by the petitioner (377 peti-
tions), or because they were not pursued
further for lack of jurisdiction (41 peti-
tions). In 656 cases, no decision was
reached because of a protest lodged by one
of the parties involved. 92 cases were
resolved simply by providing advice. The
figures for the other Federal States are sim-
ilar, making it clear that simple structures
and relatively little effort are all it takes to
avoid unnecessary litigation proceedings
and thus save costs.
The advantage of the Arbitration Boards for
the petitioner is also obvious: the arbitra-
tion procedure is free of charge for the
patient. And with an average completion
time of just 12 months, it is also much
faster than recourse to the courts.
This, and the great acceptance of the deci-
sions, has led to an increase in the number of
petitions in the last 15 years. While, for exam-
ple, the Arbitration Board of the Northern
German Medical Chambers had to deal with
some 1,500 petitions per year in 1990, the fig-
ure had already risen to over 4,000 in 2003.
TheArbitration Boards of other State Medical
Chambers also recorded an increase in the
number of petitions received, but not to such
a great extent as at the Northern German
Medical Chambers. For instance, 1,023 peti-
tions were filed with the North Rhine Medical
Chamber in 1990, compared to a total of
1,656 recorded in 2001.
However, the results of the work of the
Expert Commissions and Arbitration Boards
do not remain confined to a regional level,
but are collected and analysed centrally. The
Standing Conference of Expert Commissions
and Arbitration Boards was founded at the
German Medical Association for this pur-
pose. Its objective is to improve and stan-
dardise the individual procedural workflow.
The results are not only used to compile
national statistics. The information on med-
ical malpractice is also used in the State
Medical Chambers for the systematic analy-
sis of the causes of mistakes and to pass on
the findings to doctors in the framework of
continuing education events. This helps to
ensure continuous quality assurance.
Not only doctors, but also patients and the
public at large, must accept that mistakes and
damage can occur during any activity.
Playing down medical malpractice, or even
making a taboo of the subject, breeds doubt
and suspicion. Mutual mistrust fosters com-
pensation claims and liability suits.
Comprehensible and exhaustive patient
information that is documented in writing,
evidence-based and transparent work, and an
efficiently functioning system for managing
faults are essential elements for regaining
and promoting the confidence of patients
both in the individual doctor and medicine in
general. The medical community must learn
to openly face up to its own mistakes and
learn from them. Then, the patient will also
understand that the access of the general
public to medical care is worth more than the
right of the individual to compensation.
Bibliography:
(1) „Bericht der Gutachterkommission für
ärztliche Behandlungsfehler bei der
Ärztekammer Nordrhein“, 2003
(2) Heinz D. Laum et al. „Schlichtung mit
grosser Akzeptanz“, Deutsches
Ärzteblatt 12/2003
(3) German Medical Association,
Tätigkeitsbericht 2003/2004, p. 330 ff.
(4) www.schlichtungsstelle.de
WHO
25
Human Evolution
Out Of Africa
According to Professor Fred Spoor of
University College, London, man has
evolved primarily through his capacity to
run rather than climbing ability. Fossil evi-
dence shows that man developed the art of
walking around 4.5 million years ago, fol-
lowing ape evolution at 13 million years,
and thence the ability to stride and run in
order to escape his enemies and hunt in
groups. In response to the changing envi-
ronment of plate tectonics, man’s legs have
gradually become longer, relative to those
of his nearest neighbour the chimpanzee,
and his forearms have become shorter. The
skeleton evolved directly as a reaction to
the way Homo sapiens moved around, a
classical form of evolution, over a 6 million
year period. Efficacy in running emerged
about 2 million years ago, being successful-
ly better represented through surviving gen-
erations and men capable of raising large
families. Thus man was enabled to migrate
out of Africa and spread around the rest of
the world. The question remains as to
whether survival of the fittest is a product
of random chance and deleterious muta-
tions or are there specific feedback mecha-
nisms operationg on the DNA template in
evolution to fill environmental niches?
