THE NEW MILITARY MEDICAL ETHICS: LEGACIES OF THE GULF WARS AND THE WAR ON TERROR

United States military medical ethics evolved during its involvement in two recent wars, Gulf War I (1990–1991) and the War on Terror (2001–). Norms of conduct for military clinicians with regard to the treatment of prisoners of war and the administration of non‐therapeutic bioactive agents to soldiers were set aside because of the sense of being in a ‘new kind of war’. Concurrently, the use of radioactive metal in weaponry and the ability to measure the health consequences of trade embargos on vulnerable civilians occasioned new concerns about the health effects of war on soldiers, their offspring, and civilians living on battlefields. Civilian medical societies and medical ethicists fitfully engaged the evolving nature of the medical ethics issues and policy changes during these wars. Medical codes of professionalism have not been substantively updated and procedures for accountability for new kinds of abuses of medical ethics are not established. Looking to the future, medicine and medical ethics have not articulated a vision for an ongoing military‐civilian dialogue to ensure that standards of medical ethics do not evolve simply in accord with military exigency.     

Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution

ObjectivesTo discover whether post-combat syndromes have existed after modern wars and what relation they bear to each other.DesignReview of medical and military records of servicemen and cluster analysis of symptoms.ResultsThree varieties of post-combat disorder were identified—a debility syndrome (associated with the 19th and early 20th centuries), somatic syndrome (related primarily to the first world war), and a neuropsychiatric syndrome (associated with the second world war and the Gulf conflict). The era in which the war occurred was overwhelmingly the best predictor of cluster membership.ConclusionsAll modern wars have been associated with a syndrome characterised by unexplained medical symptoms. The form that these assume, the terms used to describe them, and the explanations offered by servicemen and doctors seem to be influenced by advances in medical science, changes in the nature of warfare, and underlying cultural forces.

What is already known on this topic

Service in the Gulf war is associated with an increased rate of reported symptoms and worsening subjective healthPost-combat syndromes have been described after most modern conflicts from the US civil war onwards

What this study adds

There seems to be no single post-combat syndrome but a number of variations on a themeThe ever changing form of post-combat syndromes seems to be related to advances in medical understanding, the developing nature of warfare, and cultural undercurrentsBecause reported symptoms are subject to bias and changing emphasis related to advances in medical science or the discovery of new diseases, the characterisation of individual syndromes has to be treated with cautionAttributions by servicemen are generally consistent with symptom characteristics, though there seems to be a growing reluctance to consider the stress of military service as a cause     

Human Rights Violations among Men Who Have Sex with Men in Southern Africa: Comparisons between Legal Contexts

In 1994, South Africa approved a constitution providing freedom from discrimination based on sexual orientation. Other Southern African countries, including Botswana, Malawi, and Namibia, criminalize same-sex behavior. Men who have sex with men (MSM) have been shown to experience high levels of stigma and discrimination, increasing their vulnerability to negative health and other outcomes. This paper examines the relationship between criminalization of same-sex behavior and experiences of human rights abuses by MSM. It compares the extent to which MSM in peri-urban Cape Town experience human rights abuses with that of MSM in Gaborone, Botswana; Blantyre and Lilongwe, Malawi; and Windhoek, Namibia. In 2008, 737 MSM participated in a cross-sectional study using a structured survey collecting data regarding demographics, human rights, HIV status, and risk behavior. Participants accrued in each site were compared using bivariate and multivariate logistic regression. Encouragingly, the results indicate MSM in Cape Town were more likely to disclose their sexual orientation to family or healthcare workers and less likely to be blackmailed or feel afraid in their communities than MSM in Botswana, Malawi, or Namibia. However, South African MSM were not statistically significantly less likely experience a human rights abuse than their peers in cities in other study countries, showing that while legal protections may reduce experiences of certain abuses, legislative changes alone are insufficient for protecting MSM. A comprehensive approach with interventions at multiple levels in multiple sectors is needed to create the legal and social change necessary to address attitudes, discrimination, and violence affecting MSM.     

