JDN_17NL_MedicalEthics_Mar2020

JUNIOR DOCTORS
NETWORK
empowering young physicians to work together towards a healthier
world through advocacy, education, and international collaboration
Published by the Junior Doctors Network of the World Medical Association
The information, perspectives, and opinions expressed in this publication do not
necessarily reflect those of the World Medical Association or the Junior Doctors
Network. WMA and WMA-JDN do not assume any legal liability or responsibility
for the accuracy, completeness or usefulness of any information presented.
Junior Doctors Network Newsletter
Issue 17
March 2020
ISSN (print) 2415-1122
ISSN (online) 2312-220X
Junior Doctors Leadership 2019−2020
Junior Doctors Network Newsletter
Issue 17
March 2020
Dr Audrey Fontaine
France
Dr Yassen Tcholakov
Canada
Dr Julie Bacqué
France
Dr Christian Kraef
Denmark
Dr Uchechukwu
Arum
Nigeria
Dr Lwando Maki
South Africa
Dr Helena Chapman
Dominican Republic
Dr Lyndah Kemunto
Kenya
Dr Maki Okamoto
Japan
Dr Chukwuma
Oraegbunam
Nigeria
CHAIR
DEPUTY
CHAIR
SECRETARY
SOCIO-MEDICAL
AFFAIRS
OFFICER
EDUCATION
DIRECTOR
MEDICAL
ETHICS
OFFICER
MEMBERSHIP
DIRECTOR
PUBLICATIONS
DIRECTOR
COMMUNICATIONS
DIRECTOR
IMMEDIATE
PAST
CHAIR
Page 2
Dr Mariam Parwaiz
New Zealand
Dr Nneka Okafor
Nigeria
Dr Vandrome Nakundi
Kakonga
Democratic Republic
Dr Ricardo Correa
United States
Dr Victor Animasahun
Nigeria
Junior Doctors Network Newsletter
Issue 17
March 2020
Editorial Team 2019−2020
Page 3
Table of Contents
TEAM OF OFFICIALS’ CONTRIBUTIONS
06 Words from the Chair
By Dr Audrey FONTAINE (France)
07 Words from the Medical Ethics Working Group Chair
By Dr Lwando MAKI (South Africa)
08 Words from the Medical Ethics Working Group Project Lead
By Dr Aashish KUMAR SINGH (India)
09 Words from the Publications Director
By Dr Helena CHAPMAN (Dominican Republic)
JUNIOR DOCTORS’ PERSPECTIVES
AFRICA
10 Worker Health: The Priority in the Workplace
By Dr Lwando MAKI (South Africa)
AMERICAS
13 Termination of Pregnancy and Conscientious Objection: A Confrontation between
Science and Beliefs
By Dr Jeazul Ponce (Mexico)
17 Clinical Practice Guidelines: Exploring the “Knowledge–Action” Gap in the
Dominican Republic
By Dr Helena CHAPMAN (Dominican Republic)
ASIA
20 Patient-Physician Relationships Need Doctors’ Self-regulation
By Dr Jihoo LEE (Korea) and Dr Yujin SONG (Korea)
24 Support Us: A Plea from Young Nepali Doctors
By Dr Uchit THAPA (Nepal)
27 Physician Burnout
By Dr Aashish KUMAR SINGH (India)
EUROPE
29 Medical Ethics Challenges Related to Mental Health in Europe: Views from a
French Junior Doctor
By Dr Audrey FONTAINE (France)
Junior Doctors Network Newsletter
Issue 17
March 2020
Page 4
WMA DECLARATIONS
32 WMA Declaration of Geneva
33 WMA International Code of Medical Ethics
35 WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving
Human Subjects
Junior Doctors Network Newsletter
Issue 17
March 2020
Page 5
With great pleasure, our Junior Doctors Network (JDN) presents the first special edition
issue of the JDN Newsletter, focusing on the fundamental topic of Medical Ethics. This
robust collaboration of JDN officers promotes the JDN mission, Empowering young
physicians to work towards a healthier world through advocacy, education, and
international collaboration.
