Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Islamic ethics and war
- Kamyar M. Hedayat, MD (11 April 2003)
-
Images of war - the other side
- Syed M H Rizvi (11 April 2003)
-
Images of war must be shown
- Izhar H Khan (12 April 2003)
-
Shallow Criticism
- Thomas E. Radecki (12 April 2003)
-
Difficult act to balance
- Asad J. Raja (14 April 2003)
-
The guilty must be forced to see
- Christopher J Burns-Cox, GL53 7AN (14 April 2003)
-
Re: Islamic ethics and war
- Jerome A. Singh, Tania L. DePellegrin (14 April 2003)
-
Re: Images of war - the other side
- Jerome A. Singh, Tania L. DePellegrin (14 April 2003)
-
Re: Images of war must be shown
- Jerome A. Singh, Tania L. DePellegrin (14 April 2003)
-
Re: Shallow Criticism
- Jerome A. Singh, Tania L. DePellegrin (14 April 2003)
-
Re: Re: Islamic ethics and war
- Syed Rizvi (18 April 2003)
-
Double standards?
- Dr RS Khan (20 April 2003)
-
Photographing patients in foreign-donor funded hospitals
- Stephen Gichuhi (30 May 2003)
-
Filming in Times of War and Peace: Ethical Guidelines
- Dr. Michael S. Goldrich (26 July 2003)
|
|
|||
|
Kamyar M. Hedayat, MD, Fellow, Pediatric Critical Care Packard Children's Hospital, Stanford University, Palo Alto, CA 94304
Send response to journal:
|
Dear Sir: Singh and DePellegrin in their editorial, "Images of war and medical ethics" BMJ 2003; 326: 774-775 assume that physicians have a more or less similar standard of ethics across the world. In Islam, as in secular ethical systems, there is great emphasis on respect for and integrity of the human body, privacy, confidentiality and patient consent. However, Islamic ethics is girded by a committment to communalism and the notion that societies are not simply the sum of its individuals, but something greater. The family, not the individual, is the basic unit of society. Consequently, when there is a conflict of interest between the society and the individual, the interests of the society take precedence. In the case of Iraq, in the event that there had been a prolonged seige or urban battle for Baghdad, a graphic demonstration of civilian casualities could have altered international opinion and put pressure on the US and British forces to discontinue certain aspects of their bombing campaign--such as cluster bombs and "bunker busters" in dense urban areas, saving the lives of countless civilians. Hence, the exigencies of the moment required a possible compromise of an individual patient's privacy for the safety of the society as a whole. Physicians must continue to maintian high ethical standards in peace and war. However, as we have seen with the anarchy that has now broken out in many cities in Iraq, where hospitals are being looted (as of this writing, April 10, 2003), the primacy of a stable order and the interests of the society as a whole became very clear. It could be equally argued that the tendency of the US and British media to avoid showing civilian casualities prolonged the war and made the use of indiscriminate destruction and killing (by Allied forces) more palatable politically for their domestic audiences. Competing interests: None declared |
|||
|
|
|||
|
Syed M H Rizvi, SpR St. Mary's Hospital, W2 1NY
Send response to journal:
|
Dear Sir, In their article 'Images of war and medical ethics' Mr. Singh and Ms. DePellegrin have taken a very one sided view of the whole picture. They have left quite a lot to be said. Under many circumstances, one example is when the patient is non- compos mentis or unable to judge what is best for him/her, if the physician in-charge feels that what he/she is doing would benefit the patient, then they have the freedom to do so. It is a huge responsibility, but if carried in a just way, it can be a life saver. I would back this point with the example of the young boy, who has recently been the centre of much sympathy, who lost his limbs besides other injuries and has lost much of his family. Many organizations are now arranging aid for his treatment. Would it have been possible if the horrible images of his injured body were not portrayed? The same gory images that were repelling and too gruesome to show in one instance become an instrument of drawing symphathy for someone who genuinely needs it. Secondly, in many instances of teaching in medicine, if the identity of the patient is not disclosed by what is revealed, and the person using it sincerely believes that those images would not, in any way, adversely affect the well being of his/her patient then they are allowed to do so. One instance is using radiographs/histology slides etc. in teaching. Photographers may wish to keep that in mind while filming. In a similar