GLOBALIZATION, HUMAN RIGHTS, AND THE SOCIAL DETERMINANTS OF HEALTH

Globalization, a process characterized by the growing interdependence of the world's people, impacts health systems and the social determinants of health in ways that are detrimental to health equity. In a world in which there are few countervailing normative and policy approaches to the dominant neoliberal regime underpinning globalization, the human rights paradigm constitutes a widely shared foundation for challenging globalization's effects. The substantive rights enumerated in human rights instruments include the right to the highest attainable level of physical and mental health and others that are relevant to the determinants of health. The rights stipulated in these documents impose extensive legal obligations on states that have ratified these documents and confer health entitlements on their residents. Human rights norms have also inspired civil society efforts to improve access to essential medicines and medical services, particularly for HIV/AIDS. Nevertheless, many factors reduce the potential counterweight human rights might exert, including and specifically the nature of the human rights approach, weak political commitments to promoting and protecting health rights on the part of some states and their lack of institutional and economic resources to do so. Global economic markets and the relative power of global economic institutions are also shrinking national policy space. This article reviews the potential contributions and limitations of human rights to achieving greater equity in shaping the social determinants of health.     

Evolutionary ecology of human birth sex ratio under the compound influence of climate change, famine, economic crises and wars

1.  Human sex ratio at birth at the population level has been suggested to vary according to exogenous stressors such as wars, ambient temperature, ecological disasters and economic crises, but their relative effects on birth sex ratio have not been investigated. It also remains unclear whether such associations represent environmental forcing or adaptive parental response, as parents may produce the sex that has better survival prospects and fitness in a given environmental challenge.
2.  We examined the simultaneous role of wars, famine, ambient temperature, economic development and total mortality rate on the annual variation of offspring birth sex ratio and whether this variation, in turn, was related to sex-specific infant mortality rate in Finland during 1865–2003.
3.  Our findings show an increased excess of male births during the World War II and during warm years. Instead, economic development, famine, short-lasting Finnish civil war and total mortality rate were not related to birth sex ratio. Moreover, we found no association between annual birth sex ratio and sex-biased infant mortality rate among the concurrent cohort.
4.  Our results propose that some exogenous challenges like ambient temperature and war can skew human birth sex ratio and that these deviations likely represent environmental forcing rather than adaptive parental response to such challenges.     

Medical Evidence of Human Rights Violations against Non-Arabic-Speaking Civilians in Darfur: A Cross-Sectional Study

Background

Ongoing conflict in the Darfur region of Sudan has resulted in a severe humanitarian crisis. We sought to characterize the nature and geographic scope of allegations of human rights violations perpetrated against civilians in Darfur and to evaluate their consistency with medical examinations documented in patients'' medical records.

Methods and Findings

This was a retrospective review and analysis of medical records from all 325 patients seen for treatment from September 28, 2004, through December 31, 2006, at the Nyala-based Amel Centre for Treatment and Rehabilitation of Victims of Torture, the only dedicated local provider of free clinical and legal services to civilian victims of torture and other human rights violations in Darfur during this time period. Among 325 medical records identified and examined, 292 (89.8%) patients from 12 different non-Arabic-speaking tribes disclosed in the medical notes that they had been attacked by Government of Sudan (GoS) and/or Janjaweed forces. Attacks were reported in 23 different rural council areas throughout Darfur. Nearly all attacks (321 [98.8%]) were described as having occurred in the absence of active armed conflict between Janjaweed/GoS forces and rebel groups. The most common alleged abuses were beatings (161 [49.5%]), gunshot wounds (140 [43.1%]), destruction or theft of property (121 [37.2%]), involuntary detainment (97 [29.9%]), and being bound (64 [19.7%]). Approximately one-half (36 [49.3%]) of all women disclosed that they had been sexually assaulted, and one-half of sexual assaults were described as having occurred in close proximity to a camp for internally displaced persons. Among the 198 (60.9%) medical records that contained sufficient detail to enable the forensic medical reviewers to render an informed judgment, the signs and symptoms in all of the medical records were assessed to be consistent with, highly consistent with, or virtually diagnostic of the alleged abuses.

