Ethical issues for vaccines and immunization.

Vaccination is the only type of medical intervention that has eliminated a disease successfully. However, both in countries with high immunization rates and in countries that are too impoverished to protect their citizens, many dilemmas and controversies surround immunization. This article describes some of the ethical issues involved, and presents some challenges and concepts for the global community.

Barriers to enrolment of clients into community client led anti-retroviral therapy delivery (CCLAD) in selected health facilities in Kasese district, Uganda.

Background: Community Client Led Anti-retroviral therapy Delivery (CCLAD) Model has been associated with increased community participation and ownership, which leads to better treatment outcomes with reduced workload and increased client satisfaction of health services. Aim: To explore the barriers to enrolment of eligible clients into CCLAD in selected health facilities in Kasese District, Uganda. Materials & methods: Analytical cross-sectional study utilizing mixed method approach was conducted among 384 PLWHIV attending public health facilities of Kasese District. Sampling was done by simple random sampling method. Data was collected using researcher-administered questionnaire method and interview guide. Results: Most of the respondents 253(65.9%) had not yet enrolled into CCLAD. This was due to some client-related factors such as non-disclosure of HIV sero-status (p=0.040), person to whom HIV sero-status was disclosed to (p=0.009), not having ever heard about CCLAD (p=0.000), incorrect description of CCLAD (p=0.000), limited knowledge of advantages of CCLAD (p=0.000) or disadvantages of CCLAD (p=0.003). Other barriers were; failure to have access to organizations or groups that support PLWHIV to get treatment (p=0.025) and duration of ART refills [AOR=1.637, 95% CI (0.820 - 3.270)]. Conclusion: Adoption of CCLAD model among PLWHIV in Kasese District is still low.

Will tomorrow's medicines work for everyone?

Throughout much of the world, 'race' and 'ethnicity' are key determinants of health. For example, African Americans have, by some estimates, a twofold higher incidence of fatal heart attacks and a 10% higher incidence of cancer than European Americans, and South Asian- or Caribbean-born British are approximately 3.5 times as likely to die as a direct result of diabetes than are British of European ancestry. The health care that people receive also depends on 'race' and 'ethnicity'. African Americans are less likely to receive cancer-screening services and more likely to have late-stage cancer when diagnosed than European Americans. Health disparities such as these are one of the greatest social injustices in the developed world and one of the most important scientific and political challenges.

Indian state plans compulsory HIV testing, segregation and branding.

PIP: Health officials in the Indian state of Maharashtra have ordered the compulsory testing of all girls 12 years and older who live in designated "destitute homes." The officials also plan to tattoo a symbol on the thighs of all HIV-positive prostitutes. By April 1998, this December 1997 order had resulted in the compulsory testing of women living in 50 boarding houses and the transfer of several found to be HIV-positive to a separate institution 200 miles from the state capital. Nongovernment organizations (NGOs) have mounted a protest over this statute, but state governments in India are free to enact their own health laws. The Maharashtran government is also seeking to legalize prostitution and to force prostitutes to register with a Board that will be able to order compulsory HIV tests and tattooing. Women with HIV who continue to engage in prostitution will be quarantined, and their clients will be jailed. In response, prostitutes in the capital city of Mumbai have threatened to release a list of their client's names to the press. The only recourse available to NGOs who oppose this action is to generate a large enough public outcry to stop it. A Mumbai-based attorney noted that many private companies are also requiring HIV testing and dismissing those who test positive.^ieng

Who is at greatest risk for receiving poor-quality health care?

BACKGROUND: American adults frequently do not receive recommended health care. The extent to which the quality of health care varies among sociodemographic groups is unknown. METHODS: We used data from medical records and telephone interviews of a random sample of people living in 12 communities to assess the quality of care received by those who had made at least one visit to a health care provider during the previous two years. We constructed aggregate scores from 439 indicators of the quality of care for 30 chronic and acute conditions and for disease prevention. We estimated the rates at which members of different sociodemographic subgroups received recommended care, with adjustment for the number of chronic and acute conditions, use of health care services, and other sociodemographic characteristics. RESULTS: Overall, participants received 54.9 percent of recommended care. Even after adjustment, there was only moderate variation in quality-of-care scores among sociodemographic subgroups. Women had higher overall scores than men (56.6 percent vs. 52.3 percent, P<0.001), and participants below the age of 31 years had higher scores than those over the age of 64 years (57.5 percent vs. 52.1 percent, P<0.001). Blacks (57.6 percent) and Hispanics (57.5 percent) had slightly higher scores than whites (54.1 percent, P<0.001 for both comparisons). Those with annual household incomes over 50,000 dollars had higher scores than those with incomes of less than 15,000 dollars (56.6 percent vs. 53.1 percent, P<0.001). CONCLUSIONS: The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care.