light, one can consider the following argument. Is the awareness of the global community and subsequently the bringing to justice of those responsible for war crimes a larger moral issue or the way this is done? If it were not the public awareness of the crimes during countless other wars how would the people responsible have been brought to justice. One of the desired values in a 'civilised society' is the implementation of justice. To help to establish this is a value worthy of praise. To view images, which in most instances are not doing any adverse effect to the victims, is only to be aware of the effect of wars we rage. (Would the many dead in Nagasaki or Hiroshima object?) Why are we not responsible enough, after two world wars and many others, to take a stance against it? whatever and whosoever be the cause? or are our 'democracies' not effective? Another minor point might be that not all such pictures taken are in hospitals, and if they are then a doctor is not neccesarily there at all times? Also, during a war, it would not be an exaggeration to say that at most times the medical staff in general would be overworked, understress and focussing on more important issues that trying to keep the press out. The press on the other hand are notorious for stubbornly chasing what they want...the paparazzi ring a bell?? I am all for respecting consent and privacy of patients at all times, but don't special occasions call for special rules? Competing interests: None declared |
|||
|
|
|||
|
Izhar H Khan, Consultant renal physician Aberdeen Royal Hospitals AB25 2ZD
Send response to journal:
|
In Islam, life and death are like a continuum. These images must be shown for people to appreciate the full horrors of the US/UK aggression. The hard pressed low resourced doctors do not have the luxury to reflect and discuss your fine ethical points. Al-Jazeera is to be commended. Where were the ethicists when pictures of Halabja victims were shown. There should be a limit to the Western media's double standards. Dr Izhar Khan MD FRCP Consultant Nephrologist/Physician Tel 01224 552122/553536/554639 Fax 01224 551134 Competing interests: None declared |
|||
|
|
|||
|
Thomas E. Radecki, Research Director, Doctors & Lawyers for a Drug Free Youth 61801
Send response to journal:
|
For an Englishman and a Canadian to attack an Arab TV station for showing the hideous maiming and death being caused by a clearly illegal and immoral British-American invasion of a poor third world country is the height of audacity. And then to compare the coverage as an ethical violation similar to those of Nazi Germany and apartheid South Africa adds injury to insult. I know of no evidence that the Iraqi government was forcing the families of these tragic victims to allow Al-Jazeera to film the scenes. For all we know, the families had given their consent. In fact, I think that the large majority of families of victims of any nationality in a similar situation would be happy to expose to the world the brutality of aggressors on their families members or themselves. Just because they didn't fill out the proper form approved by the proper British or Canadian "ethics" department is no reason to complain. It will be a long time before England will stand on any high ground from which to lecture the rest of the world about ethics. Where are the weapons of mass destruction? What imminent threat was Iraq to England? Iraq cooperates with the U.N. and destroys even 60 missiles that questionably violated the guidelines, only to have Blair, Britain, and Australia invade their country against the will of the U.N. Security Council. Bush was planning all along to attack no matter what Iraq did and Blair must have known this. Almost everyone else did. The U.S. government treated Saddam as an ally when he illegally attacked Iran and even after Saddam gassed the Kurds in 1988, including giving Saddam's government a loan of over $1 billion in 1989. Rather than condemn Al-Jazeera for being like Nazi Germany, what the authors should have done is to help develop guidelines to encourage and facilitate the pictures of maimed and murdered civilian and enemy soldiers on English, Canadian, and American TV. Rather, what was unethical about the news coverage were the numerous sanitized TV portrayals of the British and American killing machines "taking out" enemy soldiers, the "shock and awe". While U.S. and British soldiers were treated as great heroes, Iraqi young men defending their country from an illegal invasion have been treated as of little importance by most British news outlets. I fear that Singh and DePellegrin have had their vision clouded by "patriotism" a lot more than they realize. Al-Jazeera provided the best and most honest TV coverage of the war. The U.S., Britain, and Australia and their media outlets are the ones who need an ethics check. Competing interests: None declared |