Conclusions

Allegations of widespread and sustained torture and other human rights violations by GoS and/or Janjaweed forces against non-Arabic-speaking civilians were corroborated by medical forensic review of medical records of patients seen at a local non-governmental provider of free clinical and legal services in Darfur. Limitations of this study were that patients seen in this clinic may not have been a representative sample of persons alleging abuse by Janjaweed/GoS forces, and that most delayed presenting for care. The quality of documentation was similar to that available in other conflict/post-conflict, resource-limited settings. Please see later in the article for the Editors'' Summary     

Continuities and changes regarding minorities in Somalia

Somali society has long since been considered ethnically homogenous. The better known pastoral-nomadic section of society was perceived as representative. Politics and economy throughout the twentieth century were controlled by ‘majority’ clan members. ‘Minority group’ members were generally marginalized and sometimes even oppressed and exploited; during the civil war from 1991 onwards, they became easy victims for majority group militias. Previously respected religious or occupational ‘castes’ also fell victim to the general insecurity and lawlessness during that period. The civil war not only had enormous negative consequences for minority group members; in some cases, it increased the self-consciousness of minority groups and led to the formation of new identities that, in combination with international organizations and their human rights policies, provided members of certain groups with chances for resettlement or made them actively demand more rights.     

Civil war: is it all about disease and xenophobia? A comment on Letendre,Fincher & Thornhill

Letendre, Fincher & Thornhill (2010) argue that pathogen intensity provides the ultimate explanation for why some countries are more prone to civil war than others. They argue that the economic and political factors highlighted in previous research on civil war are largely caused by underlying differences in pathogen intensity, and contend that disease proneness increases the risk of civil war through its effects on resource competition and xenophobia. They present empirical evidence that they interpret as consistent with their argument: a statistically significant correlation between pathogen intensity and civil war onset. In this comment, we raise concerns over their interpretation of the empirical evidence and their proposed causal mechanisms. We find that the data provide stronger evidence for the reverse causal relationship, namely that civil war causes disease to become more prevalent. This finding is consistent with the literatures on the public health effects of civil war as well as research on state capacity and public health.     

The importance of ethic in the field of human tissue banking

A tissue bank is accountable before the community in fulfilling the expectations of tissue donors, their families and recipients. The expected output from the altruistic donation is that safe and high quality human tissue grafts will be provided for the medical treatment of patients. Thus, undertakings of tissue banks have to be not only authorised and audited by national competent health care authorities, but also comply with a strong ethical code, a code of practices and ethical principles. Ethical practice in the field of tissue banking requires the setting of principles, the identification of possible deviations and the establishment of mechanisms that will detect and hinder abuses that may occur during the procurement, processing and distribution of human tissues for transplantation. The opinions and suggestions manifested by the authors in this paper may not be necessarily a reflection of those within the institutions or community they are linked to.     

Does infectious disease cause global variation in the frequency of intrastate armed conflict and civil war?

Geographic and cross‐national variation in the frequency of intrastate armed conflict and civil war is a subject of great interest. Previous theory on this variation has focused on the influence on human behaviour of climate, resource competition, national wealth, and cultural characteristics. We present the parasite‐stress model of intrastate conflict, which unites previous work on the correlates of intrastate conflict by linking frequency of the outbreak of such conflict, including civil war, to the intensity of infectious disease across countries of the world. High intensity of infectious disease leads to the emergence of xenophobic and ethnocentric cultural norms. These cultures suffer greater poverty and deprivation due to the morbidity and mortality caused by disease, and as a result of decreased investment in public health and welfare. Resource competition among xenophobic and ethnocentric groups within a nation leads to increased frequency of civil war. We present support for the parasite‐stress model with regression analyses. We find support for a direct effect of infectious disease on intrastate armed conflict, and support for an indirect effect of infectious disease on the incidence of civil war via its negative effect on national wealth. We consider the entanglements of feedback of conflict into further reduced wealth and increased incidence of disease, and discuss implications for international warfare and global patterns of wealth and imperialism.     

