Volume III Issue i

Penn Bioethics Journal

The nation’s only peer-reviewed undergraduate bioethics journal

Volume III, issue i: Bioethics of Public Health

Penn Bioethics Journal 2007 Executive Editor and Publisher Bo Peng Associate Editors Erin Cho Anand Bhagwat Claire Chang Chloe Jiang Yoon Cho Kavita Vinekar Uzy Igweatu Chandler Craig Chava Cogan Rajini Murthy Kate Wallis Alix Rogers Nadia Mikhail Charlie Robinson Benjamin Himes Victoria Tsai Stephanie Joco Jennifer Rha Julietta Chang Zuolu (Lulu) Liu Associate Pulishers Claire Chang Anand Bhagwat Kavita Vinekar Business Manager Jules Shen Cover Design Chava Cogan Webmaster Anand Bhagwat Managing Editors Markley Foreman Rachel Han Jules Shen Justin Masterman Katryn Bowe Faculty Advisors Connie Ulrich, RN, PhD Paul R. Wolpe, PhD Founder Andrew J. Rosenthal

Outstanding Contribution to Undergraduate Bioethics Award The Penn Bioethics Journal is pleased to announce the writing award for outstanding submissions. The Outstanding Contribution to Undergraduate Bioethics award, administered in conjunction with the Center For Undergraduate Research and Fellowships (CURF) at Penn, has been established to recognize outstanding undergraduate writing in bioethics. All undergraduates with articles published in Penn Bioethics Journal are considered for the prize. Two outstanding articles in the journal will be recognized with a first place prize and a honorable mention prize. The recognitions will be awarded in conjunction with the publication of each issue. See Table of Contents for the winners.

All submissions--those that meet either the early or regular deadlines--will be considered in the selection. Executive members of the PBJ editorial board and the PBJ faculty advisors, in partnership with CURF, will select the winners.

A deep understanding of the issues, insightful exploration and writing style are just some of the qualities by which prospective articles will be judged. Submissions are considered without regard to home institution.

Letter From the Editor March 2007 To all new and old readers, I proudly present to you the fourth publication (Volume III, issue i) of the Penn Bioethics Journal, entitled Bioethics of Public Health.

We live in a dynamic society, constantly re-evaluating its rules and guidelines amidst the advent of new developments in science and technology. Attention to public health issues has greatly increased in the past years, with the development of new vaccines, implementation of new federal health regulations, and natural and man-made disasters around the world. It is increasing important that we reflect on the various bioethical questions arising from public health issues.

As a society we must start the public health discussion on the public level, in forums such as the Penn Bioethics Journal.

Some of the articles published herein focus on classical bioethical issues such as access to drugs, while others investigate questions not commonly discussed, such as the value of cadavers in plastination. In tune with current affairs, we have also published an article on the recently released vaccine Gardasil, an issue still requiring much analysis. Of course, while our theme is Bioethics and Public Health, we have also published articles exploring questions outside the immediate realm of public health, such as the issue of commodification of women in pornography. While I have only scratched the surface of the diversity of topics presented in this issue, I hope I have convinced you to give our authors their well-deserved attention, and take a look inside our journal.

I am also happy to present our exclusive interview with Glenn McGee, PhD, who is the founder of the American Journal of Bioethics (AJOB) and Director of the Alden March Bioethics Institute. Our choice of Dr. McGee is particularly exciting as he is a prominent figure in the Bioethics community and also a dedicated mentor to undergraduates. He has given us a small look into his career and opinions on current issues in Bioethics.

In continuation of our Award for Excellence in Undergraduate Bioethics, funded by the Center for Undergraduate Research and Fellowships (CURF) at the University of Pennsylvania, we selected two exceptional papers from this issue. The first prize winner for this issue is Frances McCorkle of the University of Virginia on Liberal Answers to Callahan’s Communitarianism. The honorable mention goes to Virginia Portmann of Trent University on Public Access to Anatomical Knowledge: Intrinsic Value of the Cadaver and Plastination. We enthusiastically and sincerely congratulate these two authors. They went through extensive review by our executive board and external advisory board, composed of prominent professors at the University of Pennsylvania.

I’d like to thank all of the members of the PBJ board for making this issue possible. We have spent countless hours reviewing, editing and evaluating the exciting submissions for this issue. It is the dedication and diligence of each editor that makes our journal a success. However, we do not forget that it is also made possible by the increasing number of submissions we receive for each issue. We would also like to thank our excellent external advisory board composed of Dr. Paul Wolpe, Dr. Connie Ulrich, Dr. Arthur Caplan, Dr. Arthur Casciato, and founder Andrew Rosenthal. Last, but certainly not least, I would like thank our graduating seniors. Your guidance and contributions to the journal will be forever remembered.

Keep a lookout for the next issue, coming Fall of 2007 Please do take a bite out of PBJ. Sincerely, Bo Peng Executive Editor and Publisher University of Pennsylvania C’09

inside this issue...

Exclusive PBJ Interview

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with Glenn McGee, PhD, Founder of American Journal of Bioethics

Winning Articles

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First Award: Liberal Answers to Callahan’s Communitarianism

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Honorable Mention: Public Access to Anatomical Knowledge - Intrinsic Value of the Cadaver and Plastination

FRANCES McCORKLE, University of Virginia

VIRGINIA PORTMANN, Trent University, Canada

Feature Articles

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Thoughts on the Recently FDA-Approved HPV Vaccine: An Ethical and Historical Perspective on Mass Vaccination Programs

DANIEL WASSER, Cornell Univeristy

On TRIPS, Access to Drugs, and the Expectation of Profit

ALEXANDER STARKS, Northwestern University

The Legal Duty to Warn and the Evolution of Tarasoff

BIANCA GONZALEZ, University of Pennsylvania

Feminist Perspectives, Pornography: Women as Commodities?

CRAIG IFFLAND, University of Virginia

Globalization and Public Health: The Case of Bhopal

JOSHUA FARHADIAN, University of Pennsylvania

Health Outcomes in Cuba Following the Transition

KATIE TUIDER, University of Pennsylvania

Bioethics of Public Health

Interview with Glenn McGee PhD:

Founder of American Journal of Bioethics; Director of the Alden March Bioethics Institute Author: Bo Peng, Alix Rogers, Katryn Bowe, Markley Foreman, Jules Shen, Rachel Han Biography

Glenn McGee, Ph.D. is the Director of the Alden March Bioethics Institute, New York’s largest academic bioethics program located in its capital, Albany. He is the John A. Balint Endowed Chair in Medical Ethics, and a professor of medicine, philosophy, law and public health. He holds degrees in philosophy from Vanderbilt University and Baylor University and completed a postdoctoral fellowship in the NIH National Human Genome Research Institute (NHGRI). From 1995-2005 he served as Associate Director for Education of the Penn Center for Bioethics, founding Penn’s undergraduate concentration in bioethics and pioneering a way of teaching bioethics to undergraduates using the writing of legislation, a program lauded by the New York Times and described as a model for undergraduate interdisciplinary education by Harvard’s Project Zero.

He founded bioethics’ most significant journal, The American Journal of Bioethics including its Editors’ blog, the first blog by the editors of a scholarly journal. Dr. McGee’s books include The Perfect Baby: A Pragmatic Approach to Genetics (2000), Beyond Genetics (2004), Who Owns Life? (2002), Pragmatic Bioethics: A New Theory of Bioethics (1999, 2ed 2002), and The Human Cloning Debate (4ed 2005. In addition to his booklength studies, Professor McGee has authored many essays in journals of medicine, science and bioethics such as Science, JAMA, and Nature Genetics. McGee also serves on state, federal, international, foundation, and corporate advisory and directors boards. He acts as an advisor to policymakers, most notably as a recipient of the United Kingdom Atlantic Fellowship in Public Policy and as genomics and society programs reviewer for the Economic and Social Research Council. He is a member of the Board of Directors of the American Society for Bioethics and the Humanities.

McGee was the original faculty sponsor of Penn Bioethics Journal, and recently spoke at Penn on the topic of diabetes and the obesity epidemic in New York.

How did you get involved with bioethics?

I grew up the son of a bioethics professor, who was one of the first in the field, Daniel McGee, a theologian by training. He helped to create the first bioethics institution, the Institute for Medical Humanities at UT Medical Branch in Galveston, and we spent several summers at Georgetown while he did things at the Kennedy Institute. I was impressed earlier on by the role of highly skilled academics in communicating with the public. My hero in junior high was not an athlete. It was Carl Sagan, who produced a series that is just coming back into production called Cosmos.

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It isn’t exactly the earliest example of popularizing an extraordinarily complex field, but it is an example of doing it at a high level of detail. The word popularizer as a junior high student was not in my vocabulary. I just thought, gosh, this is really interesting. The way in which Carl Sagan made science and philosophy vivid for me was impossible to shake. I loved debate and was a very successful high school debater, so now here was a way that academia and rhetoric and curiosity and rigor could come together, I thought. While I was a graduate student, I got into the idea of training scientists in ethics.

And I suppose from that follows pretty naturally the work I’ve done ever since, which has mostly involved attempts to reconstruct scientific and medical problems in terms of their pragmatic epistemological and ethical implications. To make a long story short, from the very beginning of my training, I was working on the effect of the environment on genes, and my earliest work was essentially a project in philosophy of science, specifically an attack on the coherence of the idea of a genome. At the time it was a radical kind of argument, but today the notion that the genes we inherit are not the genes we carry around – that in fundamental ways and in many if not most cells of the human body our genes are really changing quite a bit is almost commonplace.

Luck figures very prominently in my career in bioethics too. I wanted to work on the genome, got into the field right as ethics and genetics was taking off as a funding area, had one of the first books about the enhancement of children and reproductive enhancement – which appeared on bookstore shelves literally days after the birth of Dolly the Sheep.

What areas of public health and bioethics have you worked on?

My career has been highly focused on the impact of new technologies, but what I have done is what is typically referred to as pragmatism. I am a scholar of classical American philosophy and so my work returns again and again to the claim of John Dewey that in our analysis of new technologies we are better off relying on the wisdom and models for experimentation we have developed in the course of building our current society. We don’t need a “new ethics” for every new technology. Ian Wilmut, the man who is most associated with cloning Dolly, and I argued for example that the same mechanisms that are used to decide who should get a kid after a divorce, or who should be able to adopt, are the same ones that should be used for analogous new technologies.

I have done a lot on clinical research and the vulnerable.

The first area of that is payment of research subjects and bribing potential subjects with what appears to the subjects to be therapy – but isn’t. I wrote the very first formula for

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how to pay research subjects, but I’ve watched the real world in which an ad agency will figure out how much you have to pay in order to get someone to participate in research.

The second area is in autism. I have a kid who has autism, so I came to this through my personal life. About one in eighty or so male children is born with autism. If we actually provided the appropriate level of care for autism by any standards, the whole health system would collapse.

So the question is how to balance research in areas where the goal is to achieve high functioning for a few kids against moderate functioning in public health more broadly. Finally, I’ve also done a lot of research about how drugs come to be covered by insurance companies. An undergrad and I have been working for four months on a piece about how companies decide how much Viagra to cover and talk about the redefinition of sex by pharmaceutical management companies.

We look to the AJOB as a model, as a professional ideal that we try to model ourselves after. Can you describe the process of starting that, and the direction you see it going?

Before AJOB, the big journals in bioethics were pretty much aiming at other bioethicists, or if they were not, that is who they were mostly reaching. Occasionally an article or supplement would come out and get wider readership, but our friends in bioethics publishing frustrated those of us who started AJOB to no end with their insistence on eschewing the technology and research necessary to reach a wider audience and thus very very little of what was published in bioethics journals got cited in medical journals or discussed in the public.

In starting the journal, I had three things in my mind.

Before AJOB; journals of bioethics had little impact on medical school deans for getting tenure or recognition. We were the first journal in ethics and history and sociology of science or medical health service research to ever go above a two on the impact scale. Going forward, bioethics scholars will have at least one, and I would imagine soon several, options for publishing in bioethics journals without wondering if it will compromise their ability to be promoted and reach their intended audience.

I also wanted to communicate in a different way and try out a new electronic technology. Bioethics.net was the first bioethics website, and we reach a lot of people. The barrier for internet journals is that they have not been paginated or listed like a regular journal. The idea I had was to mix the online and paper edition. I created a group of people from Nature, Science, JAMA, and Lancet to define some standards so that if an article appears in the electronic edition or part in the journal, it would be subject to the same peer review regardless of if it were to go online or in print.

Finally, I wanted to edit in a different way. We have a very complicated system with AJOB that allows the people who are writing in response to the big target articles to read each other’s essays, cite them, and argue with each other. So at the end of the day, you get a lawyer fighting or amplifying an issue with a sociologist. I can tell you the people who are writing about it are red faced, passionate about it. We have a system that determines who can and cannot write and peer review the commentary. The journal in its creation changed how people in bioethics communicate. Now, we

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have a spin off journal called AJOB Neuroscience, and we are working on a third journal called AJOB Global.

A lot of different public health institutions influence how we do things on controversial issues like personal dietary habits. Where do you draw the line between disease prevention and regulatory paternalism?

Bioethicists are not used to thinking about public health the way that public health agencies implement their directives. In the world of public health, they do research sometimes, but whatever they do, there is a kind of mix of research and intervention. So a lot of what gets tried out there in the world of public health is research, but doesn’t go through an IRB. So there’s an important and interesting argument that needs to go on about whether some of the things that are going on with diabetes or pandemic planning, for example, are actually experiments on vulnerable subjects. In the world of public health, it’s not that bioethics is a new thing, it’s that a lot of the rules and regulations have been subject to discussion, but there really isn’t a place for bioethics in public health. The only exception to that is that there are a few schools of public health that have some bioethics emphasis, like Hopkins.

The second piece is that the bioethics role and the questions we ask about scholarship and academics is very much similar to that of the public health role. Are we supposed to be directive, telling people not to eat, to don’t do this or do that? And if we’re making arguments about things like rationing care on the basis of behavior, then we become part of a whole family of public health folks who are directive. On one end of the continuum are genetic counselors who say you can never ever tell people what to do, that you should be value-neutral. On the opposite end are public health people and pediatricians. They say that if you don’t do something, they’ll take your kid away, or that the implications of your disease are your own fault.

Because of transplantation committees, we don’t mean for it to, but it does. So is someone going to be compliant? Will an alcoholic stop drinking for an organ transplant?

The third piece is that public health has got to be split into some different areas. One area where I have been mentoring my students lately is what I call disaster ethics. It’s an area I think is going to explode. I have been hearing that term tossed around more frequently lately. It emerges naturally after some thinking about situations like Katrina and Abu Gharib. So I think bioethicists have a lot to bring to the table about what happens in the MASH unit style of health care. We are very good about talking about a term I coined a long time ago called rescue ethics.

So we will put scraping someone off the street ahead of anything. But if someone walks into the emergency room, who hasn’t been scraped off the street, and for whom an intervention would be far more helpful, we won’t put money into it. Psychiatrists, for example, have no desire to care for anybody and will just dump people. They do not mean it to be immoral, it’s just the ethic of psychology and psychiatry is that it is fee for service. Same thing for plastic surgery.

How do you think bioethicists and public health officials interact on every day matters, and how could this relationship be improved?

I think that a lot of the time, we are engaged in conversations with public health officials but have no idea that we are. I have served on several CDC task forces,

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Exclusive Interview with Glenn McGee

there is now a CDC ethics committee on which I do not serve. It is had a hard time making an impact – though I bet it is lots of fun and very challenging work. I would like to think that in the world of public health on the national level that there are people, who are not only interested but are actually overtly listening. I came to the New York state capital instead of taking a really attractive offer to start a bioethics program at Wake Forest University because I wanted to build an institute where I could make a difference at the state level. Part of my deal with coming here was that I was made chief of bioethics for the public health labs of the state of New York, called the Wadsworth Center, and that role become controversial pretty quickly. States are not used to being told what to do, or being given advice. We need to work on the levels where we can get things done, and then be sensitive to the fact that because you are able to influence the governor but not the federal government, you’re going to anger some people.

Recently there has been some emphasis on minimizing health care costs and allocation resources on an international level. And there have been some new players in global health with celebrities, such as Bono and Angelina Jolie, and foundations like The Bill and Melinda Gates Foundation. With their voices in the media, and asking general lay people for donations and increasing awareness, it seems that they are drowning the voice of political leadership. Does there seem to not be enough political action and leadership?

The Gates foundation has done amazing work, and is the only organization that would have popped into my mind. I do not think they are guilty of exceptionalism, or creating an exceptional set of ethics for treating problems one at a time. They have put money where the issues are.

And I am excited that they have at least talked to a couple of bioethicists in the US. The question is more broadly about the relation between foundations and government, and whether foundations can end up leading governments.

As for celebrities, I think it’s stupid that a lot of the debate on stem cells is led by celebrities. I think it confuses things. With public health, it’s exactly the politicians you’re talking about, really the ones at the UN, who receive no success about getting food, or cheap drug prices, they are just exploited and asked to play pawn on other issues to get any attention. I think it’s those politicians who are thrilled to have a Bono. I think it is effective. And in comparison

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to political leaders implementing public health strategy, well that would be news of the year. Totally ineffective.

Is that the best way to communicate? No. But as long as you can make sure that Bono continues to be in the room alongside someone constructive and careful like President Carter, I’m okay with it. It’s a feeding chain that goes both ways though.

To wrap up, I wanted to talk about disaster ethics. Is there any consensus, or emerging clear lines of thought, about how resources should be allocated in disasters like the Tsunami or Hurricane Katrina?

No, but there are different viewpoints that have come about that are particularly interesting.

I like to talk about areas where there is explosive growth.

There is in disaster ethics, mostly an opportunity for new voices in the field to emerge….. Your question is about whether strong scholars and people in the literature are writing about this and establishing consensus. My answer is that no, and I am glad. One of the things that I hate about our craft, is that every year, ninety percent of what is printed in journals has been printed before. I am so excited about the new talent that has emerged in the field. Disaster ethics is not an idea that came from me, but from my and others’ students. Your lives have been shaped by one disaster or another. I don’t think you want me writing about it, so I don’t.

Do you think that there are topics that have not received attention from either the media or bioethicists?

Oh yeah. I run a blog. If you go to bioethics.net, there are 6-10 new items everyday. And it’s not just bioethicists who are writing about them. There are three jobs for every good person applying in bioethics. Most people in bioethics would tell you that the bioethicists gravitate towards the exciting areas. That just is not true. There are not enough people who are coming from different fields- most are social science. We need to get new talent from bench science and other areas. So many areas in bioethics just wither because there’s nobody to work on the stuff. I’m very very self-conscious about recruiting scientists and others with different training into bioethics for that reason.

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Outstanding Contribution to Undergraduate Bioethics: First Prize

Bioethics of Public Health

Liberal Answers to Callahan’s Communitarianism Author: Frances McCorkle, University of Virginia Faculty Sponsor: John Arras, PhD Abstract We live in an age in which medical science makes constant and dazzling advances, while scores of individuals find themselves without access to even basic care. Faced with this reality, many philosophers have determined that we simply cannot—and should not—meet all individual health needs. Daniel Callahan1 argues persuasively to this end. He concludes that since the frontier of medical progress is a movable “ragged edge” rather than a fixed boundary, and since we as individuals regularly capitulate to deep fears about disease and death, society unavoidably overspends on health care. The only way to deal with this problem is to set firm limits on health care spending based on certain sensible goals for medicine. Liberal theorists, says Callahan, are either unwilling or unable to say “No” in a coherent way to limitless health care; thus his version of communitarianism2 should be adopted. In this paper I aim to test whether individualistic theories of justice are really unequal to the task of rationing.