|||
|
|
|||
|
Asad J. Raja, Associate Professor, Department of Surgery, The Aga Khan University Stadium Road, Karachi, Pakistan - 74800
Send response to journal:
|
Singh and DePellegrin are too narrowly focused on the western notions of bioethics. According to them, “doctors who permit footage of this nature to be captured fail in their legal and ethical duty to protect their patients.” Bioethical code may not be different around the world but it has to be certainly contextual. Preaching to the doctors not to allow filming of war injured without consent is adding further insult to their injuries. Is the value of confidentiality and privacy more at stake here or the issues of justice and human rights? Would it be ethical for the doctors to censor the plight of civilian victims of war? When in public health hazard the individual rights can be usurped for the benefit of larger community; why in a war where there is danger to millions should individual rights be so sacred? Especially when the intentions are different; and moreover the individual identity could be easily concealed by long shorts or excluding the faces, thus respecting the rights of individual patients. In this day and age it is equally crucial to win the war on the electronic front as it is to win on the battle ground. There are special breeds of “embedded” journalists who are showing what they want the world to see. Not surprisingly the scenes the west sees in the backdrop of upbeat music, is of a marching army amongst the fallen defending soldiers, with the deafening blitz of heavy artillery and the roar of rolling armor, as liberators of a sovereign state. There are other journalists who are braving it out where the Daisy cutters, Bunker busters, Tomahawks and other Cruise missiles are raining relentlessly day in and day out. Should they show the fire works and illuminations on the skies or the causalities of war? I wonder as a doctor working in these conditions would it not be ethical for me to allow the world to see the horrific images of war. The realities of war are bitter and the realization of it necessary and absolute. Ethically it is equally important to try to stop or prevent such catastrophe as it is to treat war victims with respect. Competing interests: None declared |
|||
|
|
|||
|
Christopher J Burns-Cox, Locum Cons.Physician Gloucestershire Hospitals, GL53 7AN
Send response to journal:
|
It is absolutely mandatory that the results of evil and cruelty committed should be forcibly shown to those responsible. This is particularly so in distant countries. In the present war we started in Iraq, the perpetrators ie the US and UK citizens who voted for the governments responsible for the killing and maiming, must be shown the results of their governments' behaviour. Only when given the information, visual or statistical, can we assess whether to rise up and shout NO to such ghastly and unjustified violence. We deserve to be exposed to the Horror. It is obviously right even in these extreme circumstances to ask the wounded or family member for permission to publish if at all possible. Could patients be anonymised? There is scope for further discussion on this but in the mean time - Thank goodness for Al-Jazeera and the Guardian! Competing interests: None declared |
|||
|
|
|||
|
Jerome A. Singh, author Toronto, Tania L. DePellegrin
Send response to journal:
|
Hedavat is correct in saying that medical ethics are not necessarily the same throughout the world. However, in times of war societal interests are difficult to determine. The rest of Hedavat’s response is political in nature and does not speak to the contents of our paper. Jerome A. Singh and Tania L. DePellegrin
Competing interests: None declared |
|||
|
|
|||
|
Jerome A. Singh, Author Toronto, Tania L. DePellegrin
Send response to journal:
|
Rizvi is correct in saying that when a patient is comatose, a physician must act in that patient’s best interest, even if no consent was given. However, this applies only when an emergency procedure is necessary and no surrogate decision-maker is present. This role does not extend to giving consent for the patient’s image to be captured without explicit authority from the patient to do so. Images of patients are often shown for teaching purposes. However, disclosing identifiable images of patients without consent is libelous and ethically unacceptable. The motive for doing so is irrelevant. We agree that physicians may be overwhelmed by a high number of casualties during a crisis. However, this does make a neglect of their ethical duties acceptable or justifiable. To say: “special occasions call for special rules” is to advocate for a dangerous precedent. The rest of Rizvi’s reply is politically-charged and does not speak to the contents of our paper. Jerome A. Singh and Tania. L. DePellegrin