Evolution occurs when natural selection
operates in a population containing many
variations in their inheritable characteris-
tics. The genetic heritage of a community
tends to remain constant unless changed by
external environmental influences.For
example, a population living on an island
will evolve much quicker than one allowing
free mixing, as in the Galapagos Islands
originally observed by Darwin, where each
island has different varieties of finches and
tortoises. Also, Madagascar represents an
isolated island where there are no monkeys
– lemurs have developed to fill this envi-
ronmental niche. In tropical Australia there
are many new species that have been free to
develop in the absence of competition.
In terms of survival of the fittest, of malar-
ia provides survival value in some native
African populations when immunity to the
parasite Plasmodium develops. Some muta-
tions, perhaps as a result of adaptation to
metabolic requirements, can be advanta-
geous rather than damaging – and it is these
genes which in the long run may come to be
the norm within a population.
Ivan M. Gillibrand
WHO
WHO Supports Global Effort To Relieve
Chronic Pain
Geneva – The World Health Organisation
has co-sponsored the first Global Day
Against Pain, which seeks to draw global
attention to the urgent need for better pain
relief for sufferers from diseases such as
cancer and AIDS. The campaign, organised
by the International Association on the
Study of Pain (IASP) and the European
Federation of the IASP Chapters (EFIC),
asks for recognition that pain relief is inte-
gral to the right to the highest attainable
level of physical and mental health.
WHO representatives joined global special-
ists in chronic pain management and relief
at a conference in Geneva convened to
highlight the Global Day Against Pain and
to press for urgent action from governments
across the world. The conference coincides
with the release of the Council of Europe’s
newly formulated recommendations on pal-
liative care including management of pain.
The recommendations provide detailed
guidance for setting up a national policy
framework, and are available in 17
European languages.
“The majority of those suffering unrelieved
pain are in low- and middle-income coun-
tries where there is an increasing burden of
chronic conditions such as cancer and
AIDS,” said Dr Catherine Le Galès-
Camus, WHO Assistant Director-General
for Noncommunicable Diseases and
Mental Health. “Limited health resources
should not be allowed to deny sick people
and their families the dignity of access to
pain relief and palliative care, which are
integral to the right to enjoy good
health.We strongly support the Global Day
Against Pain and the efforts of IASP and
EFIC.”
New statistics released by IASP and EFIC
indicate that one in five people suffer from
moderate to severe chronic pain, and that
one in three are unable or less able to main-
tain an independent lifestyle due to their
pain. Between one-half and two-thirds of
people with chronic pain are less able or
unable to exercise, enjoy normal sleep, per-
form household chores, attend social activ-
ities, drive a car, walk or have sexual rela-
tions. The effect of pain means that one in
four reports that relationships with family
and friends are strained or broken, accord-
ing to the IASP/EFIC data.
The statistics also reveal that pain is second
only to fever as the most common symptom in
ambulatory persons with HIV/AIDS. Pain in
HIV/AIDS usually involves several sources at
once. The causes include tissue injury from
inflammation (including autoimmune res-
ponses), infection (e.g. bacterial, syphilitic or
tubercular) or neoplasia (lymphoma or sarco-
ma): so-called nociceptive pain. Nearly half of
pain in HIV/AIDS is neuropathic, reflecting
injury to the nervous system.
Oral morphine has proven to be a cost-
effective pain medication for the treatment
of moderate to severe pain when the under-
lying cause is cancer or HIV/AIDS.
However, opioid analgesics are not ade-
quately available, particularly in develop-
ing countries with limited resource set-
WHO
26
tings, due to ignorance of their medical use,
restrictive regulations and pricing issues.
“Pain relief should be a human right,
whether people are suffering from cancer,
HIV/AIDS or any other painful condition,”
said Professor Sir Michael Bond MD,
President of IASP. “Today’s Global Day
Against Pain marks an immense growth in
the interest in this area and WHO co-spon-
sorship of our campaign shows that now is
the time to take pain seriously.”
“Chronic pain is one of the most underesti-
mated health care problems in the world
today, causing major consequences for the
quality of life of the sufferer and a major
burden on the health care systems of the
Western world,” said Professor Harald
Breivik, President of EFIC. “We believe
chronic pain is a disease in its own right. For
people in developing countries, where pain
relief is at its most minimal availability, the
consequences of unrelieved pain are great.”
Professor Breivik said the decision to hold a
Global Day resulted from the success of the
European Week Against Pain, launched by
EFIC four years ago under the leadership of
its Past President Professor David Niv.