The JDN encourages junior doctors to be active participants in the global dialogue on
medical ethics issues, including commentary on World Medical Association (WMA) policies,
observance of the Declaration of Geneva, and attendance to conferences. In May 2019,
JDN members participated in the WMA conference (Theme: Physician 2030), held in Tel
Aviv, Israel. JDN members will also attend the upcoming United Nations Educational,
Scientific and Cultural Organization (UNESCO) Bioethics conference (Theme: Bioethics,
Medical Ethics, and Health Law), held in Porto, Portugal.
Over the last 10 years, the JDN has continued to empower junior doctors to participate in
analyses and debates about global health topics, advocate for a healthier word, and build a
strong network under the auspices of the WMA. Recently, the expansion of medical ethics
activities included the development of a JDN working group and webinar series. This
special edition issue provides an opportunity for junior doctors to share and gain insight on
diverse medical ethics topics and current challenges in the workplace. We appreciate the
continued support of the WMA leadership toward achieving these goals.
As the JDN celebrates the 10th anniversary in October 2020, a special celebration will
recognize the continued engagement and dedication of our current and past JDN
management teams and members. This historic moment shows that JDN-WMA remains
committed to enhance junior doctors’ engagement in global health leadership and advocate
for a healthier, equal, and ethical world.
Enjoy your reading,
Audrey
Junior Doctors Network Newsletter
Issue 17
March 2020
Words from the Chair
TEAM OF OFFICIALS’ CONTRIBUTIONS
Audrey Fontaine, MD
Chair (2019−2020)
Junior Doctors Network
World Medical Association
Dear colleagues from around the world,
Page 6
On behalf of the Medical Ethics Alive Team (2019-2020) of the Medical Ethics Working
Group, it is with great pleasure that I introduce to you all the inaugural Medical Ethics
Special Edition of the JDN Newsletter.
The World Medical Association (WMA), in its medical ethics manual, recognises medical
ethics as the branch of ethics that looks at moral issues in medical practice (1). It further
describes medical ethics to have a strong relation with biomedical ethics. It clarifies that
medical ethics primarily address issues that originate from the practice of medicine, whilst
biomedical ethics focus on moral issues that arise from the developments in the biological
sciences (1). Medical ethics form the foundation of the medical profession and comprise an
integral part of global health. Over the decade, the issue has been brought into the limelight
as a result of the intense participation of health professionals in discussions on diverse
topics related to medical ethics. These include clinical competencies and responsibilities,
human and animal research, patient confidentiality, and end-of-life care. As such, it
behooves junior doctors to take the lead in championing the dissemination and awareness
on this vital aspect of medical practice.
This Inaugural Medical Ethics Special Edition of the JDN Newsletter marks the first
collaborative effort between the JDN Publications Team and the JDN Medical Ethics
Working Group. The collaboration is a symbol of the leadership, synergy, and enthusiasm
of junior doctors who share their experiences and expertise in topics that affect junior
doctors.
The Medical Ethics Officer and the Medical Ethics Working Group will continue to work
towards empowering young physicians with the knowledge and understanding of medical
ethics as they continue to work towards a healthier world through advocacy, education, and
international collaboration.
Stay connected, and let your voice reach the world!
Sincerely,
Maki
Reference
1) World Medical Association. Medical Ethics Manual, 3rd ed. Ferney-Voltaire: WMA; 2015.
Junior Doctors Network Newsletter
Issue 17
March 2020
Words from the Medical Ethics Working Group Chair
Lwando Maki, MD
Medical Ethics Officer (2019−2020)
Medical Ethics Working Group Chair (2019−2020)
Junior Doctors Network
World Medical Association
Dear Junior Doctors, Members of the WMA, and Colleagues in health,
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 7
Around the globe, Medical Ethics has been recognized as an essential topic at the core of
medical education. From the first day of medical school, we are trained to treat our patients
with dignity and respect, build positive rapport, and strengthen communication skills. These
actions can foster patients’ trust, albeit in today’s world with increasing litigation and
physical attacks on doctors. For this reason, the debate on medical ethics topics holds
special significance.