First, I will give a brief synopsis of my understanding of Callahan’s argument, then I will evaluate the arguments of Ronald Dworkin and Norman Daniels to show that they are stronger than he claims. Finally, I will show that there are some notable commonalities between the theories of Callahan and Daniels with respect to age-based rationing, concluding that we can achieve a comprehensive rationing scheme without abandoning liberal theory in favor of a communitarian framework. ss) of a certain act.

Callahan argues that our current predicament stems in large part from our exceedingly open-ended conception of health. The World Health Organization’s definition, for example, reads: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Callahan, 1990, p. 34). Callahan remarks that such a definition carries with it the implications that good health means being complete, and that any failure to achieve completeness is a failure to meet health needs.

With such broad notions of health and need, it is inevitable that there will be disagreement over the level of care that is adequate for individuals to flourish. The problem is Frances McCorkle is a Senior at the University of Virginia and is majoring in Political Philosophy, Policy and Law, with a minor in History Email: francesmccorkle@gmail.com Dr. John Arras is the faculty sponsor for this submission.

He is the Porterfield Professor of Bioethics in the Department of Philosophy at the University of Virginia.

Address: 1515 Stoney Creek Dr., Charlottesville, VA, 22902 Email: jda3a@virginia.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

exacerbated by our unwavering faith in the ability of science to cure all that ails us, up to and including death (Callahan, 2005). It is here that Callahan introduces the concept of the ragged edge, which describes the dual character of medical progress: just as innovative treatments continually emerge to treat old problems, new problems crop up to take their place (Callahan, 1990, p. 63). It is inherently impossible to achieve perfect outcomes in all cases, and yet that is what we accept as our goal. “We thus remain dissatisfied,” concludes Callahan (1990), “because it is the problems of those frontiers, on those ragged edges, that capture our attention and imagination” (p. 64). The high cost of new technologies, in turn, ensures that health care spending will only increase over time.

Thus runs Callahan’s basic argument with regard to the ragged edge, and it seems quite salient in light of society’s current inability to finance health care in a satisfactory way.

It is clear that leading liberal bioethicists such as Daniels and Dworkin share Callahan’s concerns, given their attempts to balance budgetary constraints with the demands of justice.

They acknowledge, along with Callahan, that we must establish certain limits to prevent health care spending from spiraling out of control. Callahan commends the liberals for their attempts, but he maintains that their individualistic framework will limit their ability to forge lasting solutions.

He rejects the common solution of liberals, which leaves decisions about what we truly need to the political process, because individual voters and experts alike will feel morally adrift without certain concrete standards (Callahan, 1990, p. 45). Much more than mere political deliberation within the liberal framework, escaping the ragged edge will require an entirely new theoretical framework—namely, one which emphasizes society’s needs before those of the individual.

In short, Callahan concludes, we need a shared vision of the common good that favors caring over curing.

Given his drastic solution, it bears asking whether liberals are as incapable of setting limits as Callahan claims.

Are their justifications ultimately just flimsy qualifications?

Do they really fail so thoroughly? I will examine the rationing schemes of Dworkin and Daniels to determine how strong Callahan’s claims against them are.

Callahan argues that when individuals make decisions Callahan’s basic line of argument with regard to health care rationing is that it cannot be undertaken without first articulating what we think of as the basic purpose of health care, and what goals we can reasonably pursue in light of that purpose.

2 The term “Communitarianism” encompasses those theories which criticize liberalism for its tendency to value individual rights over the interests of the community and its refusal to espouse a particular vision of “the good.”

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in their own interest, society as a whole loses out. For Dworkin3, the opposite is true—what is good for the ideallyconceived individual is good for society, too. He bases his account of just rationing of health care on the choices that individuals would hypothetically make for themselves, given (1) a fair distribution of wealth, (2) adequate information about health risks and medical technology, and (3) total ignorance about their likelihood of disease or injury (Dworkin, 2000, p. 311). Given these assumptions, what sort of insurance scheme would the prudent individual choose to purchase with her own money in the free market?

Dworkin argues that the decisions reached by the individual in this hypothetical society will tell us what decisions we should make in our own, real society. Thus, if the prudent individual would buy for herself a basic package of medical services, then society cannot be justified in its toleration of a health care system that sometimes denies people basic primary care. Conversely, since the prudent individual would probably elect not to buy insurance to maintain herself in a persistent vegetative state, society is justified in declining to fund that sort of treatment. The point is that some rationing is perfectly compatible with what justice requires; indeed, “we would…accept certain limits on universal coverage, and we would accept these not as compromises with justice but as required by it.” (Dworkin, 2000, p. 314).

Under Dworkin’s theory, current patterns of medical spending are unacceptable according to the demands of justice. His hypothetical consent theory asks us to impose restraints on precisely those forms of spending that Callahan deems unjustifiable, such as heroic end-of-life measures and rare, expensive medical procedures with low success rates. We may wonder with Callahan whether such restraints would go far enough in holding down escalating costs over time. Callahan will of course argue that because Dworkin relies so heavily on the fulfillment of individual needs—“preferences,” if you like—his theory is doomed to position us firmly and indefinitely on the ragged edge.

However, I think Dworkin’s treatment of hard cases goes a long way toward answering that objection. Dworkin argues that whenever it is unclear what the prudent individual would do, society ought not to err on the side of generosity, but rather ask individuals to purchase their own supplemental care (Dworkin, 2000, p. 318). In the same vein, Dworkin also argues that the results of the prudent insurance test are provisional and subject to change. This claim makes him seem rather vulnerable to Callahan’s charge that liberals do not sufficiently account for changing conceptions of Dworkin tries to show that a system based on individual, rational choices (made through the market in a genuinely fair society) would be capable of setting reasonable limits on health care spending and honoring the demands of justice. Both Dworkin and Daniels use hypothetical choosing scenarios to argue that rationing does not necessarily require the infringement of rights. Indeed, Dworkin argues that rationing is not only compatible with justice, but is demanded by it.

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normality, since the prudent insurance test might start directing us to spend more on conditions previously thought to be the acceptable results of natural variation. But it is not evident a priori that the prudent insurance test would redefine normality at a rate society could not keep up with. I am inclined to believe that concerns about other important goods such as education and housing would be enough to prevent the prudent individual—and real-life society—from spending too much on health care, even accepting that appropriate standards of care fluctuate over time. Viewed in that light, Dworkin’s basis for setting limits on health care spending seems fairly robust.

No evaluation of Callahan’s argument against liberalism would be complete without a look at the theory of Norman Daniels4, who approaches health care from the perspective of equal opportunity. Daniels (1994) believes he is morally justified in limiting to a certain extent the task of protecting equality of opportunity, for “otherwise [it would] be discredited as too demanding an ideal” (p. 127).

He maintains that, with respect to health care, individuals do not have an unlimited right to have all their needs met (Daniels, 1988, p. 72). One implication of this is that society has no obligation to provide people with “enhancements” for the sake of equalizing capabilities, but should only fulfill its responsibility to treat disease or disability. He therefore resists attempts to redefine normality that, for instance, treat the trait of extreme shortness as a disease. Daniels (1994) urges us to instead focus on “opportunities a person would have had in the absence of disease and disability”—their fair share of a particular “normal opportunity range”—without any reference to the seemingly unfair results of normal statistical variation (p. 126). Though many liberals disagree with him over his disease-oriented mode of defining health needs, he is careful to toe the line (Daniels, 1994, p. 127).

Even at this basic level, his theory seems capable of setting some limits. A closer examination of his views shows his justification of rationing to be much stronger than Callahan would have us believe.

Daniels (1988) argues that his theory of fair equality of opportunity gives us a ready criterion for addressing problems of allocation: the impact of any given treatment on normal opportunity range will indicate its importance compared to other health care services (p. 72). Where preventative measures would do more to ensure fair equality of opportunity than, say, curative measures, the former ought to be treated as more worthwhile. This implication of Daniels’s theory tends to disprove the claim that liberal individualism5 cannot address society’s obsession with curative measures. Curing a few conditions at the cost of letting many less-urgent needs go unattended is not Daniels is a seminal figure in the field of Bioethics for his efforts to establish a “right” to health care using Rawls’ principles of justice; he argues that health care policy (like all public policy) should be judged in terms of its overall effect on equality of opportunity.

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Liberal Answers to Callahan’s Communitarianism

something Daniels will necessarily endorse. While he places heavy emphasis on meeting the individual’s health needs in order to improve his or her opportunity range, Daniels also asserts that the goal of a just society is to protect opportunity on the whole. That means new and expensive technologies ought to be judged against other alternatives according to their overall impact on opportunity (Daniels, 1988, p. 72). It also means that “reasonable and fair choices must be made about how much to invest in health care and how much in other kinds of goods…which also promote equal opportunity” (Daniels, 1996, p. 10). He acknowledges that since our resources are scarce and our needs are many, protecting opportunity to the best of our ability will require rationing. Like Dworkin, he concludes that justice does not merely permit rationing, but ultimately demands it.

Daniels (1996) offers another line of reasoning, for he himself concedes that the principle of guaranteeing fair equality of opportunity is sometimes “too indeterminate” to solve crucial rationing issues (p. 10). In reply to Callahan he points out that if equal opportunity (or any principle of justice) fails to give principled answers to problems of allocation, establishing general goals in medicine does little to help us, either. The objectives we can agree on are just too broad to be helpful--deciding, for example, “that reducing ‘premature death’ is a reasonable goal of medicine while [the goal of] eliminating all fatal disease is not [reasonable] does not provide us with solutions… (Daniels, 1996, p. 10).”

Our only recourse, Daniels says, is to emphasize fair, public decision-making procedures, and to treat their outcomes as fair. He does not think of this as an explicitly political process (like that used in Oregon’s priority-setting scheme), but rather as a sort of gradually evolving case law; our goals in medicine would not be predetermined, but would emerge over time through sustained social deliberation (Daniels, 1996, p. 11). This attempt of Daniels to “bridge the gap” between his interest in justice and Callahan’s interest in goals is striking in two ways. First, it illustrates yet another way in which Daniels is able to justify rationing. Second, it suggests that Daniels’s liberalism and Callahan’s communitarianism may not be totally at odds with one another. I now turn my attention to the latter subject—in particular, the similarities between Daniels and Callahan on the topic of age-based rationing.

Both authors start with the unfortunate truth that we will all unavoidably die one day; both end with the conclusion that some systematic effort should be made Broadly defined, “Individualism” is the doctrine that individual needs and interests trump those of society as a whole. With respect to health care allocation, the implication is that a person’s health needs must not go unmet even if society as a whole would suffer a net dimunition of overall utility.Broadly defined, “Individualism” is the doctrine that individual needs and interests trump those of society as a whole. With respect to health care allocation, the implication is that a person’s health needs must not go unmet even if society as a whole would suffer a net dimunition of overall utility.

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to deal with that fact in an economically reasonable way (Daniels, 1988, p. 40; Callahan, 1990). How? Callahan (1990) emphasizes that our bodies are finite things that will “insist upon decline and decay, later if not sooner, but always implacably” (p. 152). This realization alone is enough to convince him that health care should be rationed partly according to age. Specifically, society ought to ascertain a general reasonable life expectancy beyond which expensive curative treatments are deemed inappropriate. Daniels’s means of arriving at age-based rationing are a bit more complicated, and his conclusions are highly qualified. Ever the good Rawlsian6, he imagines a hypothetical choosing situation (the Prudential Lifespan Account) in which prudent decision-makers behind a partial veil of ignorance are charged with the task of designing a health care system (Daniels, 1988, p. 76). They would seek a principled way to fairly distribute health services over everyone’s lifespan, having some knowledge of what society looks like in terms of age, disease and health care, but not knowing their own ages. Daniels supposes that prudential designers would reach the following conclusions: that the impact of diseases and disabilities on opportunity range is different during different stages of one’s life; that transfers of resources between age groups should reflect the disease/age profile and demographic changes in society; and that the more unproductive years we live, the more we have to save during our productive years (Daniels, 1988, p. 77). Playing out this hypothetical choosing situation under various constraints, Daniels concludes that the deliberators would never rule out as unfair the rationing of health resources according to age. Importantly, he argues that the deliberators would employ age-based rationing not because our later years are intrinsically worth less, but simply because they are marked by a higher incidence of disease and death. This is exactly the sort of consideration Callahan thinks liberal theory incapable of—recognizing that getting sick is a part of getting old. And according to Daniels (1988), an agebased rationing scheme based on this assumption would not violate his principle of justice, since its ultimate goal would be to make each individual better off overall (that is, over time) (p. 92).

Daniels and Callahan fundamentally differ in their general approaches to the problem of rationing health care for the elderly. However, certain similarities are apparent. First and foremost, both authors emphasize a view that urges us away from the current singular obsession with lengthening life. Callahan (1990) de-emphasizes longevity because he takes it for granted that length of life and satisfaction with life are not one in the same (p.

In Rawls’ imagined Original Position, the “veil of ignorance” prevents the hypothetical framers of a just society from knowing anything about their particular circumstances, thereby ensuring that the outcome of their deliberations will be fair. An important part of Rawls’ philosophical legacy has been to define justice as fairness.

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52). Daniels (1988) seems to affirm this intuition when he writes: “Prudent deliberators draw the conclusion that their own lives are less important to extend at one stage than at another—and that is the kind of judgment we do in fact make when we prudently plan our actual lives” (p. 94).

Though he couches it in the language of rationality and fairness, Daniels recognizes along with Callahan that length of life ought not to be our primary concern.

Another similarity is the emphasis both theorists place on transparent decision-making processes. It almost goes without saying that Callahan’s goal-setting solution demands extensive public debate, and he explicitly rejects the practice of covert age-based rationing since it results in decisionmaking that is subject to individual tastes and values rather than systematic principles (Callahan, 1996). Daniels, too, criticizes covert rationing. Generally speaking, he dislikes the idea because it undercuts the legitimacy of setting limits, as in the case of health management organizations (Daniels, 1996, p. 10). With Rawls, he accepts as a rule that principles of justice and the reasoning behind them should be public (Daniels, 1988, p. 97). Moreover, it appears that publicity is an important part of Daniels’s requirement that agerationing be pure—that is, that age not act as a stand-in for some other trait, like “crumbliness” in the elderly (Daniels, 1988, p. 84). Presumably, age-based rationing of dialysis in the British National Health Service would have been much purer had it not been undertaken covertly. Callahan (1996) echoes Daniels’s concern for purity when he objects to the opinion that treating elderly patients is futile “simply because they are elderly” (p. 744). Though they both support some age-based rationing, neither Callahan nor Daniels wants to endorse age-based stereotyping.

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In sum, the thoughtful and detailed health care rationing theories of Dworkin and Daniels are sufficiently strong to refute Callahan’s challenge. Even if they are not totally adequate in their specifics, they at least demonstrate a consistent and serious commitment to dealing with allocation problems in a sensible way. Their conclusions and justifications serve as an important reminder that liberal individualism is not egoism; none of these theorists thinks that respecting individual rights amounts to the unyielding pursuit of one’s particular interests regardless of expense to everyone else. Although liberals do not form their principles on the basis of community values, they remain capable of providing schemes that serve the interests of the community fairly well.

Acknowledgements The author would like to thank Amy Gilbert and Professor John D. Arras for their help in writing this paper.

References 1. Callahan, D. (1990). What kind of life: The limits of medical

progress. New York: Simon and Schuster.

2. Callahan, D. (1996). Controlling the costs of health care for the

elderly—fair means and foul. New England Journal of Medicine,

335(10), 744-746.

3. Callahan, D. (2005). Conservatives, liberals, and medical

progress. The New Atlantis, 10 (Fall 2005), 3-16.

4. Daniels, N. (1988). Am I my parents’ keeper?: An essay on justice

between the young and the old. New York: Oxford University

Press.

5. Daniels, N. (1994). The genome project, individual differences,

and just health care. In T. F. Murphy (Ed.), Justice and the human

genome project. Berkeley: University of California Press.

6. Daniels, N. (1996). Justice, fair procedures, and the goals of

medicine. Hastings Center Report, 26(6), 10-12.

7. Dworkin, R. W. (2000). Sovereign virtue: The theory and practice

of equality. Cambridge: Harvard University Press.

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Penn Bioethics Journal Vol III, Issue i Spring 2007

Outstanding Contribution to Undergraduate Bioethics: Honorable Mention

Bioethics of Public Health

Public Access to Anatomical Knowledge: Intrinsic Value of the Cadaver and Plastination Author: Virginia Portmann, Trent University Faculty Sponsor: Christine Freeman-Roth, PhD Abstract

Artists have long been entrusted with elevating human dignity along with anatomists; their partnership with anatomists dates back to the Renaissance, enabling a transformation from the view of the body as a burden to the appreciation of its wondrous beauty and function. Artistic contributions by anatomists are not only responsible for enlightening humankind to understand concepts of self and life, but they have also improved medical knowledge of the body’s inner workings, which to a certain degree has been kept secret. For most people, the human body represents an “unknown frontier”, as knowledge thereof has been exclusive to medical professionals, previously unattainable because of the high level of academia required – until now.

Plastination exhibitions have been fiercely criticized and conversely, applauded. Developed by Gunther von Hagens of Germany, plastination is a technique in which a cadaver’s fluids are replaced with resins and plastic such that the body retains ironically “lifelike qualities,” even after death, and is indefinitely preserved (Wetz, 2000, p.385). The applications of plastination were originally limited to medical institutions’ teaching purposes, but have more recently been made publicly available in the hugely successful Body Worlds exhibitions that have travelled the globe (Bleyl, 1999, p.309). Due to the paucity of published debates in English on plastination exhibitions, this paper translates the main arguments on human dignity issues in plastination by two German philosophers, Bleyl and Wetz, and examines the classic conflicts of duty that occur when using Kant to argue against plastination.

anatomy art]” by Uwe Bleyl, Bleyl (1999) presents arguments against the artistic nature of plastination and accuses it of being a constitutional offence. Because the German constitution is based primarily on the ideas of Immanuel Kant, Bleyl’s central argument is of a Kantian perspective in which duties, autonomy, and absolute or universal rules are exercised by rational beings. The universal rule is, however, affronted by plastination exhibitions, according to Bleyl (1999, p.311-312): the rule states to never treat people as a means only, but as ends in themselves. He argues no individual has the right to degrade universal human dignity by objectifying their body to a mere display, becoming mere means. Bleyl’s (1999, p.315) other focus, artistic freedom, although granted by the constitution, is not guaranteed when other rights such as human dignity can trump it. He even suggests that consent is invalid because donors expect only educative, not aesthetic, purposes to be satisfied through their donation. Also, body donors do not (or should not) have full autonomy over their cadavers, for it annuls consent between artist and donor (Bleyl, 1999, p.313, 315).

