little research is done on this and almost none in Canada. Canada could become a prime contributor. "Much of the cost-explosive research now in progress in major institutions of the developed world is not directly relevant to the vast majority of the world's population. This is a result of totally disordered priorities that limit the supply of scientist and research funds for global health problems." His words were particularly appropriate in light of this year's CHR theme: Health research - a road to a healthier future. Marjorie Guthrie, widow of folksinger Woody Guthrie, who died of Huntington's Chorea in 1967, stressed the necessity for a team approach to the disease. "There is evidence that, despite ongoing degeneration, patients with chronic neurologic disorders can benefit from a team of health profes-

sionals. But teamwork must begin immediately the diagnosis is confirmed if a more satisfying and productive life is to be maintained for the patient." Father's plea Pierre Delisle, father of a 5-yearold girl suffering leukemia and secretary of a recently formed Montreal parents' group called Leucan, told delegates in an impassioned plea that ordinary families no longer care about the reasons for not getting research done. "We need a highly effective maintenance program right now if our children are going to have any sort of chance of growing up. My own daughter did respond to radiation and chemotherapy, but doctors say she has only a 50% chance of making it through the next 2 to 5 years. That's not good enough," he said. "Concerted efforts should be under-

way right now; tomorrow might be too late." From beginning to end, CHR delegates representing scientists, voluntary health organizations, social service clubs and members of the general public were alternately stimulated, educated, appalled or moved to action by the speakers. As a national organization of Canadians concerned with biomedical research, CHR, a federally chartered non-profit voluntary organization, is already experiencing serious financial difficulties, not to mention lack of delegate support. Because of its all-encompassing approach, CHR, perhaps better than most groups, is in a position not only to stimulate public awareness, but to provide the impetus for funding support. But if its attendance continues to drop, whether through apathy or despair, it may become a defunct operation.u

How coercive is the medical profession? M.E. KRASS, MD, PH D

The medical profession, through ignorance, entrepreneurial enterprise, bureaucratic entrapment or a combination of these factors, seems to be becoming in certain respects a harmful force. The abuse, or potential abuse, of our power ranges from overt force and coercion to more subtle forms of restraint and repression, and I believe that physicians might usefully organize their thinking about the ethical and philosophical aspects of their power in society and about how they might have overstepped legitimate boundaries in the exercise of that power. Physicians have not always realized the importance of maintaining high ethical standards. This failure has led to the development of formal codes of ethics to chart our way through difficult ethical judgements. The Hippocratic Oath was the first of these, an ethical tradition tested for many centuries. But more recently there have been other codes1 specifying appropriate medical behaviour Reprint requests to: Dr. ME. Krass, 5400 Portage Road, Suite 504, Niagara Falls, Ontario 1340

under particular difficult circumstances. For example, the Nuremberg Code, developed following the Nuremberg trials, specified behaviour for doctors in wartime medical experiments; the International Code of Medical Ethics guided physicians engaged in research and experimentation; the Declaration of Helsinki and the Declaration of Tokyo reviewed and codified the doctor's role in protecting patient rights, particularly where force and coercion are applied (as they still are, despite the fact that these rights have been continually reaffirmed by prestigious medical groups).2 In our complex technological society certain aspects of this abuse, crude or subtle, are gradually becoming institutionalized, and physicians must continually guard against this. Coercion Although physicians are rarely involved in physical coercion or torture, Dr. Leo Alexander, consultant to the United States war secretary during the Nuremberg trials, extensively examined the medical profes-

CMA JOURNAL/DECEMBER 9, 1978/VOL. 119

sion's behaviour in this regard.3 He found that organized medicine in Germany collaborated with the Nazis, ..... particularly in . the mass extermination of those considered socially disturbing or racially or ideologically unwanted; the individual, inconspicuous extermination of those considered disloyal within the ruling group; and the ruthless use of human experimental material for medicalmilitary research." Alexander observed that small steps from the path of clear ethical duty can easily lead to radical departure from morality. But not all physicians under totalitarian regimes cooperated with the authorities: in Holland, the medical profession recognized and rejected very early the subtle attempts by the occupying Germans to entrap doctors in morally objectionable actions. Despicable practices (both by and to physicians, unfortunately) neither began nor ended with World War II..'. Amnesty International reports that torture is becoming an epidemic in many countries; in some, it has become integrated into the criminal justice system.6'7 Since there is clear evidence of physician involvement in