Opportunities in Reform: Bioethics and Mental Health Ethics

Last year marks the first year of implementation for both the Patient Protection and Affordable Care Act and the Mental Health Parity and Addiction Equity Act in the United States. As a result, healthcare reform is moving in the direction of integrating care for physical and mental illness, nudging clinicians to consider medical and psychiatric comorbidity as the expectation rather than the exception. Understanding the intersections of physical and mental illness with autonomy and self‐determination in a system realigning its values so fundamentally therefore becomes a top priority for clinicians. Yet Bioethics has missed opportunities to help guide clinicians through one of medicine's most ethically rich and challenging fields. Bioethics' distancing from mental illness is perhaps best explained by two overarching themes: 1) An intrinsic opposition between approaches to personhood rooted in Bioethics' early efforts to protect the competent individual from abuses in the research setting; and 2) Structural forces, such as deinstitutionalization, the Patient Rights Movement, and managed care. These two themes help explain Bioethics' relationship to mental health ethics and may also guide opportunities for rapprochement. The potential role for Bioethics may have the greatest implications for international human rights if bioethicists can re‐energize an understanding of autonomy as not only free from abusive intrusions but also with rights to treatment and other fundamental necessities for restoring freedom of choice and self‐determination. Bioethics thus has a great opportunity amid healthcare reform to strengthen the important role of the virtuous and humanistic care provider.     

Health and human rights in Chin State, Western Burma: a population-based assessment using multistaged household cluster sampling

Background

The Chin State of Burma (also known as Myanmar) is an isolated ethnic minority area with poor health outcomes and reports of food insecurity and human rights violations. We report on a population-based assessment of health and human rights in Chin State. We sought to quantify reported human rights violations in Chin State and associations between these reported violations and health status at the household level.

Methods and Findings

Multistaged household cluster sampling was done. Heads of household were interviewed on demographics, access to health care, health status, food insecurity, forced displacement, forced labor, and other human rights violations during the preceding 12 months. Ratios of the prevalence of household hunger comparing exposed and unexposed to each reported violation were estimated using binomial regression, and 95% confidence intervals (CIs) were constructed. Multivariate models were done to adjust for possible confounders. Overall, 91.9% of households (95% CI 89.7%–94.1%) reported forced labor in the past 12 months. Forty-three percent of households met FANTA-2 (Food and Nutrition Technical Assistance II project) definitions for moderate to severe household hunger. Common violations reported were food theft, livestock theft or killing, forced displacement, beatings and torture, detentions, disappearances, and religious and ethnic persecution. Self reporting of multiple rights abuses was independently associated with household hunger.

Conclusions

Our findings indicate widespread self-reports of human rights violations. The nature and extent of these violations may warrant investigation by the United Nations or International Criminal Court. Please see later in the article for the Editors'' Summary     

Two faces of death: fatalities from disease and combat in America's principal wars, 1775 to present

Throughout America's first 145 years of war, far more of the country's military personnel perished from infectious diseases than from enemy action. This enduring feature of war was finally reversed in World War II, chiefly as a result of major medical advances in prevention (vaccines) and treatment (antibiotics). Safeguarding the health of a command is indispensable for the success of any campaign. Wars are lost by disease, which causes an enormous drain on the military's resources and affects both strategy and tactics. Disease and combat mortality data from America's principal wars (1775-present) fall into two clearly defined time periods: the Disease Era (1775-1918), during which infectious diseases were the major killer of America's armed forces, and the Trauma Era (1941-present), in which combat-related fatalities predominated. The trend established in World War II continues to the present day. Although there are currently more than 3,400 U.S. military fatalities in Iraq, the disease-death toll is so low that it is exceeded by the number of suicides.     

论知情同意制度的不足以及术中改变术式的法律责任

知情同意制度贯穿于医疗活动的整个过程，尊重患者的知情同意权是医务人员的法定义务，国内诸多法律法规均对医疗活动中的知情同意做了原则性的规定。但是由于缺乏针对具体医疗行为如何适用知情同意制度的指引或者规范，导致医务人员常常不知如何正确地履行知情同意程序。而且，当前的知情同意制度存在诸多不足，司法实践也对知情同意缺乏深入的研究，这为医务人员的执业活动带来了潜在的法律风险。     

Mild manifestations of COVID-19 in healthcare workers

Medical staff treating Coronavirus Disease 2019 (COVID-19) patients are at high risk for exposure to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and many have been infected, which may cause panic among medical workers, their relatives, health professionals, and government leaders. We report the epidemiologic and clinical characteristics of healthcare workers and that the majority of infected medical staff had milder symptoms/conditions with a better prognosis than admitted patients. Timely improvement to medical staff’s working conditions such as allowing adequate rest and providing sufficient medical protection is extremely important.     