Some of the tough decisions required by a national health plan.

The goals of providing coverage for everyone in the United States and controlling the growth in national health expenditures require difficult decisions about what medical services to provide. Currently accepted practices vary enormously in the amount of health they produce for a given expenditure. Studies of the health effects of several major interventions in relation to their costs--Pap smears, mammography, coronary care units, bypass surgery, and cholesterol reduction--indicate the kinds of choices to be made.

Science, technology, and the limits of judicial competence.

KIE: Federal courts are increasingly being called upon to adjudicate disputes involving controversial new biomedical technologies or government efforts to control environmental and health risks. The authors cite some examples and examine various proposals that have been made to better equip the courts to deal with these complex disputes. They conclude that the proposals fall seriously short by focusing on questions of technical competence without addressing the basic moral and public policy implications of modern science and technology.^ieng

Health rights issue emerges in El Salvador.

KIE: Institute of Medicine members Alfred Gellhorn and Robert Lawrence visited El Salvador in January as observers for the American Association for the Advancement of Science, the National Academy of Sciences, the New York Academy of Sciences, and the International League for Human Rights. Their findings paralleled those of an earlier delegation--"a virtually complete breakdown of the health system" and continuing violence against health professionals. A number of scientific organizations in the U.S. are reported to be exploring ways to channel private aid from health professionals and to protect the rights of patients and health personnel without antagonizing the government of El Salvador.^ieng

Medicine as business: are doctors entrepreneurs?

KIE: The emergence of health care in the United States as an industry, with a major role being played by for-profit providers, has stimulated debate over what happens to traditional medical values and relationships when medicine and money mix. In 1986, the Institute of Medicine contributed to the debate with the publication of its report, For-Profit Enterprise in Health Care. Two members of the committee preparing the document, physician and editor (The New England Journal of Medicine) Arnold Relman, and Princeton economist Uwe Reinhardt, corresponded concerning their differing views on the physician's role in a profit-oriented health system. Edited versions of some of their letters appear here, with Reinhardt arguing that doctors are and have always been businessmen, and Relman defending his profession as a calling entailing special obligations to patients.^ieng

The global drug gap.

Global inequities in access to pharmaceutical products exist between rich and poor countries because of market and government failures as well as huge income differences. Multiple policies are required to address this global drug gap for three categories of pharmaceutical products: essential drugs, new drugs, and yet-to-be-developed drugs. Policies should combine "push" approaches of subsidies to support targeted drug development, "pull" approaches of financial incentives such as market guarantees, and "process" approaches aimed at improved institutional capacity. Constructive solutions are needed that can both protect the incentives for research and development and reduce the inequities of access.

Prescription drug ads put FDA on the spot.

KIE: Spurred by increasing competition in the pharmaceutical industry, some drug companies would like to be allowed to advertise their prescription drugs to the general public as well as to health professionals. The Food and Drug Administration, concerned about the legal and ethical implications of direct-to-consumer advertising, has asked for time to study the proposal.^ieng

Ethical issues in the prevention and treatment of HIV infection and AIDS.

The epidemic of infection with the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) poses a major ethical question: How can we control the epidemic and the harm that it causes without unjustly discriminating against particular social groups and without unnecessarily infringing on the freedom of individuals? This question pertains to three spheres of public policy in the United States: public health, the delivery of health care, and research. In the public health sphere, vigorous educational efforts will be required, as will modified approaches to intravenous drug use, prostitution, and homosexual and bisexual sexual activity. Carefully targeted, voluntary testing and screening programs should be coupled with counseling and with guarantees of confidentiality and nondiscrimination where these are appropriate. Both health care workers and the health care system have a moral obligation to provide care to people with HIV infection, but heroic self-sacrifice should not be required provided that infection control precautions are observed. Patients with neurological involvement and terminally ill patients will benefit from statutes allowing recognition of advance directives about preferred modes of care or nontreatment. There is a moral imperative to perform intensive research directed toward the understanding, treatment, and prevention of HIV infection and AIDS. The research process will raise challenging ethical questions.

