“Health and Human Rights,” edited by Doris Schroeder, welcomes contributions on all health topics related to human rights and relevant generic contributions from the human rights debate. To submit a paper or to discuss suitable topics, please e-mail Doris Schroeder at [email protected].Thoughts raised here have been floated at seminars and workshops at Cardiff University, the Open University at Milton Keynes, University College London, Anglia Polytechnic University, the University of Brighton, and University of Wales, Newport. I am grateful both for these chances to float them and for the rich and helpful comments received on each occasion—too many to credit individually, but very much appreciated.

Scientific misconduct can jeopardize scientific progress and destroy the credibility and reputation of academic institutions and their faculty and students; ultimately it can compromise scientific integrity and result in a loss of confidence for the entire scientific community. Only recently in Japan has scientific misconduct become a central public topic. This increased attention to the topic, in turn, has highlighted a paucity of ethical standards within the Japanese scientific community and a lack of an apt process for conflict resolution. In this brief report, we first provide an overview of several high-profile cases of scientific misconduct recently uncovered in Japan. Next we consider how a recent rise in competition within the academic and scientific communities is possibly related to a concurrent increase in reported cases of scientific misconduct. Last, after discussing what actions have already been taken, we recommend further actions needed to deal with the problem of scientific misconduct in Japan.

Those who read only the introductory section of “Physician Obligation in Disaster Preparedness and Response,” the statement from the AMA's Council on Ethical and Judicial Affairs, apparently an elaboration on CEJA Opinion 3-I-04, E-9.067, will find an expression of laudable professional responsibility in the face of a disaster. There the AMA authors explicitly acknowledge “that unique responsibilities beyond planning rest on the shoulders of the medical profession” (emphasis added). They also declare that, “physicians are needed to care for victims. In some instances, this will require individual physicians to place their health or their lives at risk” (emphasis added). As the AMA authors note, these responsibilities have been accepted at least since the writing of Thomas Percival in 1803 and endorsed by the AMA in posting their 1847 code. The commitments are also asserted in the preamble of the AMA's most current Principles of Medical Ethics, which states that “a physician must recognize responsibility to patients, first and foremost,” and again in Principle VIII, which states that “[a] physician shall, when caring for a patient, regard responsibility to the patient as paramount” (emphasis added).

On September 28, 2002, 11-year-old Jakob von Metzler, a banker's son, was abducted on the way to his parents' house in Frankfurt. A sum of one million Euro was demanded for his release. Three days after Jakob's disappearance, Magnus Gäfgen, a 32-year-old law student, collected the ransom from the arranged tram stop in Frankfurt during the night. While under observation by the police, he ordered a new Mercedes and booked a holiday abroad. Seventy-six hours after Jakob's disappearance, the police arrested Gäfgen and his 16-year-old girlfriend while simultaneously searching his flat. There they found the missing ransom, but no sign of Jakob.I would like to thank participants of the Newport, University of Wales, Research Seminar, the Amsterdam Bioethics Retreat, and the London School of Economics Political Theory Seminar for very valuable comments. Thanks also to Peter Herissone-Kelly, Armin Schmidt, and Katrin Flikschuh for comments on an earlier version.“Health and Human Rights,” edited by Doris Schroeder, welcomes contributions on all areas outlined below. Submitted papers are peer-reviewed (short discussion papers will be reviewed by at least one, full papers by at least two reviewers). To submit a paper or to discuss suitable topics, please e-mail Doris Schroeder at [email protected].

The profession of medicine has developed codes of ethical conduct for thousands of years. From the Hippocratic Oath of ancient Greece onward to modern times, a universal and central element of such codes has expressed the imperative that a physician shall “Do no harm.”

In a previously published multicenter, prospective, randomized, controlled trial of more than 500 intensive care unit patients involved in conflicts over treatment decisions, ethics consultations were found to be helpful in resolving the conflicts and reducing nonbeneficial treatments. The intervention received favorable reviews by 80% of patient surrogates and more than 90% of physicians and nurses. Nevertheless, several participants in the ethics consultation process expressed dissatisfactions with the intervention. In this paper, we report our efforts to determine the factors associated with these negative responses in hopes that we might provide insights of future use to ethics consultants.We gratefully acknowledge the contributions of Jeffrey Blustein, Kathleen B. Briggs, Ronald Cranford, Glen I. Komatsu, and Ernle W.D. Young to the original randomized controlled trial phase of this research. Grant support came from the Agency for Healthcare Research and Quality, 1 R01 HS10251.

The AMA's Council on Ethical and Judicial Affairs' position statement on “Disaster Preparedness and Response” is a welcome discussion of an important issue: the extent to which physicians have a responsibility to treat people affected by disasters in which the nature, source, and cause of the harm is unclear and where the risk is largely unknown.All authors contributed fully to drafting and shaping this paper.

These CQ Sources were compiled by Bette Anton.