this extreme exercise of force, even the scant literature is worthy of comment. Solzhenitsyn8 has described how doctors took part in torture sessions by certifying whether prisoners could survive further abuse and falsifying death certificates of prisoners eventually killed. Sagan and Jonsen4 have shown that doctors may act as expert advisers in the design of torture. Greek torture victims during the recent dictatorship in that country agreed that some military and prison doctors had been involved in the practice of torture; substantial allegations also exist that physicians supported the system of torture in Portugal and Chile.0'7 In addition, British physicians are alleged to have been involved in psychologic abuse, such as sensory deprivation and other brain-washing techniques, in the interrogation of Irish Republican Army prisoners.9 Sheila Cassidy, a British physician describing her personal experience as a torture victim in Chile10 demonstrated that doctors are also victims of force and coercion. Abuse in reseach

The possibility of abuse in clinical research has resulted in numerous codes of ethics; constant monitoring of all clinical research is a rule in hospitals and research institutes. Still, many clinicians regard patients as their tools for research, and although informed consent is a well-understood concept, it is more easily defined on paper than put into practice.11 Most patients trust their doctors and will accede to requests from them; but informed patients will usually not take grave health risks for the sake of science. Even when all proprieties are observed, the risks must not outweigh the gains in research. The problem of long-term clinical studies where concepts of treatment may change with time has not been resolved. The infamous Tuskagee syphilis study,12'13 which recently ended in a multibillion-dollar lawsuit and United States Senate investigation, is a good example. This study, begun in 1932, involved the followup of rural southern black males with untreated syphilis. At the outset the treatment of syphilis was potentially as hazardous as the disease, but relatively early in the study safe and

effective treatment for syphilis became available. This untreated group of approximately 400 patients, plus a group treated with the toxic heavy metal method used prior to the discovery of penicillin, remained without the benefits of modern treatment until the study was discontinued in 1973. A United States governmental panel found that the Tuskagee study was unethical after the advent of penicillin. Certainly, no research study can be considered ethical post hoc. Ends do not justify means in research. There are numerous other examples of unjustified research, or research without informed consent.14'11'16 Clinical research in prisons has been a relatively common practice.17 Although informed consent is obtained, it is difficult to imagine a more oppressive environment for prisoner volunteers, who where health risks are involved are unlikely to be able properly to assess hazards. Prisoners are considerably more vulnerable to abuse even if it is unintentional. Capron17 poses the question, "When may a society actively, or by acquiescence, expose some of its members to harm in order to seek benefits for them, for others or for society as a whole?" Nowhere is that question more starkly posed than in research with prisoners. Children are also vulnerable to coercion in research.18 Recently, Fost'9 discussed the advisability of using children donors for renal transplants. He argued, first, that if reasonable consent had been obtained from a child and family, and if the procedure could be proved beneficial to the child donor, the operation should be considered ethical. He also argued that, in general, the risks to the child donor were trivial; furthermore, he felt that since even in adults rarely does the donor refuse, the situation would unlikely be different given close relationships of identical twin donor. In a rebuttal to this, Hollemburg"" argued that in no way could a child be considered not to be potentially if not actually coerced, where a sibling life is threatened unless a kidney is donated. I agree that children should not be used, because of their vulnerability to coercion, as living donors. This issue is not a common problem to most physicians, but, I believe) sharpens our focus on an important ethical issue.

1342 CMA JOURNAL/DECEMBER 9, 1978/VOL. 119

The power invested in psychiatrists has been extensively reviewed by Thomas Szasz."1"'""'" The main element in this potential area for harm is the power to commit a non-criminal person without his consent to a mental hospital. While involuntary hospital admissions are not as common as they once were, they still take place and are documented in the lay and scientific literature.2""'4 Although physicians generally act in good faith, the law on involuntary incarceration is not always followed. For example, in May 1977 the Ontario Ministry of Health circulated a memo reminding physicians to follow the law in this area: ... A recent study which has been made, reviewing the commitment of involuntary patients, has shown that a large number of the physician's applications for involuntary admissions were far from meeting the necessary elements to justify such a request, and that, at least, technically [they] did not conform to the spirit of the Mental Health Act. This potential infringement on civil rights is addressed in the recent amendment to the Ontario Mental Health Act (Bill 19), clarifying the criteria for involuntary commitment. Russian situation