The purpose of this paper is to explore the concept of dignity more fully and to call attention to the classic conflict of duties that occurs when using Kantian arguments.

Furthermore, other perspectives (including Wetz’s) will show dignity does not extend to corpses, consent is indeed valid, and artistic presentation not only enhances human dignity, but is necessary to meet teaching goals.

Introduction The controversy accompanying Body Worlds does not concern the plastination technique itself, but arises out of concern for human dignity, which is also referred to as intrinsic value. Protestors argue that such “artistic” display instrumentalizes humans and, as such, is detrimental to human dignity of both the individual and society as a whole (Wetz, 2000, p.385). In the article “[Man must always remain an end unto himself - ethical reservations against so-called

Degrees of Dignity Kant grants us moral worth by virtue of the human ability to reason - this “worth” is argued by Bleyl (1999, p.313) to be a universal possession of humankind and as such, maintaining dignity imposes a duty on everyone. This implies human dignity is not within individual possession and so cannot be given away as an object (Bleyl, 1999, p.310); it is on this premise that slavery is immoral and illegal, despite those who would freely consent to slavery.

At this point we encounter the first conflict of duties: that of upholding a collective human dignity versus that of promoting individual autonomy. It is interesting to note the same society that would have plastination banned (and supersede the autonomy of donors) on the same principle that slavery is prohibited (namely, injury to dignity), simultaneously allows other acts of degradation like prostitution. If these kinds of decisions are made exclusively with utmost regard for dignity, then prostitution

Virginia Portmann is a Junior at Trent University and is majoring in Nursing.

Email: vportman@trentul.ca Dr. Christine Freeman-Roth is the faculty sponsor for this submission. She is an Assistant Professor in the Department of Philosophy at Trent University Address: Champlain College, 1600 West Bank Drive, Peterborough, ON, K9J7B8 Email: cfreemanroth@trent.ca Penn Bioethics Journal Vol. III, Issue i Spring 2007

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should not be permissible under Kantian ethics, yet this is the current state of affairs in Germany precisely because of the view of individual autonomy. And what of donor autonomy?

Bleyl must find a way to reconcile sacrificing the donor’s autonomy, a deeply-rooted component of Kant’s ethics, for an ideal to safeguard universal dignity of humankind, especially because he finds autonomous decisions involved in body donation for other purposes acceptable, which will be discussed later.

Bleyl argues that since dignity is a universal “good”, it consequently exists whether a human has yet to exist or has already died. Although he admits that corpses do not have self-awareness, self-control or autonomy, (the keystones to his definition of intrinsic value), because the body has such intimacy to the personal identity of the living, it shares in the value of the living (Bleyl, 1999, 312). Despite the lack of the above mentioned qualities, because dignity from a Kantian view is absolute and incomparable, this alone commands full respect and for that reason cannot be partial, thus extending from prior-to-life to post-mortem and hence, to corpses as well. Bleyl (1999, 313) even extends this universality to exclude the possibility of appointing a power of attorney to act as a surrogate decision maker when plastinating the body. Regardless of the incompatibility between the autonomy of a rational being that Kant uses as his paradigm model and the ethical absolutism required of us to firmly advocate for a collective dignity, I find it difficult to equate the value of a living human with that of his organic leftovers. Kant values rational beings, so should we not value rational beings over corpses that are not? Bleyl takes a decidedly black and white stance when assigning intrinsic value, where I am inclined to think that there are degrees of intrinsic value. Intrinsic value is a product of interaction with society and pegs interest in the living, with dignity being something that is earned (Wetz, 2000, p.391).

A corpse earns no value by rotting away, but can contribute in other ways to earn value, i.e. plastination. However, by accusing plastination of being an immoral use of corpses or a violation of the cadaver’s dignity, Bleyl’s absolutist view unwittingly calls into question the validity of other uses of the body in organ donations or cadaver use in teaching institutions.

Prioritizing Autonomy Based on Value Status Wetz suggests separating the ideas of the body and the deceased: the body is buried, the deceased is remembered (2000, p.388-389). He does not imply the deceased’s body is not owed respectful treatment; on the contrary, it is respect for the deceased that moves us to carry out the autonomous decisions one made while alive. The body, however, becomes reduced to an object to be cared for according to its owner’s wishes. It is far worse, he says (and I strongly agree) to deny the will of the deceased whose decisions were made while possessing rational capacity; to

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refute this decision in favour of upholding the minimally existent intrinsic value of a corpse, the shell or husk of what once was, is by far more detrimental to dignity (Wetz, 2000. p. 391). Wetz (2000, p. 391) also suggests we are already masters over our corpses, deciding where they are to be buried, whether organs are to be donated, and how the corpse is to be prepared. So the question is not just a matter of why plastination exhibitions are an invalid method of how a corpse is laid to rest, but also how Bleyl can legitimately demand that plastination exhibitions should be outlawed, without revoking all of the other autonomous decisions we currently make for our remains. In the end, there is no difference between those choices and the choice to donate oneself for plastination except for the fact that plastinates are on display, in which the real issue lies in their artistic presentation.

Means and Ends Before artistic value is scrutinized, the idea of preserving intrinsic value and its opposite, objectification, must be examined. The notion of duty to uphold dignity in Kantian ethics stems from the second version of his categorical imperative, which states people should not be treated as a means only, but as an end in themselves (Freeman-Roth, 2006). Bleyl interprets this rule to mean that human dignity is injured when people are degraded to means without considering their ends, or even sacrificing their ends for one’s own gain, especially when against one’s will. This does not mean we cannot use people for our own ends, but that they should be respected to make their own choices (which may coincide with our own) (Freeman-Roth, 2006). Indeed, in society, we constantly use one another to attain our own ends, examples being the waitress or bus driver. However, Bleyl errs in generalizing means; it is the mere objectification of people that is forbidden, not becoming a means in general. So long as we see and respect the person in question, intrinsic value is maintained.

I have argued a cadaver does not have significant intrinsic value, and to add support to this conclusion, the categorical imperative requires that entities have individual ends that need satisfying – which corpses do not possess.

Assuming the body and the deceased are separate entities once death occurs, we can infer bodies alone do not have ambitions, goals, purposes, or “ends”, and so have no significant purpose other than fulfilling the deceased’s pre-death wishes. The deceased’s wishes can be purposeful in a limited number of ways but not of the body’s own accord.

Without means or ends, the corpse cannot possibly have intrinsic value on its own, and therefore, with death an object obtains trivial, residual value from the person it once inhabited.

Potential Problems The slippery slope concern should be addressed, for

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Public Access to Anatomical Knowledge: Intrinsic Value of the Cadaver and Plastination

critics have suggested that if we accept the notion of the human body as an object of minimal worth in comparison to its living state, what is to stop us from turning plastinated people into ashtrays, coat-trees or chairs (Wetz, 2000, p.390)?

A macabre example is the case of “Ruan”, an exhibition by a Chinese artist in which the head of a fetus was grafted to the body of a bird (Herzog, 2005). The resulting furor after its display in a Swiss museum led to its banishment.

The only moral justifications for Ruan’s existence was cultural relativism (in Chinese culture, unborn children have no value) and subjectivity of artistic beauty. It is a valid concern of plastination opponents that plastinates would be used for questionable purposes. Because of plastinates’ lifelike qualities, they carry the potential to harm the image of humanity by insinuating that abuse of living people is tolerable; by abuse, I mean that it sends the message that it is acceptable to treat humans as objects or household items that can be bought, sold, or thrown away. Such disrespectful use of cadavers by an artist degrades the image of presently living humans beyond the way offensive art does, but I do not see this as an issue of dignity of the corpse itself.

Defamation of the corpse’s image as a representation of humanity advocates for acceptance of human exploitation while the corpse without means and ends cannot even react to the supposed offense. Wetz’s separation of the deceased and the body should clarify moral dignity as a possession of the living. The corpse should be respected not because of its intrinsic value but out of respect for the deceased person and its plausible effects on the living.

But if the deceased should wish to become a chair, should it be allowed? The answer is no. The true issue here is not mistreatment of the corpse’s dignity or invalid consent of the donor, but rather dehumanizing living people via their mirror reflection. In this manner, the deceased can reduce human dignity, from beyond the grave, to mere means - this is deplorable by the living and is therefore also objectionable by the dead. Also, since many believe humankind to be modeled in God’s image, this could be viewed as an insult to God by degrading His wondrous creation. Therefore, the use of cadavers should be limited to ways that do not abuse this image, the representation of humanity, but rather, revere this marvel and uphold its dignity; this, therefore, depends on purity of the image. In the unlikelihood that slippery slope prophecies are fulfilled, it is difficult to imagine one would consent his/her body to be used in this way, and that a market for such items would exist.

Issues in Aesthetic Presentation At last, we turn to the argument that if one still adamantly believes a corpse has the same intrinsic worth as its living counterpart, using it in an artistic, creative fashion insults said worth and serves to objectify it (Bleyl, 1999, p.312), This issue has been sensationalized because Penn Bioethics Journal Vol III, issue i Spring 2007

of von Hagens’ eccentric scientist persona and his artistic showmanship. While he professes to dedicate his mission toward teaching people about their bodies, he undeniably presents some of his plastinates as famous works of art, such as Michelangelo’s Bartholomew from the Sistine Chapel, to cite one example (Wetz, 2000, p.386). One train of thought is that an artistic rendition of one’s body is owed to the donor to prevent objectification. The justification for this conclusion lies in the likelihood that without some aesthetic component, plastinates more closely resemble a medical or scientific specimen, comparable to a moth pinned on a board with its Latin name written below. A purely scientific approach, especially of full-body plastinates, would come across as devoid of emotion, an important human attribute, and downplay the social contributions that humans make.

More importantly, without aesthetic measures, meeting teaching goals is not as likely since many express fear, disgust or loathing of corpses. Were museums to display cadavers the way they have traditionally been preserved, as the grey, odorous, shrivelled shadows of former greatness and functionality, it is doubtful they would enjoy the same success as Body Worlds. An engaging artistic “presentation” is the means by which said fear and disgust can be overcome, encouraging even non-science oriented people to draw near the body who otherwise would not. When the shuddering is gone, it can be replaced by amazement at this wonder that is the human body. The “liveliness” of the dead plastinate promotes a relaxed approach, but it is the artistic flair, such as positioning plastinates as joggers or cyclists, that piques the curiosity. I believe aesthetic touches to be a value, not a detriment to the corpse’s dignity, although I maintain its worth is slight.

Finally, Bleyl (1999, p.310) finds consent given by plastinate donors to be invalid, since he assumes donors only consent to educative purposes for their bodies and not to aesthetic purposes. At least in organ donation, he says that consent is given with specific knowledge of what will be done with one’s organs, and does not serve some other random purpose as in artwork (1999, p.313).

He does admit to a conflict of duties between protecting artistic freedom (different from individual autonomy) and upholding collective human dignity, but argues that dignity overrides rights to artistic freedom (1999, p.315).

Even if we do ignore the fact Kantian duties have once again conflicted, the arguments are problematic. First, he assumes that donors do not donate with artistic wishes in mind, although this is not necessarily so. Second, he suggests that using the body for organ donation does not degrade dignity but leaving full discretion to artists to decide what is done with the body can; simply put, the process is more transparent. If we dissect this assumption, the same argument used against the discretionary nature of the artist can be employed against the surgeon who harvests his organs. Yes, organ donors have consented, but given

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the choice to be intricately involved in the process of parcelling out those organs, would they approve of how those organs were distributed? Would they want their liver to go to an alcoholic? Or more subjectively, if they could meet the organ recipients and discovered they did not like them, is this grounds for condemning and withdrawing consent to organ donation overall? Bleyl’s argument is not strong enough to invalidate consent if he considers organ donation acceptable - neither use of the body is completely transparent for those who consent cannot partake in subsequent decision-making.

Conclusion Although Bleyl’s arguments generally focus on a couple of main premises, rebuttals to each point have been independent of one another and develop a multifaceted case for the acceptable use of plastinates in public exhibitions. We should not fear degradation of a corpse’s intrinsic value by equating it to the living, nor should we value it so highly that it comes at the expense of the deceased’s autonomy. I have argued that the “art” of plastination is necessary in enabling the public to overcome fears and moreover enhancing humanity’s image, as opposed to worrying about misconceptions that plastination exhibitions will lead to morally questionable displays of poor taste.

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Placing the body on a pedestal via plastination does not threaten, but rather celebrates, human dignity. Finally, if consent to other uses of corpses must be respected, then consent to plastination exhibition must also necessarily be acceptable. Technology’s continued advancement muddles the transparency of many procedures, but conclusions still need to drawn. In the art world, these conclusions are subjective, as no exhibition can evoke specific emotions consistently or be objectively measured on a scale of moral soundness.

References 1. Bleyl, Uwe. (1999). “Der Mensch muß immer Zweck an sich

selbst bleiben - Der rechtsethische Vorbehalt gegen die sog.

Anatomiekunst [Man must always remain an end unto himself

– ethical reservations against so-called anatomy art] ”, Annals of

Anatomy, 181: 309-316.

2. Herzog, Samuel. “Im Grenzbereich des ethisch Vertretbaren [In

the borderzone of the ethically justifiable] ”, Neue Zürcher Zeitung,

August 2005.

3. Freeman-Roth, Christine. Kantianism and Consent - Lecture

Notes, January 31, 2006.

4. Wetz, Franz-Josef. (2000). “Tote sind nur ein Problem für

Lebende - Menschenwürde und Plastination [The dead are only

a problem for the living - human dignity and plastination],” Annals

of Anatomy, 182: 385-391.

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Bioethics of Public Health

Thoughts on the Recently FDA-Approved HPV Vaccine:

An Ethical and Historical Perspective on Mass Vaccination Programs Author: Daniel Wasser, Cornell University Faculty Sponsor: Thomas Seeley, PhD Abstract On June 8th 2006, the Food and Drug Administration approved the first vaccine ever developed to prevent cervical cancer and precancerous genital lesions due to human papillomavirus (USFDA, 2006). Many in the media and scientific community have declared the new vaccine Gardasil a victory against sexually transmitted disease and even cervical cancer itself. Recognizing the potential health benefits of the vaccine, Texas Governor Rick Perry on February 2nd 2007 ordered through executive mandate that all girls entering the sixth grade in Texas be vaccinated against HPV starting in 2008. This is in accordance with FDA guidelines as it approved the vaccine for all females between the ages of nine and twenty-six who had not yet contracted the virus (USFDA, 2006). Nevertheless, the tragic history of recent mass vaccination failures, such as the 1976 National Influenza Immunization Program against swine flu and the 2003 Smallpox Vaccination Program, demonstrates the inherent danger of rapid vaccination programs undertaken without adequate clinical research. The medical community must balance its fundamental ethical principles of patient autonomy and non-maleficence against the potential health benefits of Gardasil in assessing the government’s efforts to vaccinate such a large, indiscriminate and vulnerable segment of the population.

“When arbitrary decisions in the mandating of vaccines are made by government bureaucracies… we have all the potential ingredients for a tragedy of historic proportions.”

— Harold Buttram, MD Human Papillomavirus and Gardasil

Human papillomavirus (HPV) is a widespread sexually transmitted pathogen that has been correlated with an increased risk of cervical cancer as well as precancerous genital lesions and warts. HPV infection is most common among the young and the sexually active. The virus is known to cause inflammation leading to dysplastic, precancerous and cancerous lesions of the cervix.

Traditionally, HPV prevention options have been limited Daniel Wasser is a Junior at Cornell University and is majoring in Biology and History.

Email: dew32@cornell.edu Dr. Thomas Seeley is the faculty sponsor for this submission. He is a Professor and Chairman of the Department of Neurobiology and Behavior at Cornell University Address: Mudd Hall, Cornell University, Ithaca, NY, 14853 Email: tds5@cornell.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

to complete abstinence due to the inability of condoms to offer absolute protection and the virus’s potential to be transmitted by non-coital sexual activity (Weaver, 2006). HPV is so prevalent in the population that approximately half of all sexually active men and women will acquire a genital HPV infection at some point in their lives, and by age fifty at least eighty percent of women will have acquired a genital HPV infection. Each year nearly 6.2 million Americans develop a new genital HPV infection (CDC, 2004). HPV ranks as the most common sexually transmitted infection in the United States (Weaver, 2006). The World Health Organization reports that the virus accounts for over 195,000 deaths each year, making it the second most common terminal cancer in women worldwide (World Health Organization, 1998). It can be therefore be concluded statistically that HPV infection is significantly more widespread than earlier contagious viruses that have been combated with mass vaccinations programs such as poliovirus (Oshinsky, 2005).

With the recent FDA approval of Merck Corporation’s vaccine Gardasil, vaccination advocates now believe that the possibility exists for the eventual eradication of HPV and a significant percentage of cervical cancer in the coming years. Following Texas’ lead, state legislatures across the nation have begun considering mass vaccinations of their female youth. This drive to vaccinate is principally due to the fact that the initial results from Merck Corporation’s sole domestic study have been incredibly promising. Among women who have not already been exposed to the virus, the study reports that Gardasil is nearly one hundred percent effective in preventing precancerous cervical lesions due to HPV (Steinbrook, 2006). A number of members of the health care community share the expectation expressed by pediatrician Phillipe Simon that, “Vaccinations will probably change our approach to the screening and therapy of human papillomavirus-related diseases in the next few years. The mass vaccination of adolescent patients should lower the frequency of these very frequently lethal infections” (Simon, 2005).

Recognizing the dramatic potential benefits any vaccine would have, a guarded approach is needed in evaluating Gardasil’s actual efficacy. The FDA, cognizant of public sentiment and positive media reports concerning Gardasil, evaluated and approved the drug in a mere six months. The unusual rapidity of the FDA’s approval of Gardasil is cause for concern as most pharmaceuticals are subject to several years of review before approval is granted and even more time until they are mandated by the various states. Remarkably, the FDA approved Gardasil without any independent studies and with only one published domestic study conducted by the Merck

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Corporation itself. The FDA acknowledged the significance of these serious safety and research shortcomings when it stated in a press release that the “manufacturer has agreed to conduct several studies following licensure, including additional studies to further evaluate general safety and long-term effectiveness” (USFDA, 2006). It is important to remember that Merck is the same corporation infamous for the 2004 Vioxx scandal in which it is alleged to have been aware of“the unacceptable cardiovascular risks of Vioxx…as early as 2000 - a full four years before the drug was finally withdrawn from the market” (Horton, 2004). Furthermore, political watchdogs have begun examining Merck’s relationship with Texas Governor Rick Perry, who mandated the vaccine through executive order. Besides receiving campaign contributions from the corporation during his 2006 reelection, one of Merck’s three main lobbyists in Texas is Mike Toomey, Perry’s former chief of staff (Peterson, 2007). In light of the Merck Corporation’s recent history of disregard for patient safety, a growing portion of the medical community has begun to raise concerns over the FDA’s decision to approve and Texas’ decision to mandate Gardasil so rapidly.