For further information please contact
WHO: Dr Cecilia Sepulveda, +41-22-791-
3706, or David Porter +41-22-791-3774
(o), +41-79-477-1740 (m).
IASP: Prof Sir Michael Bond, President,
Emeritus Prof of Psychiatry, University of
Glasgow. UK, +44-141-330-3692.
www.iasp-pain.org
EFIC: Prof Harald Breivik, President,
Prof of Anaethesology, University of Oslo,
Norway, +47-23073-691 www.efic.org
Clinical Obesity Pandemic
Fight Childhood Obesity To Help Prevent
Diabetes, Say WHO & IDF
Geneva — Worldwide, it is estimated that
more than 22 million children under five
years old are obese or overweight, and more
than 17 million of them are in developing
countries. Each of these children is at
increased risk of developing type 2 diabetes
(which used to be known as mature onset
diabetes), say the World Health Organization
and the International Diabetes Federation
(IDF).
“Tackling childhood obesity now is a high-
ly effective way of preventing diabetes in
the future,” said Dr Catherine Le Galès-
Camus, WHO Assistant Director-General
for Noncommunicable Diseases and Mental
Health.
Chronic diseases such as diabetes, heart
disease, cancer and stroke are a barrier to
economic development. While undernutri-
tion continues to be a key concern, particu-
larly in developing countries, governments
are also facing up to the fact that many chil-
dren in all regions of the world have poor
eating habits and are not getting enough
exercise.
Globally, an estimated 10% of school-
aged children, between five and 17 years
old, are overweight or obese, and the situ-
ation is getting worse. In the United
States, for example, the rate of obesity
and overweight among children and ado-
lescents aged 6 to 18 years increased to
more than 25% in the 1990s from 15% in
the 1970s.
Such increases are not restricted to devel-
oped countries. In China, the rate of over-
weight and obesity observed in a study of
urban schoolchildren increased from
almost 8% in 1991 to more than 12% six
years later. In Brazil, the rate of overweight
and obesity among children and adoles-
cents 6 to 18 years old more than tripled
from 4% in the mid-1970s to over 13% in
1997.
The link between obesity and diabetes is
well-established. Around 90% of people
with diabetes have type 2 diabetes and of
these the vast majority are overweight or
obese. “Overweight and obesity increase
the risk of many chronic diseases, includ-
ing type 2 diabetes, heart disease, stroke
and some cancers. Unless we address the
underlying causes of the obesity epidemic
it has the potential to overwhelm health
systems throughout the world,” said Dr Le
Galès-Camus. “The direct health care costs
of diabetes already account for between
2.5% and 15% of annual health care bud-
gets.”
WHO is working with its Member States
throughout the world to implement the
Global Strategy on Diet, Physical Activity
and Health, which was adopted at the May
2004 World Health Assembly.
The strategy recommends a comprehen-
sive range of changes at the individual,
community, national and international lev-
els which, if effectively implemented,
have the potential to turn around the obe-
sity epidemic. The strategy addresses
changes needed in lifestyles that have
been linked to the increase in overweight
and obese children over the last twenty
years.
Increased availability and promotion of
foods high in fat and sugar mean that chil-
dren no longer eat the way their parents
did. Nor do they do the same amount of
physical activity. In each country the situa-
tion is different, but the reasons why chil-
dren are less active than a generation ago
include increased urbanization and mecha-
nisation, changes to transport systems and
increased hours spent in front of TVs and
computers.
Yet small changes can make a big differ-
ence. In Singapore, nutrition education
in class, combined with a school envi-
ronment offering healthy foods and
drinks, and special attention for students
who were already overweight or obese,
resulted in a significant decline in the
number of obese students. In the UK,
limiting access to sweet, fizzy drinks at a
group of primary schools resulted in
slimmer children. Other studies have
demonstrated success by increasing
WHO
27
physical activity in school, making
changes to school lunches, limiting hours
spent watching TV and providing health
education.
