Medicine and nuclear war: from Hiroshima to mutual assured destruction to abolition 2000

To determine how physicians might participate in the prevention of nuclear war in the post-Cold War era, we review, from a medical perspective, the history of the nuclear weapons era since Hiroshima and the status of today's nuclear arsenals and dangers. In the 1950s, physicians were active partners in governmental civil defense planning. Since 1962, physicians have stressed prevention of nuclear war as the only effective medical intervention. Public advocacy by physicians helped end both atmospheric nuclear testing in the 1960s and superpower plans for fighting a nuclear war in the 1980s. Today's dangers include nuclear arms proliferation, an increasing risk of nuclear terrorism, and the 35000 warheads that remain in superpower-nuclear arsenals, many still on hair-trigger alert. Physicians have recently joined with military and political leaders and over 1000 citizens' organizations in calling for the complete elimination of nuclear weapons. Global medical collaboration in support of a verifiable and enforceable Nuclear Weapons Convention would be a major contribution to safeguarding health in the 21st century.

Greek theories on eugenics

With the recent developments in the Human Genome Mapping Project and the new technologies that are developing from it there is a renewal of concern about eugenic applications. Francis Galton (b1822, d1911), who developed the subject of eugenics, suggested that the ancient Greeks had contributed very little to social theories of eugenics. In fact the Greeks had a profound interest in methods of supplying their city states with the finest possible progeny. This paper therefore reviews the works of Plato (The Republic and Politics) and Aristotle (The Politics and The Athenian Constitution) which have a direct bearing on eugenic techniques and relates them to methods used in the present century.

The socially constructed breast: breast implants and the medical construction of need

When silicone gel breast implants became the subject of a public health controversy in the early 1990s, the most pressing concern was safety. This paper looks at another, less publicized issue: the need for implants. Using a symbolic interactionist approach, the author explores the social construction of the need for implants by tracing the history of the 3 surgical procedures for which implants were used. Stakeholders in this history constructed need as legitimized individual desire, the form of which shifted with changes in the technological and social context.

A map to a new treasure island: the human genome and the concept of common heritage

While the 1970's have been called the environmental years, the 1990's could be seen as the genome years. As the challenge to map and to sequence the human genome mobilized the scientific community, risks and benefits of information and uses that would derive from this project have also raised ethical issues at the international level. The particular interest of the 1997 UNESCO Declaration relies on the fact that it emphasizes both the scientific importance of genetics and the appropriate reinforcement of human rights in this area. It considers the human genome, at least symbolically, as the common heritage of humanity.

Francis Galton: and eugenics today

Eugenics can be defined as the use of science applied to the qualitative and quantitative improvement of the human genome. The subject was initiated by Francis Galton with considerable support from Charles Darwin in the latter half of the 19th century. Its scope has increased enormously since the recent revolution in molecular genetics. Genetic files can be easily obtained for individuals either antenatally or at birth; somatic gene therapy has been introduced for some rare inborn errors of metabolism; and gene manipulation of human germ-line cells will no doubt occur in the near future to generate organs for transplantation. The past history of eugenics has been appalling, with gross abuses in the USA between 1931 and 1945 when compulsory sterilization was practised; and in Germany between 1933 and 1945 when mass extermination and compulsory sterilization were performed. To prevent such abuses in the future statutory bodies, such as a genetics commission, should be established to provide guidance and rules of conduct for use of the new information and technologies as applied to the human genome.

What should we do about Eduard Pernkopf's atlas?

Eduard Pernkopf created a classic anatomy atlas during World War II. He was also an ardent Nazi. Questions have been raised recently about the propriety of using an atlas created by a Nazi and illustrated by dissections of cadavers whose identities are unknown, but who could have been victims of Nazi political terror. To examine the ethical issues involved, the author first reviews recently published work regarding Pernkopf and his atlas, with the caution that facts are few in a debate where emotions run high and opinions abound. He then considers what has been written by bioethicists on the use of scientific data from the Nazi era and how those arguments might apply to Pernkopf and his atlas. Important questions remain, however. For example, are scientific data tainted by their associations with Nazism, or should such data (including the atlas) be assessed on their own merits, separate from the persons and ideologies involved in their creation? Finally, the author offers his own perspective as a young gross anatomist and physician. He argues that rejecting the hateful beliefs of Pernkopf and his fellow Nazis does not necessitate rejecting the elegant anatomic images they produced. The author further suggests that use of the atlas is itself the most fitting tribute to those who died for it, whether they were victims of Nazi repression or not. Those cadavers not only teach anatomy, they "can remind us of suffering not only in the past but in the present, that we may be more compassionate physicians, more compassionate citizens of the world."