The experimental design of the Merck study has also begun to come under intense scrutiny from the medical community. The Merck study presents no experimental data on Gardasil’s long-term effectiveness or subsequent impact on fertility and/or pregnancy. Marcelle Pick, co-founder of Women to Women Health Clinic, sums up these concerns over patient safety when she writes, “Talk of mandating such a vaccine for young women is very premature. Little is known at this point about the vaccine’s long-term side effects or its interaction with other drugs” (Women to Women, 2006). It is only a matter of time before more health care professionals begin to voice similar concerns and recognize the magnitude of bureaucratic irresponsibility which allowed the FDA to approve and Texas to mandate a vaccine for children based on a single domestic study clouded with such pronounced conflict of corporate interest and dearth of long term experimental data. Therefore whatever positive potential Gardasil does possess, responsible members of the medical community must ensure that a more thorough scientific understanding of the vaccine is achieved before further mandatory state vaccinations are considered for schoolchildren. This perspective is only strengthened by the sobering legacy of recent mass federal vaccination failures previously approved by the FDA. Recent Federal Mass Vaccination Failures Over the last thirty years the FDA has repeatedly been plagued with an inability to strike the proper balance when it comes to government mandated mass vaccination programs. Any effective vaccination effort must achieve a balance between rapid immunization and essential safeguards to ensure the safety, the quality, and the efficacy of a vaccine. As a result of the FDA’s repeated failure to develop sound criteria for vaccine approval, a number of vaccination efforts have resulted in devastating medical disasters with severe repercussions for patients, including death. The 1976 National Influenza Immunization Program and the 2003 Smallpox Vaccination Program best epitomize the recent legacy of

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mass vaccination efforts undertaken without adequate clinical research to ensure patient safety.

In 1976 an outbreak of swine flu in two Army recruits stationed at Fort Dix, New Jersey startled the nation as the virus was found to be similar to the influenza strain that caused the Spanish Influenza pandemic of 1918. Responding to widespread public concern and political pressure public health authorities formed the National Influenza Immunization Program tasked with inoculating the entire population of the United States against swine flu as quickly as possible (Sencer and Millar, 2006). As the vaccination effort unfolded, a gradual recognition began to emerge regarding the swine flu vaccine’s causal relation with a rare paralytic disease known as Guillain-Barré Syndrome (GBS). GBS, similar to polio, causes an onset of polyneuritis that can eventually lead to paralysis.

While most vaccinated patients who developed GBS recovered in the following months, there was a five percent mortality rate and ten percent remained partially paralyzed (Silverstein, 1981, p. 23). By the time the program was abandoned a staggering one quarter of the American population had been vaccinated and been exposed to the potential pernicious health effects of the vaccine (Sencer and Millar, 2006). The program was prematurely terminated, leaving much of the population vulnerable, but the feared epidemic never materialized.

In fact no incidence of swine flu was ever documented in the United States beyond the initial two cases. The national fiasco of the 1976 Swine Flu “Pandemic” stands as a stern testament of the FDA’s and the government’s tendency to disregard a lack of rigorous clinical research and minimize patient safety concerns under the pressure of powerful sociopolitical forces.

Following September 11th and Anthrax attacks of 2001 the government once again sought to undertake a federal mass vaccination program. Evaluating the potential vulnerability of the nation to any future release of weaponized smallpox the FDA felt that, “If terrorists were to intentionally introduce just a single case of smallpox…it could mushroom into a public health emergency” (USFDA, 2003). In 2003, Congress, acting on these concerns, initiated a program to inoculate 440,000 civilian health care providers to protect the nation’s medical personnel against any potential future outbreak of smallpox in the general population. This first phase was to be followed by the immunization of an additional ten million public safety and health care workers. In less than a year, however, the government was once again forced to abandon a mass vaccination program due to unforeseen side effects and a mounting death toll.

The smallpox vaccine was found to be causally related with an increased incidence of post-vaccination encephalitis and cardiac complications, specifically myopericarditis (Aragón and Semyak, 2003). When the vaccine led to a number of patient deaths in 2003, many states including New York and Illinois took the drastic action of suspending any further federal smallpox vaccinations in their states to protect their populations (Meckler, 2003). As a consequence of these developments, the health care community overwhelmingly avoided being vaccinated despite

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Thoughts on the Recently FDA-Approved HPV Vaccine

government efforts to administer immunizations, further defeating the purpose of the entire enterprise. Doctors Aragón and Semyak acknowledge this trend when they write, “Clearly, health care workers have voted with their arms on this initiative despite [government] recommendations to get vaccinated” (Aragón and Semyak, 2003). The 2003 Smallpox Vaccination Program, though undertaken for valid national security reasons, failed as once again the FDA kowtowed to a timetable dictated by political and social pressures rather than sound clinical vaccination research.

Ethical Analysis Overall, it can be understood from both the 1976 and the 2003 immunization programs that the FDA has repeatedly yielded to political and public clamor in approving vaccines without adequate clinical study. Government mandated vaccination programs are fundamentally based upon a utilitarian logic that unacceptably violates the critical ethical concepts of individual freedom and patient autonomy under the aegis of public safety. Utilitarianism defines the justness of an act on its potential to further social welfare despite whatever damage it may cause to a single individual.

The government, by advocating utilitarian social health policies such as mandatory mass vaccinations on the state or federal level, violates the fundamental ethical principle of patient autonomy understood as the ability to direct one’s own medical care. Even more problematic, by mandating an untested and potentially dangerous vaccine, the government forces health care providers to decide between their commitment to the principle of non-maleficence on one hand and the potential welfare of society on the other. In short, before any further mass vaccination of the nation’s female youth can be responsibly undertaken, the medical community and society must fully recognize the FDA’s past mass vaccination failures in assessing the organization’s ability to advocate new vaccination efforts on the any level.

It is ethically and scientifically irresponsible that the FDA approved and the governor of Texas mandated a vaccine based on a single domestic study with results tarnished by such pronounced conflict of corporate interest and a complete absence of long term experimental data. It is critical that as state governments begin considering mass vaccination of all female youth with Gardasil that the safety of semi-autonomous school children not be trampled under the mandates of utilitarian logic. The medical community must recognize its fundamental ethical principles of patient autonomy and non-maleficence in assessing the government’s efforts to vaccinate such a large, indiscriminate and vulnerable portion of the population with Gardasil. In treading cautiously, the health care community will ensure that its primary focus remains on the individual patient, thereby ensuring that a potential tragedy of historic proportions does not befall us under the auspices of public safety.

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References 1.

2.

3.

Aragón, T.J. and Semyak, F.E. (2003). The Risks and Benefits of Pre-Event Smallpox Vaccination: Where You Stand Depends On Where You Sit. Annals of Emergency Medicine, 42(5): 681-4.

Centers for Disease Control and Prevention. (2004). Genital HPV Infection – HPV Fact Sheet. Press Release. Atlanta, Georgia: Department of Health and Human Services.

Retrieved on 12/11/06. < http://www.cdc.gov/std/HPV/STDFact-HPV.htm > Horton, R. (2004). Vioxx, The Implosion of Merck, and Aftershocks at the FDA. The Lancet, 364: 1995.

4. Meckler, L. (2003, March 29). “2 States Suspend Smallpox Vaccinations.” CBS News. Retrieved on 8/13/06. <http://www.cbsnews.com/stories/2003/03/27/health/main546386.shtml>.

5. Peterson, L. (2007, February, 2). “Texas Requires Cancer Vaccines for Girls.” ABC News. Retrieved on 2/7/07. <http://abcnews.go.com/Health/wireStory?id=2845221>.

6 Oshinsky, D.M. (2005). Breaking the Back of Polio. Yale Medicine. Retrieved on 12/12/06. < http://www.yalemedicine.yale.edu/ym_au05/polio.html>.

7. Sencer, D.J. and Millar, J.D. (2006). Reflections on the 1976 Swine Flu Vaccination Program. Emerging Infectious Diseases Journal, 12(1): 29-33.

9. Silverstein, Arthur M. (1981) Pure Politics and Impure Science: The Swine Flu Affair. Baltimore and London: The John Hopkins University Press.

10. Simon, P. (2005). Progress Towards a Vaccine for Cervical Cancer. Current Opinion in Obstetrics & Gynecology, 17(1): 6570.

11. Steinbrook, R. (2006). The Potential of Human Papillomavirus Vaccines. New England Journal of Medicine, 354 (11): 1109–1112.

12. United States Food and Drug Administration. (2003). An Update on Smallpox. Press Release. Washington, DC: U.S. Food and Drug Administration, Office of Public Affairs.

13. United States Food and Drug Administration (2006). FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus.

Press Release. Washington, DC: U.S. Food and Drug Administration, Office of Public Affairs.

14. Weaver, BA. (2006). Epidemiology and Natural History of Genital Human Papillomavirus Infection. The Journal of the American Osteopathic Association, 106(3) Supp 1: S2-8.

15. Weinstock, H., Berman, S., and Cates, W., Jr. (2004). Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates, 2000. Perspectives on Sexual and Reproductive Health, 36(1): 6-10. Centers for Disease Control and Prevention.

16. Williams, K. (1995). National Vaccine Information Center Statement. Speech presented at the Institute of Medicine Vaccine Safety Forum, Washington, DC. 17. Women to Women. (2006). Hype About New HPV Vaccine Is More Good Marketing Than Good Medicine. Press Release. Yarmouth, Maine: Women to Women. Retrieved on 8/13/06. <http://www.womentowomen.com/sexualityandfertility/hpvvaccinepressrelease.asp> 18. World Health Organization. (1998). World Health Report 1998.

Geneva, Switzerland.

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Bioethics of Public Health

On TRIPS, Access to Drugs, and the Expectation of Profit Author: Alexander Stark, Northwestern University Faculty Sponsor: Mark Sheldon, PhD Abstract In 1994, the World Trade Organization (WTO) implemented the Trade-Related Aspects of Intellectual Property (TRIPS) Agreement, which established standards for the protection of patents worldwide.

Citing a utilitarian justification, known as the “incentiveto-invent-and-innovate” argument, the pharmaceutical industry has supported the enforcement of TRIPS, maintaining that pharmaceutical profits should be protected in order to maximally benefit society.

However, it is worried that the protection of drug patents will further limit access to essential medicines in the developing world. In this paper, I use Peter Singer’s moral directive—“if it is within our power to prevent something bad from happening, without thereby sacrificing anything of comparable moral importance, we ought, morally, to do it”—in an attempt to show that the utilitarian justification for TRIPS is unethical and inadequate when applied to the developing world.

In fact, considering that an insignificant portion of the industry’s profits actually comes from the developing world, it seems that the loss of that portion of profits is exactly the sort of thing that—under Singer’s directive—should be sacrificed in order to prevent access to drugs from declining. Finally, if access to drugs in the developing world is ever going to be substantially improved, then society must move away from the expectation that business in the developing world must always be profitable.

I. Introduction In 1994, the members of the World Trade Organization (WTO) signed the Trade-Related Aspects of Intellectual Property (TRIPS) Agreement, thereby establishing a global standard for the protection of intellectual property. Justified by a utilitarian argument, the goal of TRIPS is to sustain incentive for firms to develop new products: an undeniable social benefit. However, there has been considerable worry that TRIPS—when applied to pharmaceutical patents on essential medicines—will further limit access to drugs Alexander Stark is a Senior at Northwestern University and majoring in Philosophy.

Email: a-stark@northwestern.edu Dr. Mark Sheldon is the faculty sponsor for this submission. He is a Lecturer in the Department of Philosophy and in the Medical Humanities and Bioethics Program of the Feinberg School of Medicine at Northwestern University Address: 1922 Sheridan Rd., Evanston, IL, 602089030 Email: sheldon@northwetern.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

and essential medicines in the developing world. In the developing world, it seems that the social justice concern of access to drugs is in direct conflict with the utilitarian protection of profit.

Peter Singer has argued, “if it is within our power to prevent something bad from happening, without thereby sacrificing anything of comparable moral importance, we ought, morally, to do it” (Singer, 1972, p.231). The argument that Singer makes to establish this moral directive is not within the scope of this paper, and I only wish to use his directive insofar as it provides an interesting framework for evaluating the conflict that TRIPS attempts to mediate.

The question is whether the justification for obliging developing nations to comply with TRIPS is moral—that is, does respecting intellectual property rights in developing countries prevent the occurrence of something bad without sacrificing something of a comparable moral status?

In this paper, I will argue that the protection of the pharmaceutical industry’s profit in the developing world does not warrant the accompanying sacrifice of access to drugs. This assertion is philosophical in nature; I will refrain from making any rigorous economic or empirical arguments. Furthermore, this paper does not intend to bring into question the ethical nature of profit in general.

However, it is widely acknowledged that one third of the world’s poor lacks access to essential medicines, and that “in the poorest parts of Asia and Africa this figure rises to onehalf ”(Access, 2007, para. 1). It is upon these grounds that I claim that the utilitarian justification for the enforcement of TRIPS in the developing world is unethical under the context of Peter Singer’s moral directive.

II. Background concerning TRIPS and the protection of intellectual property Under TRIPS, all members of the WTO (including developing nations) are obliged to honor the patent laws of other members. The goals of the agreement are, as stated in Article 7 of the Trips Agreement: The protection and enforcement of intellectual property rights should contribute to the promotion of technological innovation and to the transfer and dissemination of technology, to the mutual advantage of producers and users of technological knowledge and in a manner conducive to social and economic welfare, and to a balance of rights and obligations. (Walker, 2001, p.9)

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With respect to the pharmaceutical industry, ‘intellectual property’ generally takes one of two legal forms: product patents (i.e. chemical structures of a drug) and process patents (the way in which the drug is produced) (Cohen, 2003, p.29). It is interesting to note that the protection of social welfare is one of the stated goals of the agreement.

TRIPS mandates that members of the WTO must respect the patents of pharmaceutical products for up to twenty years, even in countries where such patents have been traditionally rejected. In fact, many developing nations—such as India—have, in the past, adopted an explicit policy not to honor pharmaceutical patents in the hopes of stimulating domestic production of cheaper, ‘generic’ drugs (Cohen, 2003, p.33). Furthermore, the UN Commission on the Promotion and Protection of Human Rights proclaimed in August 2000 that there are “apparent conflicts between the TRIPS regime, on the one hand, and human rights (including the right to health) on the other” (Sterckx, 2004, p.59).

Developing nations were given until 2006 to comply with the terms of the agreement, a deadline that was extended until 2016 after the Doha Agreement on TRIPS and Public Health in November of 2001. The Doha Agreement also emphasizes an important aspect of the TRIPS Agreement, which allows governments to “issue a compulsory license for a pharmaceutical product without the permission of the patent owner when it can be justified in the public interest” (Cohen, 2003, p.32).

It is thus apparent that the TRIPS Agreement attempts to address two opposing methods of promoting social wellbeing; it appears that developed nations argue for the rigid protection of intellectual property laws in order to increase the incentive to innovate, whereas developing nations generally believe that the rejection of such laws allows for increased access to drugs via cheap, ‘generic’ alternatives (Sterckx, 2004, p.60). As it will be seen, the question of which pathway actually promotes the social well-being is somewhat contingent upon both real economic and empirical circumstances, as well as the needs of the culture in which it is asked. However, an evaluation of the most common argument made for increased patent recognition may indicate which pathway is backed by a more ethical argument.

III. Analysis of the utilitarian justification for TRIPS The most commonly cited justification for the protection of intellectual property rights is utilitarian in nature, and it is this argument that is cited in Article 7 of the TRIPS agreement. This has been called the “incentiveto-invent-and-innovate” argument, and it relies upon the notion that exclusive marketing rights must necessarily be granted to pharmaceutical companies in order to guarantee a reward large enough to promote continued innovation of

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medicines and technologies (Sterckx, 2004, p.66). When applied directly to the application of TRIPS in developing nations, this argument suggests, “pharmaceutical patent protection should encourage firms to invest in the research and development of new drug therapies specific to the disease burden of developing states that had previously not protected pharmaceutical patents” (Cohen, 2003, p.31). The incentive argument—or the need for sufficient incentive—is especially critical for the pharmaceutical industry for two reasons: (1) due to the high costs of bringing a drug to the market, only 30% of new drugs are profitable, and (2) it is generally not disputed that new drugs constitute a considerable social benefit. (Resnik, 2001, p.27).

However, there is reason to question the validity of the utilitarian argument in the context of the developing world. It must be noted that only developed countries have promoted intellectual property rights as a means to increase innovation in the pharmaceutical industry. It is doubted that TRIPS will be able to “promote new investment towards innovation in developing countries, or to promote the informal innovation that is characteristic in many developing countries” (Walker, 2001, p.x). Thus, developed nations have promoted drug patents in order to support the continued growth of an established pharmaceutical industry, but it seems that strict patent enforcement may be detrimental to the growth of domestic pharmaceutical industries in developing nations. As mentioned before, India’s domestic pharmaceutical industry was developed as a result of a policy that did not recognize foreign patents (Cohen, 2003, p.33). It seems that TRIPS supports continued innovation in developed nations (a social benefit, to be sure), but it does not seem to support the self-sufficiency of domestic pharmaceutical industries in developing nations. If the goal is to promote global social well-being, does it not seem that promoting the dependency of developing nations is counter-productive?

Before we can directly apply Singer’s directive to the utilitarian justification for TRIPS, let us consider one last argument in support of global patent protection.

Pharmaceutical industry representatives estimate that the global non-recognition of intellectual patents results in the loss of “as much as 10%” of the industries potential profits (Resnik, 2001, p.28). It is argued that the realization (through universal patent recognition) of this ‘lost profit’ will increase investment in pharmaceutical research and development, thereby promoting society’s best interests in the form of increased innovation and new products.

Furthermore, in accordance with the common assumption that “companies can afford to do business in a country and exercise social responsibility insofar as they have a guarantee of reasonable profits,” [italics added] patents are often considered economically necessary to promote the “business environment” necessary for such a guarantee (Resnik, 2001, p.28). These arguments, grounded in a firm

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On TRIPS, Access to Drugs, and the Expectation of Profit

belief that patents provide the necessary incentive for firms to innovate, seem sufficient to justify the pharmaceutical industry’s insistence that developing nations rigidly respect intellectual property rights as a pre-condition for the development of drugs specific to the needs of those countries.

IV. Applying Singer’s moral directive The very nature of the concerns raised by the above arguments suggests that there is something that ought to be sacrificed under Peter Singer’s moral directive. The definition of ‘profits’ alone is sufficient to show that the protection of profits is expressly not in accordance with the principle that we should prevent something bad from happening if nothing of a comparable moral status is thereby sacrificed. ‘Profits’ are what remain of a firm’s revenue after all the costs of production, employment, and marketing have been covered: if it wasn’t extra then it would not be called ‘profit’ (instead, it might be called ‘returns’). If firms are making a profit, they are not merely able to afford to do business—they are benefiting insofar as they are making more money than was invested in those operations. If increased access to drugs can be accomplished through the non-recognition of patents in the developing world, then the sacrifice of a percentage of profits is not merely morally acceptable, but morally necessary under Singer’s directive. To argue otherwise, one would have to show that the loss of 10% (given from the industry’s own arguments) of the pharmaceutical industry’s profits is a moral sacrifice on a comparable level as increased access to essential medicines in those countries that need it most.

If not, the protection of a profit margin is explicitly not the kind of thing that Singer’s directive would protect, but rather exactly the kind of thing that should be sacrificed in order to prevent something bad from happening.