The situation in Russia is instructive and may exemplify an extreme of the ultilitarian (or totalitarian) philosophy regarding the medical profession as an arm of state repression. In the USSR there appear to be two groups who undergo psychiatric abuse: political . who may, by political pressure (and as there is less precision in psychiatric nosology in the USSR), be labelled as psychotic and therefore be involuntarily incarcerated in special psychiatric hospitals, where a variety of abuses are perpetrated. Members of the second group are equally unfortunate. These are the truly psychotic whose illnesses include delusions that are political in nature. Evidence exists"8 that these patients are also likely to be placed in the special psychiatric hospitals reserved for the dissidents and treated similarly. While the situation in the USSR may be extreme, it is similar to ours in that social expediency is an important part of the rationalization of the system. Also it is possible, given

the general looseness of psychiatric diagnostic criteria even in the western democracies, that our Canadian psychiatric system functions, in general terms, as it does in the USSR, in subtly coercing society into obeying rules. The problems I have cited are obviously complex, and even the proposed changes in Ontario's Mental Health Act (Bill 19, 1978) have implications that ultimately may adversely affect the treatment of mentally ill patients. As well, the success of the civil liberties groups in this area in changing both attitudes and legislation has not yet been shown to improve the lot of the mentally ill. It is important, however, for physicians to be sensitized to the longterm implications of the various legislative prescriptions. In the end, I believe that the stance of the political system should be to limit physicians. legal power and to encourage noncoercive policies. Physicians in the marketplace

In schools and universities considerable psychologic assessment and treatment take place, involving certain judgements on the individual's mental state and intelligence. Such assessments are usually made by psychiatrists and psychologists.29 Students with problems may ask to see mental health professionals; they may not be aware that these professionals may not only help the student, but may also, by their permanent records and relationships with institutions, seriously impair the individual's chance of success or admission to institutes of higher learning. Psychiatric intervention in our school system, well intentioned though it may be, is increasing, and frequently the recipient does not always understand that the therapist may be serving the educational system as well as the client. Physicians as well may have double allegiences.30 For example, many MDs are employed by companies to aid in sorting out and treating worker health problems. In some circumstances the workers view the physician as a primary care doctor although in fact the physician's main role is to serve the needs of the company; often, the health needs of the workers and the company's needs are divergent. The company physician often must attempt to deduce

whether an illness is physical or men- withstanding the complexity of our tal or falls into the so-called class of present society, the physician's role malingering. Since physical or mental should not change. New forms of illness is not generally punished (but medical insurance and payment malingering is), often great effort is schemes, new philosophies and ideolexpended in making these determina- ogies (such as the self-care movement tions. Enough has been written to espoused by Ivan Illich) may either show that no useful purpose exists help or hinder physicians, but our in pursuing this end, since it is primary goal - to help the individdifficult to differentiate this mal- ual patient - must remain the same. adaptive behaviour from other non- Physicians can always exercise their organic maladaptive behaviour prob- fundamental right to serve the patient lems, such as hysteria or neurosis.22 and to refuse to cooperate as interI contend that physicians should not mediaries or agents of outside ininvolve themselves in these tenuous terests. judgements, owing to the severe social stigma attached to the notion of ma- References lingering. If patients are in fact faking illness, then company investigators or 1. The Nurem berg Code, International Code of Medical Ethics, Principles for other non-medical personnel could be Those Engaged in Medical Research used, since the physician's relationand Experimentation, Declaration of ship with people is based on trust. Helsinki, 1964. Readings #614, Institute of Society, Ethics and the Life Tabershaw,31 in a review of this probSciences, Hastings-on-Hudson, NY, lem, stated that "the physician in 1964 industry, even though on the payroll 2. Doctors and torture: Declaration of of the corporation, must be the agent Tokyo largely concurs with CMA of his profession and not of the orstatement. Can Med Assoc J 116: 800, 1977 ganization for which he works." Tabershaw points out that it is 3. ALEXANDER L: Medical science under dictatorship. N Engl J Med 241: 39, "...most important that the physi1949 cian not have the 'mind-set' of a hired employee, but rather that of a self-employed contractor. . with clearly defined functions and responsibilities . and owning or renting his physical facility even though it * S S may be on company property. This exteriorization of occupational med£ A ical practice would greatly alleviate the fears of the worker.. A