Rationing and patient selection is inevitable in medical care, but in its most extreme form—when doctors and nurses decide about life and death—it is an almost unbearable burden for the profession. Eric Goemare, the Head of the South African Mission of Médicins Sans Frontières (MSF) and his staff faced three equally difficult selection issues when rolling out antiretroviral treatment to HIV/AIDS patients in South Africa. Initially, the treatment had to be rationed due to lack of financial resources. Today, rationing is mostly due to lack of human resources. But at the same time, patients are being deselected because of nonadherence to the treatment regime to avoid the creation of multi-drug-resistant strains of the HIV virus.

Sick to Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life, by Joanne Lynn. Berkeley: University of California Press and New York: Milbank Memorial Fund, 2004. 217 pp. $24.95.

According to Joanne Lynn, the author of Sick to Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life, those of us spared an accidental or traumatic death will experience one of three trajectories of health and decline toward the end of our lives. People experiencing the first trajectory will remain active and comfortable until only a few weeks prior to death, when a severely debilitating decline will occur. Those experiencing the second will live for years with relatively minor debilitations associated with chronic illness, but these will be exacerbated at intervals over time, and death will occur unexpectedly. Those experiencing the third trajectory—nearly half of all Americans—will dwindle away slowly, becoming increasingly incapacitated from frailty and/or dementia over years or even decades.Readers are invited to contact Greg S. Loeben in writing at Midwestern University, Glendale Campus, Bioethics Program, 19555 N. 59th Ave., Glendale, AZ 85308 ([email protected]) regarding books they would like to see reviewed or books they are interested in reviewing.

In February 1975, a group of leading scientists, physicians, and policymakers convened at Asilomar, California, to consider the safety of proceeding with recombinant DNA research. The excitement generated by the promise of this new technology was counterbalanced by concerns regarding dangers that might arise from it, including the potential for accidental release of genetically modified organisms into the environment. Guidelines developed at the conference to direct future research endeavors had several consequences. They permitted research to resume, bringing to an end the voluntary moratorium that the National Academy of Sciences (NAS) had instituted several months earlier. They also served to illustrate that the scientific community was capable of self-governance, thereby securing public trust and persuading Congress not to institute legislative restrictions. Finally, they underscored the importance of weighing unforeseen risks inherent in some research against potential benefits that may arise from these same endeavors.The Council on Ethical and Judicial Affairs of the American Medical Association (AMA) formulates ethical policies for the medical profession through its interpretations of the AMA's Principles of Medical Ethics. The Council at the time this report was adopted consisted of Michael S. Goldrich, M.D. (Chair); Priscilla Ray, M.D. (Vice-Chair); Regina M. Benjamin, M.D., M.B.A.; Daniel Higginson (student member); Mark A. Levine, M.D.; John M. O'Bannon III, M.D.; Robert M. Sade, M.D.; Monique A. Spillman, M.D., Ph.D. (resident member); and Dudley M. Stewart, Jr., M.D. Staff to the Council at the time the report was adopted were Audiey Kao, M.D., Ph.D. (Vice President, Ethics Standards Group); Karine Morin, L.L.M. (Secretary); and Sara Taub, M.Be. Shane K. Green, Ph.D., was a Fellow in the AMA's Institute for Ethics.

As pressures increase to contain growing healthcare expenditures, there is currently a prominent rise in the shift of healthcare costs to patients in the form of deductibles, co-pays, and co-insurance. Rising co-payments are part of a larger picture of increasing overall out-of-pocket healthcare expenditures. From 1990 to 2000, per capita out-of-pocket payments for healthcare reached $707 in the United States, and doubled in several European countries with universal health insurance, reaching $396 in Denmark, $290 in Germany, and $466 in Italy in 2000.The authors thank Dan Brock, Nir Eyal, Alex Rajczi, and Dave Wendler for their invaluable criticism of the manuscript. This study was funded by the National Institutes of Health. The National Institutes of Health was not involved in the design of this study. SAH was partially supported by a grant from the University Hospitals of Geneva. This work was conducted while Dr. Hurst was a fellow in the Department of Clinical Bioethics at the National Institutes of Health. The views expressed here are the authors' own and do not reflect the position of the National Institutes of Health, the Public Health Service, the Department of Health and Human Services, or the University Hospitals of Geneva.

Ethics rounds in clinical ethics have already taken hold in multiple venues. There are “sit-down rounds,” which usually consist of a bioethicist setting a specific, prescheduled time aside for residents and/or others to bring a case or two for discussion with the bioethicist. Another kind of rounds that occurs on an ad hoc or infrequent basis is to have either a staff or outside bioethicist give hospital-wide and/or departmental “grand rounds.” Grand rounds is a traditional educational format in medicine and adding bioethics to the topics covered in grand rounds is an important means of elevating ethical awareness within a department or throughout a healthcare organization. Newer is the rounding practice of adding a bioethicist to other established rounding processes, such as case management and utilization review rounds. All of these kinds of ethics rounds are important opportunities to elevate the level of moral discourse within a healthcare setting and are becoming part and parcel of any full-service hospital bioethics program.Some of the content of this paper was delivered by DeRenzo in her talk, “Having a Bioethicist Round Weekly in the Intensive Care Unit: Benefits to Patients and Staff of Upstream Preventive Ethics versus Conflicted Downstream Consultations,” presented at the Second International Conference on Clinical Ethics Consultation, Basel, Switzerland, March 2005.