As grounds for the enforcement of TRIPS in developing nations, the expectation of maintaining a ‘reasonable profit’ makes even less sense with respect to the pharmaceutical industry. “In 1999, the top ten pharmaceutical companies had an average profit margin of 30%, and the pharmaceutical industry averaged an 18.6% return on revenues” (Resnik, 2001, p.13). In 2001, the pharmaceutical industry was considered the most profitable business sector with an average profit margin of 16.2% (Henry, 2002, p.1591). These figures become significant when contrasted with the profit margins of other industries such as the financial industry (which operates on a 11.6% profit margin) and the textile industry (which operates on a 5% profit margin) (Resnik, 2001, p.13). Thus the pharmaceutical industry does not make just a ‘reasonable profit’: it has become accustomed to operating on one of the largest profit to revenue ratios of any industry. For example, Pfizer was ranked 127th in the world for total revenues in 2001, but 7th in the world in terms of profits Penn Bioethics Journal Vol III, issue i Spring 2007

(Henry, 2002, p. 1591).

Furthermore, in order to argue that the loss of a percentage of pharmaceutical profits is something worth preventing to the extent that we can thereby justify limiting access to drugs, it must be shown that the profitability of the pharmaceutical industry is endangered by the nonrecognition of patents in developing countries. “Given the fact that North America, Europe and Japan together represent 80% of the global pharmaceutical market, and that of the remaining 20%, Africa represents only 1%, [the] concern about an ‘undermining’ of incentives for drug development is without foundation. The continuation of pharmaceutical R&D is not dependent on the markets of developing countries” (Sterckx, 2004, p.73). Thus, even if pharmaceutical companies made absolutely no profit in developing nations, the industry itself would remain profitable on a magnitude greater than almost any other industry. This further supports the notion that pharmaceutical companies would not be sacrificing anything of moral significance when foregoing expected profit from the developing world.

The pharmaceutical industry’s emphasis on research and development (R&D) is sometimes offered as a reason for the enforcement of TRIPS. According to the Pharmaceutical Research and Manufacturers Association, the estimated average expenditure on research and development for most industries is 4% of total revenues, while the average pharmaceutical company devotes 16% of total revenues into research and development (Henry, 2002, p.1591). However, insofar as pharmaceutical profits derived from the developing world are insignificant in comparison to the industry’s total revenue, the hypothetical profits gained by the pharmaceutical industry as a result of the enforcement of TRIPS in developing nations (especially Africa) will not have a significant impact on pharmaceutical R&D. That is to say, the non-enforcement of TRIPS in the developing world will not cause the pharmaceutical industry to sacrifice anything significant with regards to R&D. Once again, I wish to stress that I am not arguing that profits are, in general, unnecessary. It is well established that the ability for industries to make profits is an important condition for a thriving economy, creating many social benefits. Instead, I hope to have made clear that foregoing profits in the developing world is a morally acceptable sacrifice for the pharmaceutical industry to make. The argument here is not merely semantic in nature, though it may be true that our society has come to use the term ‘profitability’ in ways that are synonymous with ‘affordability’. It must be realized that the notion that firms cannot ‘afford’ to operate without making some sort of profit is an assumption that may have the consequence of limiting access to essential medicines in the developing world.

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V. Conclusion It has been several years since the implementation of TRIPS, and the consequences of increased patent protection are becoming known. Studies, such as the one conducted by Dr. Amir Attaran, have found that it is doubtful that patents are “to blame for the lack of access to antiretroviral drug treatment in most African countries”.

We were unable to identify any evidence, systematic or anecdotal, that antiretroviral treatment is more accessible in countries with few or no antiretroviral patents (eg. Mozambique, Namibia). Similarly, we were unable to identify any evidence that the antiretroviral drugs of, for example, Abbot, patented in 0 countries, are consumed in any greater numbers than those of GlaxoSmithKline, patented in up to 37 countries (Attaran, 2001, p.1890).

The danger is to interpret such data as proving that patents do not negatively affect access to medicines. In fact, even though developed nations such as the US were the driving force behind the implementation of TRIPS (Sterckx, 2004, p.60), it appears that the option to patent drugs has often gone unexercised in Africa, signaling that many pharmaceutical companies have decided that pursuing patents in developing countries is simply not worthwhile.

Throughout Africa, access to medicines is poor, whereas patent status “varies extensively by country and drug” (Attaran, 2001, p.1890). This data cannot be used as a valid argument for the protection of intellectual property rights in developing nations. Though this data does show that there are other factors that more severely affect access to drugs, such as a “lack of infrastructure, doctors and nurses, diagnostics, clean water, and food, as well as political corruption” (Novak, 2003, p.1272)—it does not follow that the enforcement of drug patents in the developing world is morally permissible. Such an argument would be analogous to saying that stealing a single candy bar from a gas station is morally permissible, so long as it is stolen during a riot in which theft is rampant.

In the article “Developing Drugs for the Developing World: An Economic, Legal, Moral, and Political Dilemma”, David Resnik argues that pharmaceutical companies have a ‘social responsibility’ to developing nations. This social responsibility is, among other things, grounded upon the principles of beneficence and justice, but can be perhaps more simply understood under the context that “a study of

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21 drugs introduced between 1965 and 1992, and considered to have had the highest therapeutic effect on society, found that public funding of research was instrumental in the development of 15” (Henry, 2002, p.1593). Unfortunately, Resnik falls prey to the common assumption that the fulfillment of these ‘social responsibilities’ in the developing world is contingent upon two factors: “(1) the prospects for a reasonable profit and (2) the prospects for a productive business environment” (Resnik, 2001, p.11). This leads him to argue that TRIPS needs to be strictly enforced by developing nations.

Such a position, in the context of Singer’s moral directive, necessarily implies that the (potential) restriction of access to medicines caused by patent protection is a morally acceptable sacrifice to make in the protection of the pharmaceutical industry’s profit margins. But considering the extreme nature of drug scarcity in the developing world, society’s opinion must shift to recognize that the protection of ‘profit margins’ is not ethically comparable to the pursuit of increased access to essential medicines. At least with regards to business in developing nations, perhaps the best way in which the pharmaceutical industry can fulfill Resnik’s ‘social responsibility’ is to do away with the expectation that business must always be ‘profitable’.

References 1. “Access to Medicines.” Medecins Sans Frontiers. Retrieved March

3, 2007, from http://www.doctorswithoutborders.org/news/access/

index.cfm.

2. Attaran, Amir. Lee Gillespie-White. “Do Patents for Antiretroviral

Drugs Constrain Access to AIDS Treatment in Africa?” JAMA.

October 17, 2001- Vol 286, No. 15. 1886-1892.

3. Cohen, Jillian Clare; Patricia Illingworth. “The Dilemma of

Intellectual Property Rights for Pharmaceuticals: The Tension

Between Ensuring Access of the Poor to Medicines and

Committing to International Agreements.” Developing World

Bioethics ISSN 1471-8847. Volume 3 Number 1 2003. 27-48 4. Henry, David. Joel Lexchin. “The pharmaceutical industry as a

medicines provider.” The Lancet. Vol 360. November 16,2002.

1590-1595.

5. Novak, Kristine. “The WTO’s balancing act.” The Journal of

Clinical Investigation. November 2003, Volume 112 Number 9.

1269-1273.

6. Resnik, David B. “Symposium: Drugs for the Developing World.

Developing Drugs for the Developing World: An Economic, Legal,

Moral, and Political Dilemma.” Developing World Bioethics ISSN

1471-8731. Volume 1 Number 1 2001. 11-32.

7. Singer, Peter. “Famine, Affluence, and Morality.” Philosophy and

Public Affairs. Vol. 1, No. 3 (Spring, 1972). 229-243.

8. Sterckx, Sigrid. “Patents and Access to Drugs in Developing

Countries: An Ethical Analysis.” Developing World Bioethics ISSN

1471-8847. Volume 4 Number 1 2004. 58-75.

9. Walker, Simon. “The TRIPS Agreement, Sustainable

Development and the Public Interest.” Center for International

Environmental Law. IUCN Environmental Policy and Law Paper

No. 41. 2001. http://www.ecolomics-international.org/iprsan_

simon_walker_iucn_trips.pdf. vi-60.

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Bioethics of Public Health

The Legal Duty to Warn and the Evolution of Tarasoff Author: Bianca Gonzalez, University of Pennsylvania Faculty Sponsor: Nadia Sawicki, PhD Abstract Tarasoff v. The Regents of the University of California (1974) has established the legal duty of clinicians to warn foreseeable victims of potential violent acts that have been communicated by psychiatric patients.

Tarasoff has been cited by many courts and legislatures that have either chosen to broaden its application or to criticize it for being too broad and ambiguous. Some who stand in extreme opposition have even deemed it unnecessary to legally impose the duty to warn. This paper will address these contradicting views on Tarasoff, examining how the duty to warn has evolved over time and discussing the future of this controversial case.

HISTORICAL BACKGROUND ON THE DUTY TO WARN The duty to warn potential victims of the risk of harm has been a heated topic of debate between legislatures and physicians, widening the already growing gap between the practices of law and medicine. These controversies are rooted in the decision of whether to protect public interest or to honor patient privacy, which is the foundation of the patient-physician relationship. This paper will focus on necessary breaches of confidentiality occurring when a patient communicates future violent acts towards a third party and examines how the controversial case of Tarasoff v. The Regents of the University of California (1974), with its imposition of a psychiatrist’s duty to warn potential victims, has evolved and influenced legislation.

THE FACTS AND HOLDING OF TARASOFF On August 20, 1969, Prosenjit Poddar, while undergoing psychotherapy, disclosed to therapist Dr. Moore that he was going to kill former girlfriend Tatiana Tarasoff. Moore called the police to detain Poddar which was initially successful.

However, the police released Podder on the grounds that he seemed rational and promised to stay away from Tarasoff.

A few months later, Podder carried out his threats of killing Tatiana (Tarasoff v. Regents of the University of California, 1974). Subsequently, Tatiana’s parents filed a suit against Moore and the Regents of the University of Bianca Gonzalez is a Junior at the University of Pennsylvania and is majoring in Nursing.

Email: biancag@nursing.upenn.edu Dr. Nadia Sawicki is the faculty sponsor for this submission. She is a Lecturer in the Department of History and Sociology of Science at the University of Pennsylvania Address: Logan Hall, 249 South 36th Street, Philadelphia, PA, 19104 Email: nsawick2@sas.upenn.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

California alleging negligence for failing to detain Podder and warn them or Tatiana of the threat. Since Podder had never been hospitalized, like in previous cases where psychiatrists have been found liable, the Tarasoff case had charted on unfamiliar legal territory. The court weighed considerations of public safety against patient privacy and sided with public safety ruling that “when a doctor or psychotherapist, in the exercise of his professional skill and knowledge, determines or should determine, that a warning is essential to avert danger arising from the medical or psychological condition of his patient, he incurs a legal obligation to give that warning” (Tarasoff v. Regents of the University of California, 1974).

In 1976, the case was revisited and the court decided that there should be an exception to patient confidentiality, concluding that “the protective privilege ends where the public peril begins” (Tarasoff v. Regents of the University of California, 1976). Not only do mental health professionals have a duty to warn potential victims, psychiatrists also have to take “whatever other steps necessary under the circumstances”(Tarasoff v. Regents of the University of California, 1976) to protect identifiable potential victims.

According to the 1976 Tarasoff definition, the duty to warn exists when (1) a psychotherapist-patient relationship existed, (2) that the psychotherapist knew of dangerousness, (3) a foreseeable victim exists, and (4) that the psychotherapist take the necessary steps to discharge the duty (Tarasoff v. Regents of the University of California, 1976). No court before Tarasoff has recognized a legal duty to warn the potential victims of a patient, making Tarasoff a milestone case that has set precedence for following court cases and ethical codes.

ARGUMENTS AGAINST TARASOFF Many argue that the Tarasoff decision has substantial flaws in its reasoning and in its impact from implementation.

Critics who question the reasoning behind the Tarasoff decision cast doubt on the need to impose legal duty to protect a third party when a “special relationship” exists between therapist and patient. According to Paul Appelbaum, there is no method of determining the existence of a “special relationship” and that the courts often concoct the existence of one when they believe that the duty to rescue should be implemented (Appelbaum, 1997).

Other flaws found with the Tarasoff decision have to do with its impact on psychiatric clinicians and their patients. Mental health professionals were at the forefront of the dissent expressing concerns about privacy of patients, the difficulty of predicting violent behavior, and the increased legal liability that they will incur. Some psychotherapists disagree with the Tarasoff case, arguing that civil commitment of a potentially violent patient (which

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was often the primary method of controlling patients before Tarasoff) is preferable to warning an identifiable victim (Fletcher, Lombardo, & Marshall, 1997). However, this method is problematic since it restricts the liberty of the patient.

Many therapists also believed that Tarasoff challenged the process of treating patients because it would be difficult to persuade patients to confide their emotions if they did not trust that therapists will honor privacy. In a study conducted in California on therapists, 79 percent of respondents believed that patients would confide less information if they knew that there may be a breach in privacy (Appelbaum, 1997). Additionally, 22 percent of psychiatric patients surveyed in a New Jersey study said that they had hesitated to seek treatment due to fears concerning disclosure (p. 251) The difficulty predicting violent behavior was an additional concern for mental health professionals. Before Tarasoff, most psychiatrists thought themselves fully capable of undertaking the task of predicting future violence of their patients. Some influential psychiatrists who thought very highly of their own skill even suggested the abolition of prisons and in place would send wrongdoers for psychiatric treatment (Appelbaum, 1997). This led to the adoption of statues in some states that permitted indefinite sentences in psychiatric facilities rather than serving time in prison.

However, society’s faith in the infallibility of psychiatric treatment came to a halt by the early 1970s. This resulted from follow-up studies on defendants who were predicted to be dangerous by psychiatrists, but were released by either disagreement from a judge or by a legal imperfection. The follow-ups of these released patients showed that only a small fraction was arrested for violent acts, proving that mental health professionals were over predicting future violence. Therefore in the 1970s many authoritative medical bodies such as the American Psychiatric Association (APA) drew the conclusion that psychiatric prediction of violence should not be solely relied on as a definitive judgment (p.

250).

Similarly, the element of increased liability put upon mental health professionals by Tarasoff added to the woes of medical community. A survey of California psychotherapists one year after Tarasoff reported that increased liability did affect their practices. A majority of the respondents noted that they felt increased anxiety when the subject of violent acts arose with their patients. Almost one-fifth felt tempted to avoid the subject of dangerousness altogether and one-fourth have admitted that Tarasoff had caused them to change their methods of note taking with the goal of avoiding legal liability (Wise, 1978).

In addition to concerns over liability, mental health professionals have grown concerned about how the third party would be affected. The warnings may increase anxiety on potential victims where their activities of daily living would be interrupted. Anxiety may also cause the third party to take preemptive strikes on patients (Appelbaum, 1997).

Clearly from the multiple surveys of psychiatrists and interviews with patients undergoing psychiatric therapy, Tarasoff has had a great impact on the field of psychiatry.

While the opponents of the Tarasoff decision have been aggressive in communicating their concerns, advocators of the duty to warn have been less vocal.

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ARGUMENTS SUPPORTING THE DUTY TO WARN The first attempts of combating the overwhelming opposition of the duty to warn had been the Tarasoff court itself. Having been harshly criticized, the Tarasoff court revisited their decision in 1976. The court found irrelevant the ability of therapists to predict dangerousness, stating that the therapist must act only with the same reasonable degree of care exercised by other members of the profession. The court also rejected the speculative opinion that imposing the duty to warn would deter violent patients from seeking psychiatric intervention and would disrupt the treatment process (Wise, 1978). But what the 1976 court concluded as their true purpose for imposing Tarasoff was that the alternative of not having this type of legislation would pose a greater danger.

After the 1976 revisit of Tarasoff, there have been other arguments by individuals who conclude that the Tarasoff decision is indeed necessary. When addressing liability concerns of psychiatrists, those siding with the Tarasoff decision have suggested that not every instance of a patient carrying out an act of violence which was previously a threat disclosed to the psychiatrist would impose liability on the psychiatrist. In situations that involve termination of therapy, there are few options for the psychiatrist to exercise a reasonable care. According to Judith Leonard (1977), it is not a case deciding whether the patient-doctor relationship or the doctor-public relationship should take priority because this relationship no longer existed when Podder’s treatment had been terminated and the risk of violence towards Tarasoff had only increased due to the absence of treatment. The APA almost reached this same conclusion by departing from total opposition of the duty to warn third party potential victims. The APA suggested an alternate scenario where the psychotherapist’s duty to warn a potential third party victim applied to a patient who had terminated treatment and wrote that this would be one particular instance where there exists a “suitable duty consistent with psychotherapy” (Leonard, 1977, p.

317). By the APA recognizing that there exists particular circumstances where duty to warn should be required, “the Tarasoff decision may have struck a more acceptable balance than the psychotherapists are willing to admit” (p. 317). Leonard concludes that the California court was not unreasonable in finding liability for failure to warn potential victims and that “Tarasoff represents no greater burden than the profession would likely impose on itself ” (p. 317).

CASES IMPACTED BY TARASOFF Cases Extending Tarasoff During the late 1970s and the early 1980s, the Tarasoff decision has been cited by multiple courts across the country. In their decisions courts have interpreted Tarasoff in different ways, broadening the scope of its definition.

This broadening of the Tarasoff decision is due to the ambiguous language used by the Tarasoff court in its definitions of adequacy of the warning and in its definition of foreseeability.

In Jablonski v. United States (1983), the Ninth Circuit

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further broadened Tarasoff ’s definition of foreseeability to include patient history (Jablonski v. US, 1983). Thereafter, states such as Arizona, Nebraska, North Carolina, and Wisconsin have followed the Jablonski example, broadening Tarasoff ’s definition. In Hamman v. County of Maricopa (1989) an Arizona court found that a foreseeable victim is one who resides within a “zone of danger” and is at risk for future violence (Hamman v. County of Maricopa, 1989). In Schuster v. Altenberg (1988) the Wisconsin court attempted to further expand the Tarasoff rule to an extreme, holding that where a duty to warn existed, “the therapist was potentially liable for any harm that occurred, regardless of forseeability” (Walcott, Cerundolo, & Beck, 2001, p. 330). The Wisconsin court had drastically taken the Tarasoff decision to the greatest extreme of clinician liability. However, in a trial of the facts, the jury supported the defendant and did not find liability (Walcott, Cerundolo, & Beck, 2001).

Cases Limiting Tarasoff In contrast, there have been cases that have either rejected or limited the use of the Tarasoff rule. Such cases are prevalent in the late 1980s and 1990s (Walcott, Cerundolo, & Beck, 2001) which seemingly suggests that Tarasoff is decreasing in significance.

In Thompson v. County of Alameda (1980), the California Supreme Court was concerned about the implications of imposing a duty to warn large groups of people and held that in the absence of a specific identifiable victim, there is no duty to warn (Thompson v. County of Alameda, 1980). In Boynton v. Burglass (1991), the Florida Court of Appeals completely rejected Tarasoff ’s application, pointing out flaws in the reasoning and standards of its decision. In Boynton the court held that the Tarasoff decision has misinterpreted the term “special relationship” by presuming that the clinician has the ability to control the patient. The Boynton court also rejected Tarasoff because of the difficulty of accurately predicting a violent act to be committed by a patient (Walcott, Cerundolo, & Beck, 2001).