From John McCain to Abu Ghraib: Tortured Bodies and Historical Unaccountability of U.S. Empire

ABSTRACT   John McCain, once considered a "friend" of Vietnam because of his support for normalized relations with the United States, has since lost his standing. Claims to inhumane treatment and torture while a prisoner in the "Hanoi Hilton" have met with angry denials and calls for more attention to the humanitarian care that McCain and others received. Recent U.S. allegations of human rights abuses in Vietnam following the Abu Ghraib prison scandal have further strained relations, as have charges leveled against Vietnamese small-scale producers of dishonest trade practices. Drawing on these exchanges, I examine competing representations of Vietnamese wartime acts that have permeated the "normalization" process. Neoliberal rhetorics aimed at "saving" the Vietnamese economy and its allegedly blemished human rights record are countered by discourses and images that lay claim to a Vietnamese "tradition" of wartime compassion and humanitarianism that also demands U.S. historical accountability for imperial violence and its aftermaths. [Keywords: neoliberalism, violence, human rights, Vietnam, historical memory]     

医疗损害鉴定制度的改革与发展

医疗损害指因医疗机构及其医务人员的故意或过失（即医疗过错）,造成就医患者身体上或精神上的损害结果。医疗损害鉴定是指医疗机构及其医务人员在日常医疗行为中存在法定过错并造成患者人身损害而导致的医疗损害民事诉讼,人民法院针对医疗技术的高风险、高技术等问题对外委托的鉴定。其内容主要针对医疗行为整个过程的审查和分析,对照卫生行政法规、部门规章诊疗护理规范及常规,判定医师有无过错,医疗过错行为与损害结果之间是否存在因果关系,医疗过错行为在损害结果中的责任程度以及人体损伤残疾程度等方面。     

Public health ethics: asylum seekers and the case for political action

This paper is a case study in public health ethics. It considers whether there is a basis in ethics for political action by health professionals and their associations in response to inhumane treatment. The issue arises from Australia's treatment of asylum seekers and the charge that this treatment has been both immoral and inhumane. This judgement raises several questions of broader significance in bioethics and of significance to the emerging field of public health ethics. These questions relate to the role of health professionals in response to inhumane treatment of people in their charge; to the discipline of public health in light of a growing recognition of its ethical basis; and the role of public health and bioethical associations in response to ethical issues arising in a political context. It is argued that, in serious cases of humanitarian and human rights abuses affecting health and well-being, there is a case for political action by health professionals, academic and professional institutions, and associations of public health and ethics.     

Mental well-being in settings of 'complex emergency': an overview

The mental state of people affected by war and other disasters has been a subject of special interest to academic researchers and practitioners in humanitarian assistance and public health for over two decades. The last decade in particular has seen a rise in the number of papers published in scholarly journals around the Post-Traumatic Stress Disorder (PTSD) debate. Anthropologists have rarely engaged in this debate. Nevertheless, some of the most illuminating contributions have come from socio-medical anthropology (Last, 2000). This volume brings together a wide range of disciplines in the human sciences to address some of the key questions that bear upon the mental health and well-being of populations affected by war and displacement, with contributions from applied biosocial and medical anthropology (Almedom; Lewando-Hundt et al.); applied psychology/public health and social psychiatry (Carballo et al.; Snider et al.; Fullilove et al.); social work (Ahearn & Noble); and political sciences (Pupavac). The four themes that run through this set of papers (outlined below) remain topical areas of contention in contemporary humanitarianism. Scholars and practitioners in the biosocial sciences may wish to engage in the empirical study of human (if not humanitarian) responses to disaster focusing on questions as yet unanswered.