Professor Pierre Levèbvre, President of
IDF, underlined the need for urgent
action. “Children and adolescents who
are overweight tend to grow into over-
weight adults. Poor habits of nutrition
and lack of physical activity are likely to
endure, putting today’s young people at
risk of type 2 diabetes in the future. Even
in childhood, overweight and obesity
lead to higher levels of blood glucose
(sugar), lipid (fat) and blood pressure. In
many populations, doctors are seeing
increasing numbers of adolescents with
type 2 diabetes, a disease that in the past
was not normally seen until middle or
older age.”
Diabetes is a chronic condition that occurs
when the pancreas does not produce
enough insulin or when the body cannot
effectively use the insulin it produces.
People who have type 1 diabetes produce
very little or no insulin and require daily
injections of insulin to survive. People with
type 2 diabetes cannot use insulin effective-
ly. They can sometimes manage their con-
dition with lifestyle measures alone, but
oral drugs are often required and, less fre-
quently insulin, in order to achieve good
metabolic control. Type 2 diabetes used to
be known as non-insulin dependent dia-
betes or mature onset diabetes.
WHO and IDF are working together to
raise awareness about diabetes worldwide.
Their joint project, Diabetes Action Now, is
supported by a World Diabetes Foundation
grant to IDF and by WHO funds.
Jakarta/Geneva – The Director-General of
the World Health Organization, Dr LEE
Jong-wook, visited Jakarta for a five-day
visit to Indonesia and Sri Lanka. During the
visit, Dr Lee took part in the Special
ASEAN Leaders’ meeting on the Aftermath
of the Tsunami.
Dr Lee, together with the Executive
Director of UNICEF, Carol Bellamy, trav-
elled to some of the worst hit areas around
Banda Aceh in northern Sumatra to meet
some of the victims of the tsunami and to
assess the most urgent health needs. He also
met and travelled with the European
Commissioner for Development and
Humanitarian Aid, Louis Michel.
After leaving Indonesia, Dr Lee travelled to
Sri Lanka to review progress in the relief
effort and to offer further support to the
country and to the communities which have
been most seriously affected by the tsuna-
mi.
Since the tsunami struck, WHO has been
working together with a core group of
countries helping to provide humanitarian
support. WHO has mobilised teams of
experts to work with countries to assess the
most urgent health needs and to ensure that
they are met as rapidly as possible.
The most urgent health need now is to pre-
vent outbreaks of infectious disease, and
particularly of water-borne diseases such as
diarrhoeal, dysentery and typhoid. It is
clear that providing clean water to as many
as possible of the affected cmmunities is
now the most pressing health priority.
WHO Director-General Travels To Indonesia
And Sri Lanka
Attends leaders’ meeting, tours stricken areas
The following is based on, and extracted
from the Presidential Address given to the
Annual Scientific Conference of the Fiji
Medical Association last year, entitled
“Profession, ethics and community in
this Millenium” .
Dr. Mary Schramm, referred to the princi-
ples of the Hippocratic Oath as follows
“Benefience – your activity should be ben-
eficial and never harmful
Respect for the patient, his home his fami-
ly”
Honour – be worthy of the honour of trust
given you by your patient
Spreading your art through learning and
teaching –
But Only to those who bind themselves to
this very same code of ethical behaviour”
She held in her hand a leaf from a tree
grown from a seed which had itself grown
from the tree under which Hippocrates
taught his pupils two and a half millenia
ago. It was passed from a pupil to his men-
tor, ultimately from another pupil and rela-
tive to Dr. Schramm herself. She valued the
leaf as “a symbol of that continuity and
trust which I had embraced to work out the
core values of my profession in the market-
place of modern medicine”.
While the values which she had embraced
have survived, despite wars, the fall of
empires, civil wars, ages of oppression and
ages of enlightenment, “medicine has also
changed”. She continued by referring to
Hippocratean practice as being that of its
own time – mainly one-to-one medicine.