There have been many cases citing Tarasoff throughout the late 1970s to present day. A pattern has evolved throughout the years with many cases accepting Tarasoff as a legislative model during the late 1970s to 1980s, while during the late 1980s and 1990s courts tended to limit and reject Tarasoff. But what does the future hold for Tarasoff and the duty to warn?

THEORIES ON THE FUTURE OF TARASOFF There are many who argue that Tarasoff is decreasing in significance which is reflected in court decisions of the late 1980s and 1990s. Some have even argued that Tarasoff is unnecessary legislation that will become insignificant as time goes by. However, there have been recent expansions of the Tarasoff rule.

In Estate of Morgan v. Fairfield County Counseling Center (1997), the Ohio court addressed whether a psychiatrist’s duty to protect a person from the violent acts of a patient extends to the outpatient setting. The court concluded that the psychotherapist-outpatient relationship embodies sufficient elements duty to warn and duty to control under particular circumstances. (Estate of Morgan Penn Bioethics Journal Vol III, issue i Spring 2007

v. Fairfield County Counseling Center, 1997) Ewing v. Goldstein (2004) is a more recent broadening of the Tarasoff rule. Geno Colello, who was undergoing psychotherapy with Dr. Goldstein, revealed that he was feeling depressed over the breakup of his girlfriend who had begun dating Keith Ewing. On June 21, 2001, Colello asked his father to loan him a gun and when he refused, Colello told his father that he would get another gun and kill whoever was then dating his former girlfriend. Colello’s father communicated this threat to Dr. Goldstein and urged him to admit Colello for psychiatric treatment. Colello was admitted as a voluntary patient, but was discharged the next day and later shot and killed Ewing. This led to a suit by Ewing’s parents against Goldstein. They alleged that their son was a foreseeable victim and that both Goldstein and the hospital were aware of the threat but had been negligent in failing to warn Ewing or police. In Ewing, the California Court of Appeals extended the Tarasoff rule to include communication of threats by family members and other credible parties (Ewing v. Goldstein, 2004).

Ewing and Morgan are recent departures from the overwhelming rejection of Tarasoff seen in the 1990s.

Similarly, other fields of medicine that do not pertain to psychiatric patients have adopted the Tarasoff decision in ethical or legal codes. Such cases are prevalent in situations dealing with infectious diseases such as Acquired Immunodeficiency Syndrome (AIDS). The APA’s AIDS policy on confidentiality and disclosure provides guidelines for clinicians in situations in which they are forced to choose between maintaining confidentiality of a patient infected with HIV/AIDS and protection of the community’s health. This policy states that notification of third parties who may be exposed to HIV/AIDS through the behavior of an HIV-positive patient is permissible if all efforts to terminate behavior that places others at risk and if the patient understands the limits of confidentiality have been exhausted (Zonana, 1989). Tarasoff ’s duty to warn has not only impacted cases in the psychiatric field, but has also been extended to other medical situations such as infectious diseases.

CONCLUSION The initial definition of duty to warn set by Tarasoff was broad and ambiguous, leaving room for different interpretations. Its opponents think of it as unnecessary to legally impose the duty to warn due to Tarasoff ’s ambiguity and ethical recommendations already set by authoritative bodies such as APA, but perhaps not having this type of legal duty poses the greater danger of under-prediction of future violent acts. Additionally, dissenters may be too quick to dismiss the need for Tarasoff in the future, overlooking emerging issues such as those considered in Ewing,Morgan, and its application to other realms of medicine. Because their practicality, Tarasoff laws should not be completely discontinued.

It is this author’s opinion that Tarasoff will continue to be interpreted in different ways, following a pendulum-like continuum, swinging from limitation to broadening of the duty to warn, each extreme displaying its significant dangers.

Future generations will seek to find more precise meanings and applications of Tarasoff, perhaps never coming to any definitive conclusion. It will be modified as new situations

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arise, expanding the legal duty to warn to accommodate future initiatives of legislative and ethical bodies.

References 1. Aragón, T.J. and SemAppelbaum, Paul S. “The Duty to Protect

Potential Victims of Patients’ Violence.” Ethics of Psychiatry

(1997): 246-262.

2. Estate of Morgan v. Fairfield County Counseling Center, 77 Ohio

St.3d 284 (1997) 3. Ewing v. Goldstein (120 Cal. App. 4th 807 [2004]) 4. Fletcher, John C., Paul A. Lombardo, Mary F. Marshall, and

Franklin G. Miller. Introduction to Clinical Ethics. 2nd ed.

Hagerstown, MD: University Group, 1997. 42-45.

5. Hamman v. County of Maricopa, 775 P.2d 1122 (Ariz. 1989) 6. Jablonski v. United States, 712 F. 2d 391 (9th Cir. 1983).

7. Leonard, Judith B. “A Therapist’s Duty to Potential Victims: a

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Nonthreatening View of Tarasoff.” Law and Human Behavior 1

(1977): 309-317.

8. Tarasoff v. Regents of the University of California, 131 Cal.Rptr.

14, 511 P.2d 334 (Cal. 1976) 9. Thompson v. County of Alameda, 614 P. 2d 728, 167 Cal. Rptr. 70

(1980) 10. Walcott, Damon M., Pat Cerundolo, and James C. Beck. “Current

Analysis of the Tarasoff Duty: an Evolution Towards the Limitation

of the Duty to Protect.” Behavioral Sciences and the Law 19

(2001): 325-343.

11. Wise, Toni P. “Where the Public Peril Begins: A Survey of

Psychotherapists to Determine the Effects of Tarasoff.”

Stanford Law Review 31 (1978): 165-190.

12. Zonana, H. “Warning Third Parties At Risk of AIDS: APA’s Policy

is a Reasonable Approach.” Hospital Community Psychiatry 40

(1989): 162-164.

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Bioethics of Public Health

Feminist Perspectives Pornography: Women as Commodities?

Author: Craig J. Iffland, University of Virginia Faculty Sponsor: James Childress, PhD Abstract Feminist debates on pornography highlight a lingering philosophical dilemma among feminist philosophersthat of how feminists should respond to the woman who “chooses” to be subordinated. Feminist authors condemning pornography must do so at the expense of a woman’s presumably autonomous choice, the very type of choice championed by feminists. How, then, would a feminist author articulate a claim against the merchandising of woman via pornography without undermining a woman’s autonomy to choose?

Some feminists suggest that the “choice” is not really autonomous, but is a result of the overarching patriarchy of modern societies. Others claim that the female actor in pornography is harmed by her participation in pornography. Feminist legal scholars have argued that toleration of pornography justified by government on free-speech grounds protects sexual abuse as speech. Justifications like these differ greatly from other condemnations of pornography in that they introduce “non-moral” concerns. However, it remains unclear why feminists should hesitate or disguise their positions against pornography as “non-moral”. Whether or not it is right that women are abused, even if they autonomously accept this abuse, is a moral question.

To say self-chosen abuse is not right is to infer that a person’s making a genuine autonomous choice to do something is not, in itself, a factor that validates the rightness (as opposed to wrongness) of a certain act.

This essay proposes a line of the moral reasoning for the regulation of pornographic films that puts forth the proposal that pornography, as it is now, should be regulated precisely because it treats “persons” (in this case women) as commodities.

Introduction Bioethics is a diverse academic and professional field.

Bioethicists come from a wide field of ethical inquiry and include doctors, nurses, lawyers, academics, and theologians.

Though bioethical inquiry is not limited to questions of the body, it is inextricably linked to it. Bioethics centers on the question of how individuals, surrogate decision makers, and Craig Iffland is a Senior at the University of Virginia and is majoring in Political Philosophy, Policy and Law, with minors in Religious Studies and Bioethics.

Email: cji6h@cms.mail.virginia.edu Dr. James Childress is the faculty sponsor for this submission. He is the Hollingsworth Professor of Ethics in the Department of Religious Studies Address: Dept. of Religious Studies, PO BOX 400126, Charlottesville, VA, 22904 Email: jfc7c@virginia.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

caregivers should care for the body. How much should we value one’s bodily integrity over their autonomous choice?

Is there an ethical limit for person’s to make autonomous choices regarding the disposition of their body? Moreover, what is an appropriate way to treat other’s bodies and parts?

Contemporary debates over ova purchases, organ selling, paid female surrogacy, and the proper scope of payment in clinical trials highlight an increasing tension over the ethics of commodification- or whether it is right to treat persons or their body parts as products to be bought or sold. This essay will discuss the ethics of commodification as it relates to the women who participate in pornographic films.

Along with abortion and homosexuality, pornography is often cited as the crème de la crème of moral issues, the formal cause of society’s eroding moral fiber.1 Of course, the issue of pornography does not only interest “religious” moralists, but also politicians, philosopher-kings, sociologists, and the like. Why is this? One possible answer is that pornography is generally divisive. It produces, on the one hand, moralists who condemn its distribution, and on the other, moralists who celebrate its availability as a testament to individual rights. The other answer is that pornography interests us because it is fundamentally connected with sex and how women are portrayed, used, and abused in the name of sex.

Consequently, the pornography debate is not over the morality of depicting sexual acts or naked body parts, but is primarily concerned with the proper role of women in sexual acts. How should she act, how should she be depicted, and what should the “ideal” sex-act look like?

Numerous moralists have articulated answers to these questions, never realizing that reflection on how women should act (or the portrayal of them) when engaging in sexual acts is itself an oppressive exercise. To suggest that women should be depicted in a “proper” way is to suggest that there is, in fact, a “proper” woman.2 It is in response to this conception of the “ideal” woman that feminist authors have argued that the central moral problem with pornography is not the type of woman it produces, but rather the type of harm it inflicts on women in society.3 Empirically, this seems to be the stance of most religious objections to pornography.

2 I mean that “moralizing” an ideal woman presupposes that there is some standard woman must be judged by.

3 Obviously, MacKinnon would not assert that pornography is a moral issue, but a “harm” issue. However, the “harm” principle is a mere moral principle, it just happens to also be universally followed in western society.

1

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This essay will focus on MacKinnon’s conception of the harm inflicted by pornography, both for women that participate in it, and the women who have their sexual, social, and physical lives defined by it. I will argue that pornography harms women because it treats women as commodities. To treat a woman or any human being as a commodity is to violate the categorical imperative to respect people as ends in themselves. Thus, pornography can be banned or regulated in so far as it seeks to prevent harm and the exploitation of persons through commodification. I will draw heavily upon the works of Elizabeth Anderson and Catharine Mackinnon to support this view from a feminist perspective.

Pornography and Society Many people would prefer not to find pornographic displays in grocery lines next to children’s candy, on large billboards littered along the highway, or among movie previews for the latest blockbuster. In effect, society and law wish that pornographers distribute their product more discreetly, so that immature and sensitive minds cannot be damaged by their presence. Parental controls, nanny nets, and federal movie ratings, provide concerned citizens with a way of minimizing the damage pornography could inflict thereby making its availability a tolerated vice. The problem is, however, that pornography, no matter how discreet, permeates society in such a way that makes it impossible for even non-consumers of pornography to escape its influence.

Catharine MacKinnon famously exclaimed that “[pornography is]…the literature of your experience, a sign of sex, sex itself ” (Mackinnon, 1993, p. 4). MacKinnon’s most devastating critique of our “pornographic” society is that pornography has become sex. She argues that pornography is sexual abuse and pornography’s protection as being “free speech” inhibits the ability of women to speak out against sexual abuse in pornography and speak out against sexual abuse in general. Moreover, MacKinnon’s suggestion that the sexual abuse in pornography has become the sexual norm for society infers that all sex is sexual abuse. 4 Pornography as Sex In what ways does pornography become sex?

MacKinnon’s arguments rest considerably on the premise that the proof is in the pictures. The depictions of women made by pornographers in film or picture “become the authority on what happened” (Mackinnon, 1993, p. 4) to the women that made them. Man’s burning desire for tangible proof is satisfied by the pictures that were made.

He views these pictures as incontrovertible evidence “of [women’s] desire and [her] consent” (Mackinnon, 1993, MacKinnon has denied that she takes this position, but a strong textual case can be made to support this claim from MacKinnon’s works on the subject.

4

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p.4) to the acts performed on her. This pictorial reality of women “acting as if they like it” (Mackinnon, 1993, p.5) convinces the man that the fulfillment of his own sexual desires and pleasure is the primary purpose for women to engage in sexual relations.

The ideal woman painted by pornography is one that generates dangerous conceptions about sexual relations.

A conception of woman as one that never denies sexual advances, one always willing to ensure the pleasure of her male partner, blinds man to women’s resistance in sex. The woman is paralyzed to deny his advances or sexual whims, for he views her as ultimately yielding to the pleasure he saw “her” experience in the videos he watched. How quickly this mindset can translate into a man’s sexual reality is a matter for psychologists, but let us assume, as MacKinnon (1993) does, that “Sooner or later, in one way or another, the consumers want to live out the pornography further in three dimensions” (p.19).

As the consumer takes his pornographic experiences into the non-diagetic world he searches for women that fit the pornographic model. The man wants a woman who exhibits the characteristics of the female subjects in pornography “a [woman] who is…aggressively passive and silent…in a word femininity” (Mackinnon, 1993, p.7).

The view of womanhood promoted by pornography is oppressive because women must live a life according to man’s examples of femininity (both passive and silent) in order to enter into any sexual relationship. Unconsciously, “women in pornography become more and more the lived archetype for women’s sexuality in men’s, hence women’s, experience” (Mackinnon, 1993, p.26). Hence, women change without even knowing it, adapting to the wants, needs, and desires of the male consumers who define her femininity. In this sense, the pornographer and his consumer no longer merely control the actions of the women in pornography, but the women in reality as well.

Is it really sex though? What defines a sex act?

Is everyone, everywhere, who engages in sexual acts “recreating” that which they saw on film? What guarantee do we have that a man who consumes pornography will map his pornographic desires onto the mattress? Harder evidence is needed. Mackinnon (1993) responds, “Pornography is masturbation material. It is used as sex. It therefore is sex” (p.17). As long as the viewing of pornography is inextricably linked to sexual acts, such as masturbation, it can in no way be separated from people’s sexual consciousness. It, in fact, forms people’s sexual consciousness; because one that lives in a society, “so saturated with pornography, what makes for sexual arousal, and the nature of sex itself…changes” (Mackinnon, 1993, p.25). What sex changes into, or takes on rather, is the pornographic images that are observed and dispersed throughout society from the moment the images were produced.

Empirically, these materials come to be the most

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abundant source of sexual education that society has. From the time that young boys find a father’s stash at a seventh grade sleepover, to the time that men first have their own personal computer, pornography continues to invade, inform, and instruct men as to what sex is. These resources are more abundant, available, and informative than anything that a parent or teacher could ever tell young men and women about sex. Moreover, pornography quickly comes to define sex for those who view it and those who don’t; for even those who don’t view pornography will be influenced by the conceptions of those who do. As pornography defines sex in the real world, and more specifically in women’s lives, what trouble lies in its commercial exchange?

Consumers and Commodities If pornography is sex, then what the pornographic consumer demands of sex is the same as what society demands of sex. The problem for feminists is that the consumer in this case is disproportionately male and thus, all sex is defined according to his standpoint. The sale of pornography entails that men commodify women thereby forcing them to act in a way that suits the man’s interest. Women must act in male’s interest because he is the consumer and she is the commodity. Elizabeth Anderson (1990) defines a commodity as a product for which “the norms of the market are appropriate for regulating its production, exchange, and enjoyment” (p.72). When one views pornography as a mere vice or offensive nuisance to society, as opposed to a destructive and oppressive force, perhaps he or she would not object to pornography being considered a commodity. However, pornography’s influence on inter-personal and sexual relations among men and women reinforces conceptions of women as commodities.

Because these conceptions are reinforced by the sale of pornographic videos and images, we should re-examine our current policy of non-regulation of the pornographic industry.

To see how conceptions of women as commodities moves from the pictorial world to reality let’s make an initial supposition that if pornography becomes sex, and pornography can be considered a “proper commodity”, then sex becomes a commodity. Moreover, when men purchase pornography, they don’t pay for the cassette or the paper it’s printed on, but rather the graphic images of women that it depicts. So, the real commodity that is purchased is the images of women engaging in sexual acts.

If these women are the commodity, then the demands and valuation of market relationships are appropriate for regulating their distribution, production, and presentation.

In other words, depictions of women in sexual relationships can be appropriately defined by market norms.

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turns the product into sex through masturbation and then “replays it in his head onto the bodies of the women… he has sex with,” (Mackinnon, 1993, p. 26) to view all women, not just the actors, as commodities. Pornography eviscerates any application of standards of dignity, responsibility, and mutual care towards women because its consumers regard women as objects of mere use. Elizabeth Anderson (1990) defines “use” as being, “the mode of valuation proper to commodities, which follows the market norms of treating things solely in accordance with the owner’s non-moral preferences” (p. 72). Thus, the consumer’s purchase and the owner’s treatment of “porn stars” requires no evaluation of her needs or desires, nor does it require that she be treated with respect. Pornography replaces moral valuations of women’s worth based on mutual human respect with market valuations of women based on their sexual use. What sort of ideas about women’s sexuality and personality does this valuation “insert into society?”

The market valuations of women’s worth that arise from man’s experience of treating them as a commodity embeds in society certain misogynistic ideas and forces upon women male conceptions of feminine sexuality. This precludes women from achieving any sort of sexual, social, or mental independence from men since “[pornography] doesn’t simply…interpret experience, it substitutes for it… [and] it stands in for reality” (Mackinnon, 1993, p.25).

The realities created by pornography and demanded by its consumers are that women are useful only as sexual objects.

Pornography presents women as being man’s “possession of an objectified other” (Mackinnon, 1993, p.29) and his subordinate in sex.

We should not be surprised by this view. When a consumer purchases his product (in this case a woman), he does so with the expectation that the product will “satisfy [his] own interest without regard for the interests of the commodities themselves” (Anderson, 1990, p. 72). If man desires that women only serve his interests, it would be prudent to require that women (in pornography and real life) act totally submissive, permissive, and silent in his use of them. All of these qualities of pornographic movies are cited by MacKinnon as being damaging to women in our society. For these “ideas” further validate and encourage the abuse of women within sexual and social relations. As these ideas make their way out of the fantasy world and into actual sexual practice, whether through masturbation or intercourse, they become dangerous for women’s liberation and equality.

“Proper” Commodities and Pornography The abuse and eradication of independence that women endure as a result of pornography stem from its treatment as a commodity. Anderson explains that we should “object to the application of a market norm to production or distribution of a good [the women depicted

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in pornography]…when the norm [fails] to value [the good] in an appropriate way” (Anderson, 1990, p.72). This is because when we fail to value a good as it should be properly valued we may exploit and abuse it without consideration of its higher value. For instance, it would be foolish and immoral for one to eat without restraint in a community that has a low food supply. The value of food to that particular community is more than just a commodity, but rather a source of survival and nutrition. To treat the food as something that is not required for survival and nutrition would fail to appreciate the food in any “appropriate” way.