Conclusion

I believe there is a threat of continuity linking coercive behaviour by physicians. This thread is the intermittent lapse in the understanding that a physician can serve only one party. The Hippocratic Oath particularly directs us to this end. Coercive behaviour may be relatively subtle, representing a repressive or restraining force, such as in the difficult ethical problems for physicians in industry, or gross, such as the situation of physicians coooperating with brutal interrogation methods. However, the mechanisms of entrapment of physicians in these and other areas are similar. The solution is simple and obvious. We do not need more declarations of principle from the World Medical Association and others. Not-

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4. SAGAN LA, JONSEN A: Medical ethics and torture. N Engi J Med 294: 1427, 1976 5. COOPERMAN EM: Doctors, torture and abuse of the doctor-patient relationship. Can Med Assoc J 116: 707, 1977 6. HEIJDER J, VAN GEUNS H: Professional Codes of Ethics, Amnesty International Publications, London, 1976 7. AMNESTY INTERNATIONAL: Report on Torture, Farrar, Straus and Giroux, New York, 1975 8. SOLZHENITSYN Al: The Gulag Arc/upelago, 1918-19S6: An experiment in Literary Investigation, I-Il, Harper and Row, New York, 1974 9. The doctor in conflict. Br Med J 1: 761, 1972 10. CASSIDY 5: Human rights in Chile. Lancet 2: 951, 1976 11. GAYLIN W: On the borders of persuasion: a psychoanalytic look at coercion. Psychiatry 37: 1, 1974 12. LINTON 0: American study of lifetime effects of syphilis ends in $1.8 billion lawsuit. Can Med Assoc J 109: 410, 1973 13. CURRAN WJ: The Tuskagee syphilis study. N Engi J Med 289: 730, 1973 14. BEECHER HK: Ethics and clinical research. N Engi J Med 274: 1354, 1966 15. VEATCH RM, SOLLITrO S: Human experimentation - the ethical questions persist. Hast Cent Rep 3: 1, 1973 16. ALFIDI RJ: Informed consent: a study of patient reactions. JAMA 216: 1325, 1971 17. CAPRON AH: Medical research in prisons. Hast Cent Rep 3: 4, 1973

18. CURRAN WJ, BEECHER HK: Experimentation in Children. JAMA 210: 77, 1969 19. FOST N: Children as renal donors. N Engi J Med 296: 363, 1977 20. HOLLEMBERG NK: Altruism and coercion: should children serve as kidney donors? Ibid. p 390 21. SzAsz TS: Law, Liberty and Psychiatry, Macmillan, New York, 1963, p 221 22. Idem: The Myth of Mental Illness, Harper, New York, 1961 23. Idem: Psychiatric Slavery: The Dilemmas of Involuntary Psychiatry as Exemplified by the Case of Kenneth Donaldson, Collier MacMillan, London, 1977

24. SCHROEDER A: Insane judgements. Weekend Magazine May 21, 1977, p 14 25. Abuse of psychiatry. Br Med J 3: 509,

1973 26. ALEX.YEFF 5: Abuse of psychiatry as a tool for political repression in the Soviet Union. Med J Aust 1: 122, 1976 27. BUCKHOUT R: The Servsky treatment. Psychology Today 11: 38, 1977 28. An observer: Delusion as a political crime (C). Am J Psychiatry 131: 474, 1974 29. CALLAHAN D: The psychiatrist as double agent. Hast Cen Rep 4: 12, 1974 30. BURNUM JF: The physician as a double agent. N Engl J Med 297: 278, 1977 31. TABERSHAW IR: Whose "agent" is the occupational physician? A rchi Environ Health 30: 412, 1975