But medicine has moved on Knowledge of,
and incidence of disease has increased, and
the technology for evaluating disease has
progressed even faster. She commented
that the comparatively cheap and simple
procedure of an exploratory operation had
been almost replaced by highly expensive
technology. However she considered “that
Regional and NMA News
Fiji Medical
Association
Regional and NMA News
28
Norwegian Telemedicine was demonstrated
by a consultation between a patient and
doctor in the north and the audience who
were thousands of miles apart, during a
presentation at the European Forum of
Medical Associations and WHO annual
meeting in Oslo, hosted by the Norwegian
Medical Association and attended by 36 of
the 51 NMAs in the European Region of
WHO, and by 5 International organisa-
tions. The telemedicine network, which
connects hospitals and many general prac-
titioners throughout Norway, enables
peripheral hospitals and practitioners to
conduct virtual consultations with the
patient and practitioner both present: it
even permits practitioners to be trained in
endoscopic techniques so that expert opin-
ion thousands of miles away can be given
on the endoscopy as it proceeds. This not
only assists diagnosis and access to expert
opinions in the more distant parts of the
country, but also reduces the need for
patients to travel great distances to hospi-
tals and diagnostic centres. In addition to a
presentation by the Norwegian Minister of
Health on the Norwegian Health System
and the report on WHO activity by
Dr. Mila Garcia-Barbero from WHO
EURO, the meeting appreciated a lively
presentation by a previous Minister of
Health on the success of the anti-tobacco
action in Norway.
European Region
European NMAs meet in Oslo
the one-to-one relationship between physi-
cian and patient remains central to good
medical care”, which she considered to be
only realised in the primary care setting
where the patient had chosen the physician
and joined himself with the physician in a
health caring partnership.
“Modern acute medical care can only be
given adequately by the team and the mod-
ern hospital and clinic is the setting in
which it is done. Yet conversely it can be
the setting for stress and frustration, if, or
when we depend on the participation of
people who do not share our (the profes-
sion’s) open-ended commitment to the
patient, persons who were appointed per-
haps to “common user” posts; whose pri-
mary commitment is to their own promo-
tion, their own career path.”
She continued “In this team setting, the
core principles of ethics still stand, but the
ways in which they are challenged and test-
ed are subject to change”. This challenge
Dr Schramm observed, was to be the chal-
lenge which the meeting would discuss
over the next three days. She elaborated this
to be considering
• “Increasing understanding of how to
focus our ethical commitment into day-
to-day work:
• Examining systems of control and regu-
lation of medical practice:
• Looking into who should blow the
whistle – when why and how loud
• and who should respond, when, for
whatever cause, people given the acco-
lade of Registered Medical Practitioner,
Doctor, are not practising up to defined
ethical standards”
The bulk of the rest of Dr. Schramm’s
speech given in the presence of the Prime
Minister and other guests, dealt with the
call for legislative action to deal with need-
ed changes needed in the registration and
regulation of Medical Practitioners, and
also the problems of emigrating medical
manpower (see WMJ (50) 1) and movement
from the government health service to pri-
vate medical care.
Extracts by kind permission of the Editors,
Fiji Medical Journal.
Excellent presentations and discussions
also covered such diverse topics as
Palliative Care, Liability without Fault, the
Bologna Process and Medicine and Health
Care in Prisons.
Following the lively discussions through-
out the meeting three Statements were
adopted. The first was on the Bologna
Process and Medicine, in which the Forum
found no evidence of any benefit for medi-
cine in the two cycle Bachelor/Master
process proposed for medical training and
qualification in European Universities. It
welcomed however its proposals concern-
ing mobility, comparability and harmonisa-
tion in medical education in Europe.
The second statement on Tobacco control,
reaffirmed NMAs commitment to tobacco
control, urged NMAs to continue support
for the Tobacco Convention, asked them
also to campaign actively for effective
“smoke free” laws in their countries and
requested all NMA meetings and premises
to be made no-smoking areas.
The third statement was on “Healthcare in
prisons and other forms of detention”, urg-
ing NMAs to address these issues in their
countries (see Human Rights page 10) All
statements were adopted by unanimous
consensus in accordance with normal
Forum procedure.
EFMA/WHO was founded in 1984 as a
Forum for positive discussions between the
National Medical Association of the whole
European Region of 51’ countries and
WHO Europe. It holds an annual meeting
hosted by one of the National Medical
Associations and aims through dialogue
between NMAs and WHO Europe:
• “to improve health and health care in
Europe,
• to promote information exchange of
information and ideas between NMAs
and between NMAs & WHO,
• to integrate appropriate aspects of HFA
policy into all basic, postgraduate and
continuing medical education, and
• to formulate consensus policy state-
ments on health issues”.