In 1999, Médecins Sans Frontières (MSF) set out to explore and demonstrate the feasibility of preventing and treating HIV/AIDS in a so-called resource-poor, economically and socially disadvantaged setting. The first MSF mission to incorporate antiretroviral (ARV) treatment into its HIV-AIDS-oriented medical program was undertaken in Bangkok. The second project was launched in Khayelitsha where MSF has been providing ARV treatment for persons with HIV/AIDS since May 2001. Khayelitsha is an enclave of some 500,000 inhabitants, most of whom live in corrugated-iron shacks, without running water or electricity. Unemployment is extremely high; crime and violence (including robbery, domestic violence, rape, and murder) are rampant. The general prevalence of HIV/AIDS is 26%, measured among pregnant women. The tuberculosis incidence rate is one of the world's highest for open-space sites (1,380/100,000). Unsurprisingly, TB/HIV coinfection is very high too: 63% of those with TB are also infected with HIV. Renée C. Fox made two field research trips to the Khayelitsha HIV/AIDS project in connection with her ongoing sociological study of Médecins Sans Frontières, which centers on moral dilemmas associated with medical humanitarian action. Her research has been supported by grants from The Acadia Institute, the Honorable Walter H. Annenberg Chair in the Social Sciences Research Fund at the University of Pennsylvania, and the Andrew W. Mellon Foundation in the United States, and from the Nuffield Foundation in the United Kingdom. We express our gratitude to Nicholas A. Christakis, M.D., the late Willy De Craemer, Ph.D., Robert L. Klitzman, M.D., and especially to Judith P. Swazey, Ph.D., for their astutely critical and encouragingly helpful comments on earlier drafts of this article. Disclaimer: Patients' consent and permission to publish are not required, because no research was conducted on patients, and the cases described in the article do not reveal the patients' identity or breach their privacy.

The question of how to prevent the malevolent use of biomedical research is not new. It has its genesis in how to prevent any new technology, invention, or scientific discovery created for the benefit and advancement of human welfare being used for the expressed purpose of harming the human community. There is the ethical component, the social responsibility component, and the intent to preserve the beneficent characteristic of biomedical research (that it not be used for malevolent purposes) at stake in this issue.The views presented are strictly those of the author and do not reflect any official policy of the United States Army or the Government of the United States.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.

The American Medical Association's (AMA's) Council on Ethical and Judicial Affairs' (CEJA's) new “Guidelines to Prevent the Malevolent Use of Biomedical Research” are both timely and appropriate. These guidelines are a product of the increasing realization of the “dual use” potential of life science discoveries. Although biomedical research usually aims at the development of new medicines, vaccines, diagnostics, and so on, the very same discoveries that could benefit humankind in these ways also often have implications for the development of biological weapons. The CEJA Guidelines draw attention to this fact and hold that physician–researchers have responsibilities regarding the uses to which their discoveries are put. Medical researchers should assess the likely social benefits and harms of their work and avoid projects where the latter outweigh the former. Knowledge and the advancement of science should not be the only aims of scientists; “commitment to public welfare and safety” are also essential. Toward the aim of preventing the malevolent use of research discoveries, the CEJA states that “regulatory oversight” of research (with an eye to potential harmful uses of potential discoveries), increased ethics education of physician researchers, and sometimes perhaps even censorship of research findings, are warranted.

Any program seeking to provide antiretroviral treatment (ART) to the many patients in need is bound to confront ethical dilemmas. Dilemmas, as we know, are situations in which decisionmakers are faced with a choice between equally unsatisfactory alternatives. Yet those in charge must make a decision or establish a policy that takes one pathway to the exclusion of another. Reasonable people may disagree over the choice, arguing that an alternative selection would have been ethically superior.

It is widely acknowledged that the HIV and AIDS pandemic is a global emergency and that cheap, effective treatment should be provided for as many people as possible worldwide. But there are many challenges to rolling out antiretroviral (ARV) treatment in resource-poor settings. These include the cost of drugs (although these are falling rapidly), sustaining their supply and distribution, the complexity of treatment regimens, selection of patients for treatment, shortage of medical and nursing personnel, inadequacy of healthcare facilities, the need for uninterrupted, lifelong treatment, and monitoring for drug resistance. Great efforts, nationally and internationally, are required to meet these challenges.This work was supported in part by the University of Toronto and a grant from the United States National Institutes of Health's Fogarty International Center to the University of Cape Town's capacity-building program in International Research Ethics in southern Africa (Program Director S. R. Benatar).