Organ shortage clouds new transplant era.

KIE: Technical advances and new drugs that prevent rejection of transplanted tissue are revolutionizing organ transplantation, but the current shortage of donated organs is expected to worsen. The reasons for this shortage and possible solutions to the problem are discussed briefly, and the ethical and legal implications of salvaging organs from brain-dead patients are mentioned. Presumed consent laws, already in force in several European countries, would drastically increase the number of available organs, but American ethicists are divided over a policy permitting automatic use of organs unless a person has left explicit instructions to the contrary.^ieng

Public health. Surveillance and privacy.

Surveillance is the radar of public health. It has provided the foundation for public health planning, intervention, and prevention. Important ethical issues regarding privacy--the extent to which name-based reporting violates the trust and assumptions made about how personal medical information will be treated--are raised by public health surveillance. This policy forum looks at the contexts of differing responses from the public health communities and general public to surveillance efforts.

The syphilis epidemic and its relation to AIDS.

This article presents an overview of the history of medical and public health responses to syphilis in the 20th-century United States and briefly evaluates the relevance and significance of these approaches for the AIDS epidemic. The parallels are numerous: they relate to science, public health, civil liberties, and social attitudes concerning sexually transmitted infection. The strengths and limits of past approaches to controlling sexually transmitted diseases are explored as a possible guide for AIDS policy.

Legal rights and duties in the AIDS epidemic.

This article provides an overview of some major areas of legal concern in which the AIDS epidemic is having an impact. The rights of infected individuals to testing, treatment, and confidentiality are reviewed, and emphasis is given to their claims to nondiscrimination regarding access to health care, employment, housing, education, insurance, and related interests. Infected persons' duties to contain transmission of AIDS are outlined under principles of criminal and civil law, including liability for provision of contaminated blood products. Uninfected people's general rights to protection are considered, and health professionals' and authorities' rights and duties are given more detailed attention. In conclusion, some legal developments outside the United States are reviewed.

Organ transplantation.

In the report "Pregnancy interception with a combination of prostaglandins: Studies in monkeys: by J. W. Wilks (30 Sept., p. 1407), figures 2 and 3 on page 1408 were interchanged.

Human organ transplantation: background and consequences.

The story of the renal transplant program of the Peter Bent Brigham Hospital (now the Brigham and Women's Hospital) in Boston weaves together three distinct threads: the study of renal disease, the phenomenon of skin grafting in twins, and the development of surgical procedures ultimately leading to the use of chemical immunosuppression. The common leitmotiv is one of a single event or report proving to be decisive. Unanticipated consequences of successful human organ transplantation include the reorganization of clinical and nonclinical disciplines, national and international cooperation in organ preservation and distribution, tissue-typing as a marker for disease, redefinition of death in terms of brain function, better understanding of disease processes, and new health care quandaries that result from the scarcity of organ donors.

Liver transplants endorsed. An NIH consensus panel recommends more transplants but does not say who will pay.

KIE: A National Institutes of Health (NIH) Consensus Development Conference on Liver Transplantation has concluded that, with some exceptions, transplantation could be considered for most patients who are near death with liver disease. This recommendation comes despite problems in interpreting existing data on survival rates. The panel did not address the issues of who should pay for liver transplants, or of how many donor livers would be needed if more transplantation centers were established.^ieng

Rationing health care: the choice before us.

Rapid technological advances and upward pressure on wages of hospital personnel are leading to a steady increase in health care spending that is absorbing an ever-larger fraction of gross national product. Eliminating inefficiencies in the system can provide brief fiscal relief, but rationing of beneficial services, even to the well-insured, offers the only prospect for sustained reduction in the growth of health care spending. The United States, which has negligible direct experience with rationing, can learn about choices it will face from the experience of Great Britain where health care has been rationed explicitly for many years.