1978 Gairdner Foundation awards

. '1

Dyazide® To lower blood pressure and conserve potassium. Before prescribing, see complete prescribing information in CPS. The following is a brief summary. ADULT DOSAGE: Hypertension: Starting dosage is one tablet twice daily after meals. Dosage can be subseguently increased or decreased according to patient's need. If two or more tablets per day are needed, they should be given in divided doses. Edema: Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet daily. Mauimum dosage foar tablets daily. INDICATIONS: Mild to moderate hypertension in patients who have developed hypokalemia and in patients in whom potassium depletion is considered especially dangerous (e.g. digitalized patients). Medical opinion is not unanimoas regarding the incidence and/or clinical significance of hypokalemia occurring among hypertensive patients treated with thiazide-like diaretics alone, and concerning the ase of potassiam-sparing combinations as roatine therapy in hypertension. Edema of congestive heart failure, cirrhosis, nephrotic syndrome. steroid-indaced edema and idiopathic edema. Dyazide is useful in edematous patients whose response to other diuretics is inadeguate. CONTRAINDICATIONS: Progressive renal dysfunction (including increasing oliguria and azotemia) or increasing hepatic dysfunction. Hypersensitivity. Elevated serum potassium. Nursing mothers. WARNINGS: Do not use potassium supplementation or other potassium-conserving agents with Dyazide since hyperkalemia may result. Hyperkalemia (>5.4 mEg/I) has been reported ranging in incidence from 40/a in patients less than 60 years of age to 12% in patients 60 and older, with an overall incidence of less than 8%. Rare cases have been associated with cardiac irregularities. Make periodic serum potassium determinations, particularly in the elderly, in diabetics, and in suspected or confirmed renal insufficiency. If hyperkalemia develops, withdraw Dyazide and substitute a thiazide alone. Hypokalemia is less common than with thiazides alone, but if it occurs it may precipitate digitalis intoxication. PRECAUTIONS: Check laboratory data (e.g. BUN, serum electrolytes) and ECG's periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyper. kalemia on Dyazide' previously. Electrolyte imbalance may occur, especially where salt-restricted diets or prolonged high-dose therapy is used. Dbserve acutely ill cirrhotic patients for early signs of impending coma. Reversible nitrogen retention may be seen. Dbserve patients regularly for blood dyscrasias, liver damage or other idiosyncratic reactions: perform appropriate laboratory studies as reguired. Sensitivity reactions may occur, particularly in patients with history of allergy or bronchial asthma. Periodic blood studies are recommended in cirrhotics with splenomegaly. Ad(ust dosage of other antihypertensive agents given concomitantly. Antihypertensive effects of Dyazide may be enhanced in the post-sympathectomy patient. Hyperglycemia and glycosuria may occur. Insulin reguirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported to exacerbate or activate systemic lupus erythematosus. Pathological changes in the parathyroid glands have been reported with prolonged thiazide therapy. Triamterene may cause a decreasing alkali reserve, with the possibility of metabolic acidosis. Serum transaminase elevations sometimes occur with Dyazide'. Thiazides can decrease arterial responsiveness to norepinephrine and increase tubocurarines paralyzing effect: exercise caution in patients undergoing surgery. Thiazides cross the placental barrier and appear in breast milk; this may result in fetal or neonatal hyperbilirabingmia, thrombocytopenia, altered carbohydrate metabolism an. possible other adverse reactions that have occurred in the adult. Use in pregnancy only when deemed necessary for the patient's welfare. ADVERSE REACTIONS: The following adverse reactions have been associated with the use of thiazide diuretics or triamterene: Gastrointestinal: dry mouth, anorexia, gastric irritation, nausea, vomiting, diarrhea, constipation, aundice (intra-hepatic cholestatic) pancreatitis, sialadenitis. Nausea can usually be prevented by giving the drug after meals. It should be noted that symptoms of nausea and vomiting can also be indicative of electrolyte imbalance (See Precautions). Central nervous system: dizziness, vertigo, paresthesias, headache, xanthopsia. Dermatologic - Hypersensitivity: fever, purpura, anaphylaxis, photosensitivity, rash, urticaria, necrotizing angiitis. Hematologic: leukopenia, thrombocytopenia, agranulocytosis, aplast ic anemia. Cardiovascular: orthostatic hypotension may occur and may be potentiated by alcohol, barbiturates, or narcotics. Electrolyte imbalance (See Precautions). Miscellaneous: hyperglycemia, glycosuria, hyperuricemia, muscle spasm, weakness, restlessness, transient blurred vision. SUPPLY: Scored light orange compressed tablets monogrammed

Dyazide SKFE93 in bottles of 100, 500, lOOQand 2,500. DIN 181528.

makes sense Drs Phil Gold (left) and Samuel 0 Freedman (right) of McGill University received $5000 each in the 21st annual Gairdner Foundation awards for their discovery of carcinoembryonic antigen. 1344 CMA JOURNAL/DECEMBER 9, 1978/VOL. 119

hydrochiorothiazide 50 mg triamterene

. Smith Kline & French Canada Ltd. SMontreal,Quebec H4M 2L6