The same standards apply to sex, hence pornography, for sex should be valued as something greater than a mere commodity, or means to “mere use” of a woman.

Elizabeth Anderson (1990) asserts that something is not a proper commodity if, “moral principles or ethical ideals preclude the application of market norms to a good” (p. 72).

What moral or ethical dilemmas arise from the unfettered distribution and consumption of pornographic materials?

Well, if it is true that commodities are only required to be treated according to prevailing market norms, and those commodities are human beings, then Kant’s categorical imperative to never treat persons solely as a means, has been violated. The objection is often raised that such use is acceptable insofar as both “actors” consent to use. Yet, that fulfills only part of Kant’s categorical imperative. Both agents must consent to an action and must also treat one another as a legitimate end in that action. The sexual acts in pornography neither require nor presuppose this type of interpersonal relationship. In fact, pornography only requires minimally that one person (the consumer) wishes to use the body of another towards his own personal end.

It is unethical to propagate a notion of sexual relations through media that presupposes the use of a woman as a mere means to pleasure. Distribution of pornography, then, should be strictly regulated because sexual relations and inter-personal dynamics cannot ever be appropriately expressed when subject to consumer demand and other market valuations.

Additionally, pornography made for men by men exists to provide men with the ideal woman- the woman who grants them uncontested consent. As this “idea” spreads throughout society, rape becomes unfathomable. A culture

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that accepts or tolerates this “idea” will continue to express national sympathy for accused rapists, and continuously cast doubt on the rape victim. Society should cease viewing pornography as an acceptable commodity and view it rather as a legalized harm that damages the lives of both the subjugator and the subject; altering the way in which the genders relate and respond to one another.

Conclusion Until pornography ceases to be subject to the norms of the capitalist marketplace, feminist concerns about subjugation and sexual abuse will remain. Viewing women as commodities comes at the cost of citizens viewing humans as products that can be bought and sold, rather than equal beings who are worthy of respect. One cannot view a woman as a commodity without violating the dignity of that woman. How can society claim to be respecting women as persons and not commodities when pornography enjoys widespread toleration?

The notion of respect as codified by Kant is that persons are to be used not solely as a means to an end, but always as an ends in themselves. There is no reason to believe that a culture which commodifies persons in pornography, organ selling, or surrogate motherhood can claim to be respecting persons as an ends in themselves. Moreover, any policy which commodifies persons will disproportionately harm women as they have historically been and presently are the persons who are most frequently bought and sold.

In a country where the trafficking of humans was “legally” abolished some one hundred and fifty years ago, it is frightening to think that there still remains a market which has constitutional protection for the sale of persons for profit, pleasure and labor.

Acknowledgements The author wishes to thank Lawrie Balfour, PhD, for her valuable comments and insight. Also, much thanks to Edmunda Richards for her help with syntax and structure.

References 1. Anderson, E.S. (1990). Is Women’s Labor a Commodity?

Philosophy and Public Affairs, Vol. 19, no. 1, 71-92.

2. Mackinnon, C. (1993) Only Words. Cambridge: Harvard

University Press.

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Penn Bioethics Journal Vol III, Issue i Spring 2007

Bioethics of Public Health

Globalization and Public Health: The Case of Bhopal Author: Joshua Farhadian, University of Pennsylvania Faculty Sponsor: Helen Sheehan, PhD Abstract On December 3, 1984, forty tons if methyl isocyanate (MIC) gas leaked from the Union Carbide pesticide plant located in the city of Bhopal, in the Madhya Pradesh Indian state. With over 200,000 individuals exposed to the toxic gas, the ensuing death and disability were disastrous. On the day of the leak, Indian hospitals recorded 2,850 associated deaths, with hundreds of thousands of injuries. Union Carbide blames internal sabotage as being responsible for the MIC leak; however exploitation and blatant neglect for Indian life, as well as globalization, appear to be contributing factors. In 1989, Union Carbide paid $470 million in an out-of-court settlement, yet many view the American company as not having faced sufficient justice. Over twenty-two years after the disaster, victims of Bhopal still suffer economic loss, unpaid healthcare bills, social disruption, and long term disability. The following paper presents an examination of the causes of the Bhopal disaster and analyzes its social, economic, and legal implications.

On December 3, 1984, slightly before 1:00 a.m., the most lethal industrial disaster began to unfold in Bhopal, India. While most families were asleep, the Union Carbide (UC) pesticide plant began to leak toxic methyl isocyanate (MIC) gas into the atmosphere. As the wind carried noxious fumes towards Bhopalâ&#x20AC;&#x2122;s most densely populated area, people awoke coughing, choking, and gasping for air.

Upon exiting their homes, they quickly learned the source of the whitish-green gas and ran in the opposite direction.

This decision proved fatal as the winter breeze caused the toxic cloud to keep pace with the fleeing Bhopal people.

Animals and people began collapsing to the ground, and the ensuing stampede trampled the injured and the dead.

By 2:30 AM Hamidia Hospital had received more people than it could accommodate, with most in critical condition (Vivek, 1990, p. 1-2). However, patients continued to pour in. Children vomiting blood and pregnant women stumbling to the ground and bleeding profusely were among those waiting for medical attention. Nearly 40 tons of MIC had Joshua Farhadian is a Junior at the University of Pennsylvania and is majoring in Health and Societies.

Email: joshuaAF@sas.upenn.edu Dr. Helen E. Sheehan is the faculty sponsor for this submission. She is a Lecturer of Health of Sociology in the Department of South Asia Studies and Faculty of the Health and Society Program Address: 820 Williams Hall, 36th and Spruce St., Philadelphia, PA, 19104-6305 Email: sheehanh@sas.upenn.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

been released from the UC plant and the city of Bhopal was in utter chaos (Hanna, Morehouse, & Sarangi, 2005, p.

3).

While 2,850 individuals officially died on the day of the gas leak, substantial evidence indicates that the true figure might have been closer to 5,000 deaths (Hanna, Morehouse, & Sarangi, 2005, p. 3). In addition, 10,000 individuals were critically injured, 20,000 were significantly disabled, and 180,000 were affected to minor degrees (De Grazia, 1985, p. 35-36). Exposure to MIC also caused many to develop MIC related diseases, including neurological disorders and cancer, later in life.

The Bhopal tragedy exposed to the world the potential health impact of globalization and corporate negligence.

Indiaâ&#x20AC;&#x2122;s effort to spur foreign investment, in conjunction with the western view of India as an exploitable source of wealth, serve to illustrate the health consequences developing nations often face when entering the global economy.

Causes of the Bhopal Disaster The factors which led to the release of MIC from the Union Carbide pesticide plant in Bhopal can be divided into proximal and distal causes. In the discussion that follows I will first explain the proximal cause of the leak, and then look at the broader social, political, and economic conditions in India which might have contributed to this disaster.

The most proximal cause of the MIC leak can be attributed to human lapses and a sequence of system failures. On the night of December 2, 1984, there was an irregular buildup of pressure in Tank-610, one of the three underground tanks containing MIC at the UC plant. Slightly after midnight, the tank reached its maximum pressure capacity of 40 pounds per square inch and opened a release valve on the pipeline leaving the MIC tank ruptured. The next checkpoint in the plant, which is a chemical agent (caustic soda) meant to neutralize the gas, failed. This occurred because the high pressure of the gas caused it to pass through too quickly, effectively exiting the checkpoint without ever being neutralized. The unneutralized gas then traveled up the thirty-three meter high flare tower which burns toxic gases before they are emitted into the atmosphere. However, on that night, the flare tower was under maintenance and consequently did not perform its function. The chain of safety devices also included a water hose which was intended to douse any active chemical that

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escaped through the flame tower. However, the sprays were only capable of shooting water 12-15 meters high, while the gas was escaping at thirty-three meters in the air, therefore rendering them futile. The Union Carbide Manual on MIC states that the MIC storage tank should be kept at 0 oC. However, the tanks in Bhopal were usually maintained at 20 oC and on the night of the disaster the refrigeration unit was not functioning. Recent research has indicated that the initial pressure buildup in Tank-610 was most likely caused by the ingress of water into the storage tank (Chauhan, 1996, p. 17-19).

However, this proximal cause of the Union Carbide MIC leak was actually the product of more distal factors, particularly negligence and other economic priorities. Union Carbide’s negligence at the Bhopal plant becomes most apparent when comparing the safety measures taken there, to those taken at Union Carbide’s pesticide plant in West Virginia. For example, at the UC plant in West Virginia, a 4-stage alarm system, developed in the early 1970’s, was put in place. However, the UC plant in Bhopal used a secondhand and obsolete MIC plant from Danbury, Connecticut which had been transferred along with its sub-standard safety system consisting of manual controls and only a 1-stage alarm system. In addition, the West Virginia plant had regulations which prevented the buildup of surplus MIC by converting it to an end-product that could be safely stored. But the Bhopal plant did not take such measures.

Instead, large quantities of MIC were stored in their lethal state (Chauhan, 1996, p. 19-20).

Furthermore, Union Carbide had not taken any steps to warn the authorities and citizens of Bhopal about the toxic nature of MIC and its potential hazards. As a result, emergency evacuation drills were never performed near the plant. In addition, the Fire Brigade of Bhopal was completely unaware of the toxic nature of the gas. Had they known that spraying water on MIC neutralizes it, then it is likely that many lives could have been saved. Similarly, health authorities were also in the dark about how to treat MIC poisoning. Union Carbide never informed them of antidotes that could have treated affected victims. This contributed to the uncertainty and confusion in the hospital, which increased and prolonged the intensity of human suffering (Chauhan, 1996, p. 20-21).

In an even more distal context, the Bhopal disaster can be attributed to the cost of globalization and India’s Green Revolution. The Green Revolution occurred in India during the 1960s and 1970s, and is described as the transformation of agriculture that resulted in the increase in cereal production. However, in order to bring about these changes, adequate amounts of chemical fertilizers and pesticides were needed. This was a major stimulus for the 1969 construction of the Union Carbide pesticide plant in India.

At the plant, economic pressures to produce affordable pesticides for Indian farmers often resulted in cost-cutting

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measures, such as ignorance of safety regulations. This blatant neglect of industrial safety was often overlooked by Indian officials who recognized the need to keep pesticide prices down in an effort to stimulate the Green Revolution (Brogard, 1989, p. 25-33). As a result, significant industrial safety risks were created, many of which are likely to have contributed to the MIC disaster. However, many felt that while still a tragedy, the Bhopal disaster was the price to be paid for development. For instance, the Wall Street Journal (as cited in Varma & Varma, 2005, p. 39) had noted, “of those people killed, half would not have been alive today if it weren’t for that plant and the modern health standards made possible by wide use of pesticides.” Similarly, the New Republic (as cited in Varma & Varma, 2005, p. 39) asserted that the pesticides manufactured by the UC plant saved 10 percent of India’s annual crop which was enough to feed 70 to 80 million people.

Economic and Social Impact While the Bhopal tragedy seriously affected the health of many, it also had important social, political, and economic implications. Bhopal, the capital of Madhya Pradesh, is known for its unique status in the state as being the center of politics, economic power, education, culture, and media (Chauhan, 1996, p. 45-47). However, Bhopal also has a dark side, namely areas of high poverty and squalor. In keeping with the social geographic characteristics of communities living with chemical industries, the Union Carbide plant was surrounded by some of Bhopal’s poorest neighborhoods, including Jaiprakash Nagar, Chola Kenchi, Kazi Camp, and Arif Nagar. On the night of the disaster, seventy percent of the Bhopal population exposed to MIC had been part of the unorganized working sector, earning subsistence wages through day labor or petty trade (Mathur & Morehouse, 2002, p. 70). Typical work included pushing hand carts, carrying heavy loads, digging soil, repairing cars, and other odd jobs that could no longer be pursued after exposure to MIC gas. Loss of income has driven tens of thousands of families to chronic starvation. This has led to the rise of local money lenders who charge up to 200 percent interest and make the chance of paying back low (Mathur & Morehouse, 2002, p. 70). As a result, debt keeps growing in Bhopal and the vicious cycle of rising debt and increasing starvation persists.

While many families had been completely eliminated by the MIC leak, others faced disability and large-scale suffering. The death and disability of family members have not only led to mental illness, but have also resulted in the breakdown of family relationships and added stress. Many Bhopal victims have expressed the desire to die rather than to live in misery. A father of two sons (his only male children) laments, “I keep thinking of my two dead sons.

Memories of the sons come to my mind. I find it difficult

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Penn Bioethics Journal Vol III, Issue i Spring 2007

Globalization and Public Health: The Case of Bhopal

to forget them. Who will care for us? Our life has been destroyed” (Chauhan, 1996, p. 51). Others have observed a loss of faith in God and complete personality changes (Chauhan, 1996, p. 58). One lady notes that reading the Quran used to provide her with relief, but since the MIC leak it has failed to do so. Another woman, who lost two of her four children and both of her in-laws, foresees a miserable future ahead of her and her colleagues have observed a marked change in her personality since the incident (Chauhan, 1996, p. 58). Indeed, the suddenness of the MIC leak not only resulted in large-scale grief, but also the destruction of interpersonal relationships and social order in Bhopal.

Legal Aftermath The MIC gas leak from the Union Carbide plant brought about a bitter legal battle that has persisted since 1984. As news of the Bhopal tragedy reached the United States, scores of American lawyers swarmed to Madhya Pradesh in search of a quick, albeit substantial, profit through personal injury lawsuits against Union Carbide.

However, in an effort to protect victims from unscrupulous lawyers who would exploit impoverished and illiterate Indians, the Government of India passed the Bhopal Gas Leak Disaster Act (as cited in Mathur & Morehouse, 2002, p. 72) in March 1985 which stipulated that “the government would pursue justice for and provide assistance for the victims of the disaster.” The pursuit was vigorous in the beginning and began in 1985 in the New York District Court where the Indian government successfully countered Union Carbide’s attempt to shift the blame to Union Carbide India Limited (UCIL), its Indian subsidiary which possessed far less assets and could not have been expected to pay generous victim compensation. Recognizing the inadequacy and shortcomings of the Indian legal system when it came to compensation for toxic exposure cases, the Government of India attempted to sue Union Carbide in the United States. However, Judge John Keenan, ruled that despite UCIL’s affiliation with the Union Carbide corporation, the case should be decided in the Indian courts.

In 1986, litigation began in the District Court of Bhopal and Union Carbide was ordered to pay interim relief of $270 million to the victims of the disaster (Mathur & Morehouse, 2002, p. 73). However, upon several appeals, in February 1989 Union Carbide and the Indian government agreed to a settlement of $470 million. To put this into perspective, Exxon was ordered pay $5 billion for the Valdez spill, in which no human lives were lost, while the Union Carbide payment of $470 million was to be divided among 600,000 claimants (Mathur & Morehouse, 2002, p.

73). In fact, Union Carbide’s stock price rose $2 a share on the New York Stock Exchange the day the settlement was announced.

This settlement was a major loss for the Bhopal victims Penn Bioethics Journal Vol III, issue i Spring 2007

in that it could not even cover basic medical expenses or financial losses due to disability. Only speculations can be made as to why the Supreme Court made such an abrupt decision. Some argue that the Supreme Court felt that the victims had waited long enough for financial relief. Others contend that it was a result of India’s unwillingness to discourage future foreign investment.

However, in October 1991, several victims’ groups successfully petitioned the Indian Supreme Court to overturn the original ruling which granted Union Carbide immunity from criminal charges and prevented unborn children at the time of the disaster (who had still been affected by the MIC leak) from opening litigation. The Bhopal case returned to New York in a 1999 lawsuit (cited in Mathur & Morehouse, 2002, p. 74) on behalf of the Bhopal victims, charging Union Carbide with “reckless and depraved indifference to human life.” In February 2001, Union Carbide merged with Dow Chemical. Dow Chemical subsequently argued that they could not be held accountable for the Bhopal incident, and Union Carbide argued that the entity responsible for Bhopal no longer exits. However, in November 2001, a United States federal appeals court upheld seven of fifteen complaints filed by Bhopal plaintiffs, opening the possibility that a trial might take place in the US (Mathur & Morehouse, 2002, p. 74).

In July 2003, the Indian government had for the first time sought the extradition from the United States of Warren Anderson, the CEO of Union Carbide at the time of the disaster. While the United States government has yet to oblige with India’s request, these developments indicate that the long legal battle is still not over.

Conclusion Over two decades since methyl isocyanate leaked from the Union Carbide pesticide plant in Bhopal, victims are still suffering, parties are still litigating, and the disaster’s legacy lives on. In addition to the health risks posed by the MIC leak, the social and economic impact of the disaster continues to inflict its victims. This agony is exacerbated by the legal battle which has largely proceeded to no avail. The victims of Bhopal continue to suffer with little financial support. While all arrows point towards Union Carbide as the culprit behind the Bhopal catastrophe, the United States government has rejected India’s call for the extradition of Warren Anderson to India. As the case lingers between the American and Indian court systems, it is likely that the Bhopal victims will never receive adequate reimbursement for what they encountered on the morning of December 3, 1984. The Bhopal catastrophe begs for a serious investigation into the costs of globalization and development. While the Bhopal plant produced inexpensive pesticides which facilitated India’s Green Revolution, Union Carbide’s corporate greed and India’s globalizing interests led to poor supervision of the MIC plant. As a consequence,

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human life was flagrantly neglected, resulting in death and debilitation that persists in Bhopal even today. Although the Green Revolution substantially increased India’s grain output, one must still wonder whether it was worth the loss of life that occurred that fateful night in Bhopal.

References 1. Banerjee, B. N. (1987). Environmental pollution and Bhopal

killings. Delhi: Gian Pub. House.

2. Bogard, W. (1989). The Bhopal tragedy: Language, logic, and

politics in the production of a hazard. Boulder, CO: Westview

Press.

3. Chauhan, P. S. (1996). Bhopal tragedy: Socio-legal implications.

Jaipur: Rawat Publications.

4. Cullinan, P., Acquilla, S. D., & Dhara, V. R. (1996). Long term

morbidity in survivors of the 1984 Bhopal gas leak. The National

medical journal of India, 9(1), 5-10.

5. De Grazia, A. (1985). A cloud over Bhopal: Causes,

consequences, and constructive solutions (1st ed.). Bombay; New

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York: Published by Kalos Foundation for the India-America

Committee for the Bhopal Victims: Popular Prakashan distributor.

6. Delhi Science Forum. (1984). Bhopal gas tragedy: Delhi science

forum report. New Delhi: Society for Delhi Science Forum.

7. Dhara, V. R., Dhara, R., Acquilla, S. D., & Cullinan, P. (2002).

Personal exposure and long-term health effects in survivors of the

union carbide disaster at Bhopal. Environmental health

perspectives, 110(5), 487.

8. Hanna, B., Morehouse, W., & Sarangi, S. (2005). The Bhopal

reader: Remembering twenty years of the world’s worst industrial

disaster. New York: Apex Press.

9. Mathur, C., & Morehouse, W. (2002). Twice poisoned Bhopal:

Notes on the continuing aftermath of the World’s worst industrial

disaster. International Labor and Working-Class History, 62, 69-

75.