Last chance therapies and managed care. Pluralism, fair procedures, and legitimacy

How can health plans make fair determinations about when "experimental" (and costly) treatments such as high dose chemotherapy with autologous bone marrow transplantation should be covered despite lack of clear clinical consensus about their benefits? Different models for managing "last chance" therapies evolving in some health plans offer promising examples of how issues of fairness and legitimacy in decision-making can be addressed.

Anonymity, neutrality, and confidentiality in the actual methods of Sigmund Freud: a review of 43 cases, 1907-1939

OBJECTIVE

The aim of this historical study was to examine the methods actually used by Sigmund Freud in his practice of psychoanalysis in his mature years (1907-1939) and to assess the relationship between these methods and Freud's published recommendations concerning anonymity, neutrality, and confidentiality.

METHOD

The authors used both published and unpublished sources, including reports or autobiographies by analysands, letters by analysands, interviews of analysands, letters by Freud, published works by Freud, and clinical records of subsequent treatment.

RESULTS

Information concerning Freud's actual methods was found in 43 cases, including 10 clinical psychoanalyses, 19 didactic analyses, and 14 with combined clinical and didactic purposes. These 43 cases probably encompassed a majority of Freud's psychoanalytic hours during these years. Deviations from Freud's recommendations were found to the following extent: for anonymity, 43 cases (100%); for neutrality, 37 cases (86%); for confidentiality, 23 cases (53%). In addition, there were significant extra-analytic relations between Freud and 31 of these analysands (72%).

CONCLUSIONS

These results show a substantial disparity between Freud's recommendations and his actual methods. Freud's prescribed method, as defined by his recommendations, was not tested or used in his practice. Freud's actual method was never explicitly described in his writings and cannot be replicated.

Addressing racial inequities in health care: civil rights monitoring and report cards

Large racial inequities in health care use continue to be reported, raising concerns about discrimination. Historically, the health system, with its professionally dominated, autonomous, voluntary organizational structure, has presented special challenges to civil rights efforts. De jure racial segregation in the United States gave way to a period of aggressive litigation and enforcement from 1954 until 1968 and then to the current period of relative inactivity. A combination of factors--declining federal resources and organizational capacity to address more subtle forms of discriminatory practices in health care settings, increasingly restrictive interpretations by the courts, and the lack of any systematic mechanisms for the statistical monitoring of providers--offers little assurance that discrimination does not continue to play a role in accounting for discrepancies in use. The current rapid transformation of health care into integrated delivery systems driven by risk-based financing presents both new opportunities and new threats. Adequate regulation, markets, and management for such systems impose new requirements for comparative systematic statistical assessment of performance. My conclusion illustrates ways that current "report card" approaches to monitoring performance of such systems could be used to monitor, correct, and build trust in equitable treatment.

Lethal autonomy: the malfunction of the informed consent mechanism within the context of prenatal diagnosis of genetic variants

In this article, Cara Dunne and Catherine Warren challenge the current role of genetic counselors in advising expectant mothers about potential genetic defects of their fetuses. They show that genetic counselors sometimes provide one-sided negative information to women undergoing prenatal diagnosis of genetic variants. This biased information promotes abortion of what are considered "defective" fetuses. The misleading information provided by the genetic counselors and the termination of the pregnancies is akin to the eugenics movement. The authors describe the early 20th century eugenics movement, explore the origin and development of the Human Genome Project, analyze the current role of genetic counseling, and explain the importance of the informed consent process to the exercise of autonomy. Dunne and Warren conclude by offering methods by which to restructure the informed consent mechanism to offer a more balanced assessment of the risks and benefits associated with genetic disability.