Competing interests: None declared |
|||
|
|
|||
|
Jerome A. Singh, Author Toronto, Tania L. DePellegrin
Send response to journal:
|
Our paper states that the rights and views of patients should be respected if their images are to be captured. It clearly states that they should not be forgotten or disregarded during a war. Patient views are surely not irrelevant or meaningless. Saying so would be taking paternalism to a new extreme. We do not say that patient images should NEVER be captured. We say that patient permission should at least be sought BEFORE their images are captured. This would be showing true respect to them. If a patient agrees, then we support a news organization showing their images. We agree with Khan that under-resourced physicians may not have the luxury to reflect on "fine ethical points". However, this does not mean that they should not do so. This is also why we believe that international law should assist in this regard by providing clear guidance on the matter, one way or another. Lastly, our article is not meant to be a personal criticism of al- Jazeera. Our position would be the same regardless of the news source. Jerome A. Singh and Tania L. DePellegrin
Competing interests: None declared |
|||
|
|
|||
|
Jerome A. Singh, Author Toronto, Tania L. DePellegrin
Send response to journal:
|
Radecki’s reply to our paper merits a response as it is a gross misinterpretation of our work. To begin, our paper is written by a South African and Canadian. Our paper is not a personal attack on any one particular media source. Our position would have been the same regardless of the geographic base of the news station. Our reference to Nazi Germany and apartheid South Africa are examples of pressure that can be brought to bear on physicians and has nothing to do with the media coverage of those times. Our commentary speaks to medical ethics – not media ethics. Our paper focuses on the ethics of physicians, not camera operators. We do not state that the Iraqi government forced families to be filmed. Our commentary clearly states that if patients consent to have their images captured then it is ethically acceptable. The rest of Radecki’s response is politically-charged and does not speak to the contents of our paper. Jerome A. Singh and Tania L. DePellegrin
Competing interests: None declared |
|||
|
|
|||
|
Syed Rizvi, SpR St. Mary's Hospital W2
Send response to journal:
|
Dear Sir, I agree with Singh in that the patients consent should be taken and that it is a gross violation of medical ethics if this is not done. My only point is that there is always a reason for any policy or law to be endorsed and usually it deals with a specified circumstance. But there are occasions when has to take a look at the bigger picture and decide what is the greater 'right' or 'wrong'. Ethics on any one issue cannot be viewed or endorsed in isolation. That most of us choose to consider our little worlds in isolation is reflected in the fabric of our nations/states. In the end it is a question of ethics and morals, but on a larger scale. If we use these principles while exercising franchise, then such occasions which raise these questions would never arise. That is our larger responsibility. There is always a 'right' or 'wrong' but honest introspection will, almost always, show the way forward. It is the person taking the decision whose integrity is reflected in how the law/ethic is used. In that light I'd amend my statement and say, 'special circumstance calls for special measures taken by special people' Just one more thing to think about... Would Abbas - The young boy, who is now being treated in Kuwait be there if it were not for the public awareness that was generated by the media coverage? Did it hurt/harm/endanger anyone? I'm sure there are many more who would stand to benefit and none of the people filmed would protest against the medium that provides them the help. Sincerely Syed Rizvi Competing interests: None declared |
|||
|
|
|||
|
Dr RS Khan, SpR 74600
Send response to journal:
|