10. Varma, D. R. (1987). Epidemiological and experimental studies

on the effects of methyl isocyanate on the course of pregnancy.

Environmental health perspectives, 72, 153-157.

11. Varma, R., & Varma, D. R. (2005). The Bhopal disaster of 1984.

Bulletin of Science, Technology & Society, 25(1), 37-45.

12. Vivek, P. S. (1990). The struggle of man against power:

Revelation of 1984 Bhopal tragedy (1st ed.). Bombay: Himalaya

Pub. House.

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Penn Bioethics Journal Vol III, Issue i Spring 2007

Bioethics of Public Health

Health Outcomes in Cuba Following the Transition Author: Katie Tuider, University of Pennsylvania Faculty Sponsor: Robert Aronowitz, PhD Abstract Rationale: Cuba is at the brink of a natural health experiment due to its imminent political transition and so it is necessary to assess what are the possible health outcomes that may result from this transition.

Background: In order to assess the possibilities of health outcomes in Cuba’s near future, this study analyzes the health outcomes of other countries during periods of transition such as Russia and Eastern bloc countries in the early 1990s.

Methods and Sources: Literature review of Pubmed, WHO website to gain background for health outcomes of Russia and Eastern bloc countries, as well as Cuba.

After the political transition in Cuba, data will be collected from MINSAP and/or directly from hospitals and clinics in Cuba. This data will be compared to Cuba’s current health outcomes.

Expected Findings: If Cuba does not have a smooth political and economic transition, the health outcomes may decline reflecting those of Russia, Hungaria and Bulgaria in the early 1990s. If Cuba does however have a smooth economic and political transition, the current positive health outcomes that exist in Cuba will remain the same or follow a similar pattern to such Eastern bloc countries as East Germany, Poland and the Czech Republic, whose life expectancies actually increased during the transition.

Limitations of Study: This study is based upon the transition of power in Cuba that is about to occur and so it is difficult to determine the nature of the transition at this point and in what direction health outcomes will go as a result of the political transition. Also, some of the health statistics from Cuba may be biased as a form of propaganda for the Cuban government.

Possible Implications: If Cuba does experience a transition similar to that of Russia in the early 1990s, it is imperative to understand what triggers caused the mortality crisis in order to prevent such an event from occurring in Cuba as well.

Cuba is at the brink of a natural health experiment due to the imminent transition of power from Fidel Castro to his successor. Currently, Castro’s brother and vice president, Raúl Castro, has assumed power since Fidel Castro’s intestinal surgery in July 2006. Considering that Raul Castro Katie Tuider is a Senior at the University of Pennsylvania and is majoring in Health and Societies.

Email: ktuider@gmail.com Dr. Robert Aronowitz is the faculty sponsor for this submission. He is an Associate Professor in the Department of History and Sociology of Science at the University of Pennsylvania Address: 325 Logan Hall, University of Pennsylvania, Philadelphia, PA, 19104 Email: aronowit@wharton.upenn.edu Penn Bioethics Journal Vol. III, Issue i Spring 2007

is 75 years old, his term as president may be short-lived.

This presents two problems: who will succeed Raúl Castro and whether this change of command will be a smooth and peaceful transition. At the eve of this transition of power, it is important to consider how the health of Cubans will be affected. Political, social and economic factors in a society are strongly correlated to the health of its citizens, and so it is necessary to draw historical comparisons of health outcomes during times of political transition in order to prevent any possible negative health outcomes in Cuba.

If the transition of political power is anything like that of Russia after the fall of the Soviet Union in 1990, there may be significant declines in health outcomes among the Cuban population. It is important to be aware of this possibility and take steps to prevent such a decline from occurring.

Background Russia and the Eastern Bloc Countries The period of transition of both political power and ideology in Russia in the late 1980s and early 1990s has been deemed a “mortality crisis” in medical literature. This is due to the significant mortality increases in Russia during the early 1990s, as well as significant increases in morbidity. In a study by Notzon et al., the direct as well as indirect causes that led to the mortality crisis in Russia during the period between 1990 and 1994 were analyzed, as well as the decline in life expectancy. From 1990 to 1994 in Russia, age-adjusted mortality rose by almost 33%. The age-adjusted male life expectancy in Russia significantly declined from 63.8 years in 1990 to 57.7 years in 1994; the female age-adjusted life expectancy also declined from 74.4 years to 71.2 during this 5-year period. The largest increases in death rates among age groups were found among those aged 35 to 44 years, who saw a nearly 100% increase (Notzon et al, 1998, pp.

793-800).

In Russia between 1990 and 1994, mortality rates for alcohol-related causes, pneumonia and influenza, and homicide increased by at least a 100%. These major causes of death were followed by diseases of the heart, which increased by 40% increase and stroke with a 20% increase. The prime factors that contributed to changes in life expectancy between 1990 and 1994 included diseases of the heart (26% of the total decline) and other injuries (18%), followed by stroke, other alcohol-related causes, homicides and suicides (Notzon et al, 1998, pp. 793-800).

There are various theories behind what factors may have led to this sudden decline in health outcomes in Russia. A consistently cited proximal factor that may have led to such a significant rise in mortality is increased alcohol

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consumption. Other factors that have been considered include impoverishment, economic and social instability, environmental pollution, increased tobacco consumption, poor nutrition, deterioration in health services, depression and psychosocial stress arising from the pace of change.

Some studies such as Leon et al. as well as a study by Shkolnikov et al. found that alcohol is the prime culprit for the rise is mortality. Shkolnikov et al. measured alcohol consumption in Russia using the Russia Longitudinal Monitoring Surveyâ&#x20AC;&#x201D;a household survey conducted eight times between 1992 and 1999. The results of this survey showed an increase in alcohol consumption in the early 1990s. The obvious association between alcohol and the increase in mortality is the link between heavy drinking and acute alcohol poisoning and cirrhosis. Alcohol can also be linked with various injuries including homicide and suicide. In terms of respiratory diseases, the Shkolnikov et al. study found a significant correlation between alcohol and pneumonia. The link between alcohol and cerebrovascular disease is multifaceted because there appears to be a positive correlation between alcohol consumption and haemorrhagic stroke, but there is little relation between alcohol consumption and ischemic stroke. For cardiovascular disease, alcohol appears to have a protective effect, with the exception of ischemic heart disease, which when associated with binge drinking has resulted in an increase in deaths (Shkolnikov et al, 2001, pp. 917-921).

Leon et al. also used the Russia Longitudinal Monitoring Survey to measure alcohol consumption in Russia during the early 1990s and had similar findings as Shkolnikov et al (Leon & Chenet, 1997, p. 383).

Various other causes, both proximal and distal, have been cited as possible causes of the mortality crisis.

Economic and social instability and the poverty that resulted are linked with the rising levels of homicide and suicide in Russia, as well as the increase in alcohol consumption (Notzon et al, 1998, pp. 793-800). Increased smoking is another factor that may have led to the mortality increase, but there is lack of evidence as to whether an increase in smoking actually led to increased mortality between 1990 and1994 in Russia. In terms of diet, there was a decrease in the consumption of fresh fruits and vegetables since 1990; however there also has been a reduction in the percentage of energy derived from fat. Overall, there is little reliable data to support any correlation between nutrition and increased mortality. In a study by Walberg et al., the rapid pace of change, especially related to employment is cited as a psychological trigger for the mortality crisis (Walberg et al, 1998, pp. 312-318). This may be a valid contributor considering that those age groups most affected by the mortality crisis were of working-age In order to create a more complete picture of the effects of political and economic transition on health outcomes, it is relevant to look at the health outcomes in the early 1990s

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of other Eastern bloc countries in transition. Romania and Bulgaria had similar health outcomes as Russia in the transition period in the early 1990s. Romania in the period between 1990 and 1996 experienced a general decrease in life expectancy of 1.71 years in men and 0.54 in women.

Major contributing factors to this decline include increases in mortality from cardiovascular diseases and diseases of the digestive system among the middle aged and elderly. The crude death rate in Romania increased from 10.7 deaths per 1000 in 1989 to 11.7 deaths per 1000 in 1994 (Adeyi et al, 1997, pp. 132-45). The main proximal factor contributing to the mortality increase was alcohol consumption, which led to Romania having one of the highest death rates from cirrhosis in Europe, besides Hungary and Moldova.

Although there are no significant data sources to measure alcohol consumption in Romania in the 1990s, the 60% rise in death rate among men from chronic liver disease and cirrhosis between 1990 and 1996 provides a significant link between alcohol consumption and mortality (Dolea et al, 2002, pp. 444-449). Other factors cited include smoking habits and nutrition, but the findings were inconclusive in terms of the effects these factors played on the mortality increase in the early 1990s in Romania. Romania also saw a 16.5% increase in its suicide rate during the period of 1989-1994, which may have resulted from a combination socio-political factors during its transition (Mäkinen, 2000, pp. 1405-1420).

During the early 1990s, Bulgaria had similar health outcomes as Romania with a decline in life expectancy that began in the late 1980s and continued into the early 1990s.

In 1989, Bulgaria had a life expectancy of 71.3 years and by 1994, it had declined by 0.6% to 70.9 years. The crude death rate in Bulgaria increased from 11.9 deaths per 1000 in 1989 to 13.2 deaths per 1000 in 1994 (Adeyi et al, 1997, pp.

132-145). Some of the major factors that led to increased mortality in Bulgaria were diseases of the circulatory system, ischemic heart disease and cerebro-vascular disease (in descending order). The continual decline in life expectancy in the 1990s in both Romania and Bulgaria can be partly attributed to the economic stagnation experienced in those countries (Dolea et al, 2002, pp. 444-449).

Not all Eastern bloc countries experienced the same negative health outcomes as Russia, Romania and Bulgaria.

The Czech Republic, Poland and East Germany (former GDR) are among the Eastern bloc countries that actually experienced an increase in life expectancy during the 1990s.

In the Czech Republic, life expectancy increased by 1.5 years from 71.8 in 1989 to 72.9 in 1993 (Adeyi et al, 1997, pp. 132145). The crude death rate in the Czech Republic decreased from 12.3 deaths per 1000 in 1989 to 11.4 deaths per 1000 in 1993 (Ibid.). Between 1991/92 and 1996/97, male life expectancy at birth increased by 2.4 years in the former GDR, 1.2 years in old Federal Republic, and 2.0 years in Poland (women: 2.3, 0.9, and 1.2 years). Granted the GDR

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Health Outcomes in Cuba Following the Transition

For example in the U.K., which also has universal health care coverage, the physician to civilian ratio is 1:434.78.

Cuba’s health care system is especially impressive considering how grave its economic situation has been since the 1990s. After the collapse of the Soviet Union, the small island country could no longer depend on the trade and monetary support from the U.S.S.R. that it had relied on for many years, so Cuba experienced a severe economic crisis (called the “Período Especial en Tiempo de Paz” by Castro) (Hemmes, 1994, pp. 52-54). The Cuban government took action by strictly rationing food and petrol, but despite careful control, the standard of living in Cuba fell. For example, the limited food supply led to nutritional deficiency, causing a neuropathy epidemic in the early ‘90s (Lloyd-Sherlock, 2000). This period of economic decline also contributed to the deterioration of health facilities and equipment. During this period, the otherwise egalitarian Cuban health care system gave priority to women and children. Thus, the demographic group of those over sixty-five years of age suffered setbacks during the hard times that befell Cuba (Ibid.).

The current health statistics in Cuba are exemplary, with mortality and life expectancy rates ranking among the bestperforming developed countries. In fact, the life expectancy Cuba’s Current Health Status in Cuba is the same as that of the U.S.: both Cuba and the Health care was nationalized in Cuba after the revolution U.S.’s life expectancy are 75 years for men and 80 for women in 1959 (Brebrick et al, 2005, pp. 297-303). The communist (World Health Organization, 2007). The major leading g o v e r n m e n t ’s causes of death in legitimacy lies in its Cuba as of 2002 are ability to improve diseases of the heart accounting for 26% Cuban citizens’ quality of life, and of the mortality rate, cancer at 21%, stroke health care outcomes did dramatically at 10%, influenza/ pneumonia at improve in the decades following the 9% and accidents Communist takeover. accounting for 6% The government of of the mortality rate (Table 1) (Cooper Cuba has focused on providing access e t a l , 2 0 0 6 , p p.

94-101). Other to health care to every Cuban citizen health indicators (Feinsilver, 1993, p. valuable for future 162), including those comparison are the *Cooper, et al, 2006, p. 101. in remote, rural areas, ag e-standardized and it has achieved mortality rate for enormous success. The country has built up a notable non-communicable diseases, which is 435.0 (per 100,000) system with a clinic in each community and specialty as of 2002. Also relevant is the age-standardized mortality clinics, hospitals and institutions strategically located for rate for cardiovascular diseases which is 214.8 (per 100,000) referrals, meaning that today, no Cuban lives farther than as of 2002. The age-standardized mortality rate for injuries 600 yards away from a physician (Brebrick et al, 2005, pp. (per 100,000) is 53.6 (World Health Organization, 2007).

297-303). Currently, the physician to civilian ratio is about Each of these health indicators may prove to be useful 1 : 169.20 (World Health Organization, 2006), though many in order to determine if there are fluctuations in health outcomes after Cuba’s political transition considering that contend that the number of doctors in Cuba is excessive.

and Poland experienced a period of worsening mortality at the beginning of the 1990s, but by 1993, both had returned to 1988/89 levels of mortality by 1993. Between the years 1989-1994, Poland saw a 0.8% increase in life expectancy from 71.1 years to 71.7 years. An exception to the improved mortality in East Germany and Poland is the increase in deaths from diseases of the digestive system, such as liver cirrhosis. There was an 18% increase in cirrhosis in East German men and 14% in women, and a 14% increase in men and 5% increase among women in Poland. Possible reasons for improved mortality in East Germany may be due to a number of factors including improved diet due to the decreased intake of animal fat and the increased consumption of fruits and vegetables. Other risk factors such as the prevalence of hypertension decreased by 5% to 25% among East German women aged 25-64 years between the early 1980s and early 1990s. Smoking prevalence among men in East Germany decreased during this time period as well. Improved medical care in East Germany is also a factor in the improved mortality statistics. All of these factors contributed to the overall decrease in cardiovascular mortality in East Germany during the early 1990s (Nolte et al, 2000, pp. 899-906).

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non-communicable and cardiovascular diseases as well as injuries had a considerable impact on the mortality crisis in Eastern Europe during the 1990s.

Methods and Findings In order to gain a greater understanding of the health situation in Russia and the Eastern Bloc countries in the early 1990s, as well as the current health status of Cuba, an extensive literature review was conducted on Pubmed and the WHO website. The health status in Russia as well as the Eastern bloc countries was determined by comparing the life expectancies of men and women from 1989 to 1993/1994. Also mortality data from the period of 1989 to 1993/1994 from each country was analyzed. To gain a greater understanding of the changes in life expectancies and mortality data in each country, major causes of death were singled out. In general, the major contributors to the increased mortality in Russia and the Eastern bloc countries were diseases of the circulatory system, ischemic heart disease and cerebro-vascular disease. These diseases, as well as others contributing to the mortality crisis, were positively correlated with alcohol consumption.

With respect to Cuba, a literature review of Pubmed, WHO website and various health-related books was conducted to order to assess of the status of Cuban health care today and the health outcomes associated with it.

There also was an emphasis placed on the life expectancies of males and females and mortality data, as well as the major causes behind the mortality data in order to draw comparisons between Russia and other Eastern bloc countries’ health status prior to the transition.

Once the political transition takes place in Cuba, data will be collected from MINSAP (Ministerio de Salud Pública de Cuba or The Ministry of Public Health of Cuba) in order to assess whether there have been any changes in health outcomes. If the transition is particularly tumultuous, it may be necessary to retrieve health statistics directly from hospitals and clinics because MINSAP may not be able to provide accurate and up to date health statistics in a period of chaos. Diseases of the circulatory system, ischemic heart disease and cerebro-vascular disease should be monitored closely as they were the greatest contributors to the mortality crisis in Eastern Europe in the early 1990s.

Other causes of mortality that will be monitored are injuries including homicide and suicide, as well as increased cases of influenza and pneumonia. Also risk factors such as smoking and alcohol consumption along with diet will also be areas of focus.

Expected Findings The expected findings are contingent upon the nature of the political transition in Cuba. If the political, as well as economic transition is fluid, Cuba’s currently impressive health outcomes will presumably remain about

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the same or improve. If Cuba’s transition of political power is revolutionary, the health outcomes could suffer tremendously. This is certainly a possibly considering that the U.S. government and hard-line anti-Castro groups in the U.S. are invested in a change of political ideology in Cuba.

In the near future, Cuba will either continue with its socialist ideology with Raul Castro or another replacement, or it will undergo a drastic political and economic transition towards democracy. Both outcomes have serious implications for the health of Cubans. Whether the transition from Fidel Castro’s term results in a different leader of socialism or democracy, there is still a possibility that either transition will be difficult considering that Castro has been in power for over 40 years. Countries such as Russia, Romania and Bulgaria during the political and economic transitions of the early 1990s provide examples of the negative health outcomes that may result in Cuba. Alcoholism, crime, diseases of the circulatory system, ischemic heart disease and cerebro-vascular disease are among these negative health outcomes.

Cubans’ health may also experience very little health effects or even improved health effects following the transition. The Czech Republic, Poland and East Germany (former GDR) provide examples of countries that underwent drastic political and economic changes in the early 1990s, but managed to make positive transitions so that their health outcomes did not suffer. This may be the case in Cuba considering that it is currently able to achieve impressive health outcomes with little resources.

Limitations of the Study This study is based upon the transition of power in Cuba that is about to occur and so it is difficult to determine the nature of the transition at this point and in what direction health outcomes will go as a result of the political transition. If the transition is not smooth, collecting posttransition data may be difficult. MINSAP may not provide accurate and up to date during this period, and so data collection may be on a smaller scale. A smaller sample group comes with limitations such as ecological fallacy. Also, some of the current health statistics from Cuba may be biased as a form of propaganda for the Cuban government. If this is the case, it is difficult to make an accurate comparison of possible increases in mortality that will occur after the transition in Cuba.

The causes of increased mortality in Eastern Europe during the transition in the early 1990s may differ from those of Cuba today. This study will focus on particular health indicators in Cuba based on the health outcomes that led to the mortality crisis in Russia and the Eastern bloc counties, but it is important to be aware of other changes responsible for a possible mortality increase in Cuba, such as growing rates of HIV/AIDS and cancer.

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Health Outcomes in Cuba Following the Transition

Possible Implications If Cuba does experience a transition similar to that of Russia in the early 1990s, it is imperative to understand what triggers caused the mortality crisis in order to prevent such an event from occurring in Cuba as well. Based on Russia’s health outcomes in the early 1990s, it is important to monitor the causes of mortality that are most vulnerable to change, such as cardiovascular disease, injuries and cerebro-vascular disease. Other causes of mortality that deserve attentions are increases in injuries including homicide and suicide, as well as increased cases of influenza and pneumonia. This assumption is based upon the major causes of mortality during Russia and Eastern Bloc countries’ transitions.

Also risk factors such as increased tobacco and alcohol consumption, as well as stress levels would be worth monitoring in order to preempt any increases in these risk factors with public health campaigns.

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