I am curious to know whether the authers condone the media/TV view as they tried to sell the world "an antiseptic war, one in which there were no torn and bleeding victims . We all come across articles & photographs in the press & popular political magazines in the west with dead/traumatized people. Politicians visiting the sick & wounded e.t.c is often shown in the press . Is consent taken from these individuals & are they informed that they are about to be a part of such a propaganda stunt.Did anyone ask these people for their consent ? Had it not been for these very images we would have faught countless wars by now . At least these images will prick the conscience of the people who have started the war. Were the people of Iraq asked whether they wanted to be liberated or not ? Please instead of targeting Doctors & other Health profesionals about Ethics It is the Onus of responsible journalism, to draw the line to the extent acceptable & to avoid double standards. Hurrah for Al-Jazzeera at least they were able to show both sides of the issue. Can the same be said of other Western Channels? Competing interests: None declared |
|||
|
|
|||
|
Stephen Gichuhi, Lecturer, Dept. of Ophthalmology University of Nairobi
Send response to journal:
|
I fully agree with the concerns of these two authors for the welfare of patients. However confidentiality should not be used as an excuse for allowing unjustified wars or political dictatorship. An interesting parallel exists in Africa. Many hospitals are built or supported to some measure by foreign donors especially non-governmental development organizations (NGOs). These organizations and/or their representatives have a notorious habit of walking in and freely taking photos of the "fortunate" patients and the healthworkers who look after them without taking consent. The local people are supposed to appreciate and realise that were it not for the donors the hospital would be non-existent. Sometimes these photos and footage is allegedly used for fundraising. As we rightly frown upon drug companies for compromising doctors, we should not forget NGOs that work in developing countries. Competing interests: None declared |
|||
|
|
|||
|
Dr. Michael S. Goldrich, Chair, Council on Ethical and Judicial Affairs American Medical Association, Chicago IL 60610
Send response to journal:
|
In “Images of war and medical ethics: Physicians should not permit filming of their patients without consent” (BMJ vol. 326, April 12, 2003), Singh and DePellegrin highlight the ethical dilemmas physicians encounter when patients are filmed. The Council on Ethical and Judicial Affairs (CEJA) of the American Medical Association (AMA) strongly supports their condemnation of filming war-affected patients without their consent. The medical profession must preserve the ethical tenets of privacy, patient confidentiality, and consent whether in times of war or peace. It is of particular concern to CEJA, however, that ethical lapses in filming may occur often during the provision of ordinary patient care. In this regard, CEJA recently established ethical guidelines regarding the filming of patients. (1)(2) The use of graphic images associated with war by Al-Jazeera news was not intended for medical purposes but rather as a commercial endeavor. In this context, CEJA has determined that physicians should not permit filming without a patient’s prior consent. (1) When medical education is the purpose of filming, however, there are certain circumstances (i.e. emergency trauma cases, unidentified infectious diseases) in which a valuable educational benefit may be lost if filming does not occur. Therefore, CEJA has provided that in limited circumstances, it may be permissible for physicians to allow filming to proceed without the prior consent of the patient, but consent must be obtained prior to using the film for educational purposes. (2) This distinction between educational and commercial filming is based on the premise that filming for educational purposes is conducted by health care professionals, who ethically are required to protect patient privacy and the confidentiality of patient information. Along with Singh and DePellegrin, CEJA recognizes that pressures may be placed upon physicians to compromise their commitment to ethics and professionalism. However, it is only by keeping their patients’ best interest as their paramount concern that physicians will preserve the integrity of their professional relationships with patients and continue to earn the public’s trust. References: (1) Opinion 5.045 “Filming Patients in Health Care Settings.” American Medical Association’s Code of Medical Ethics. 2002-2003 edition. (2) Council on Ethical and Judicial Affairs Report. “Filming Patients for Educational Purposes.” American Medical Association Annual Meeting (June 2003); Chicago, IL. Competing interests: None declared |
|||