As Junior Doctor Network (JDN) members, we are committed to highlighting the ethical
issues faced by junior doctors around the globe. This Medical Ethics Special Edition of the
JDN Newsletter provides a platform where our colleagues can share their experiences in
the clinical and community workplace. In this issue, authors from different geographic
regions have contributed scientific perspectives and reports, which highlight diverse
medical ethics topics encountered in their country.
I would like to thank our Medical Ethics officer and Medical Ethics Working Group lead, Dr
Lwando Maki, who presented the innovative idea to develop a Medical Ethics Special
Edition for the JDN Newsletter. Likewise, I appreciate the leadership of the JDN
Publications Director, Dr Helena Chapman, who led the editorial process with utmost
sincerity and dedication for this unique collaboration. I recognize the editorial expertise of
the JDN Publications Team, who supported this collaboration and editorial tasks to
completion. Finally, I thank all authors who provided their scientific perspectives and
reports on relevant medical ethics topics for this issue.
Stay connected, and let your word reach the world!
Sincerely,
Aashish
Junior Doctors Network Newsletter
Issue 17
March 2020
Words from the Medical Ethics Work Group Project Lead
Aashish Kumar Singh, MBBS
Medical Ethics Working Group Project Lead (2019−2020)
Junior Doctors Network
World Medical Association
Dear colleagues,
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 8
Junior Doctors Network Newsletter
Issue 17
March 2020
Words from the Publications Director
Dear JDN colleagues,
On behalf of the Publications Team (2019-2020) of the Junior Doctors Network (JDN), we
are honored to present and share the Medical Ethics Special Edition of the JDN Newsletter
with junior doctors across the world.
This 17th issue of the JDN Newsletter marks the first collaborative effort between the JDN
Publications Team and the JDN Medical Ethics Working Group to develop a joint Special
Edition issue. This collaboration is a symbol of the leadership and enthusiasm of junior
doctors who encourage their colleagues to share their experiences and reflections on
topical issues in medical ethics that affect junior doctors in the clinical and community
workplace.
The JDN Newsletter represents an international platform for the global community of junior
doctors, which fosters collaborative learning about relevant topics in clinical care, research,
and community practice. Through these insightful scientific reports and narratives, junior
doctors showcase their passion for global health, enthusiasm to promote a positive learning
environment, and desire to strengthen professional networks with World Medical
Association (WMA) and JDN members.
We recognize the dedicated efforts of all leaders of the Medical Ethics Working Group and
editors of the JDN Publications Team 2019-2020 as we completed the editorial tasks for
this 17th issue. We also appreciate the continued support of the JDN management team
and WMA leadership for this essential resource for junior doctors across the world. We
hope that you enjoy learning about diverse topics in medical ethics in this 17th issue!
Together in health,
Helena
Helena Chapman, MD MPH PhD
Publications Director (2019−2020)
Junior Doctors Network
World Medical Association
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 9
This article looks at the hardships and unethical treatments shared by patients working in
the construction industry. The article is meant to highlight the global workplace challenges
faced by patients and workers.
The construction industry plays an integral role in providing employment opportunities and
contributing to the global economy. The contributions to the 2018 Gross Domestic Product
(GDP) resulted in US$783 billion and US$7.94 billion in the United States and South Africa,
respectively (1). The contributions to the 2017 GDP contribution was US$13.98 billion and
US$21.75 billion in for South Africa and Nigeria, respectively (1). As the construction
industry significantly contributes to the global economic growth and development of
nations, workers’ health and well-being should be prioritized.
Globally, the construction industry is one of the most hazardous and dangerous industries
(2). It is associated with all categories of occupational hazards, such as psychological (e.g.
occupational stress), physical (e.g. noise, temperatures, vibration, confined spaces),
ergonomic (e.g. poor tool design, awkward postures), biological (e.g. mosquitoes,
venomous animals), and chemical (e.g. solvents like lead-based paint, glues with
isocyanates, silica, asbestosis, cement) (3). The relationship between silica exposure,
tuberculosis, and occupational lung diseases has been established in the literature. For
example, construction workers who are exposed to silica in dust or cement may be at
increased risk of tuberculosis or occupational lung diseases. These occupational hazards
can cause high morbidity and mortality rates, poor work performance, and increase
projected expenditure of established projects (3).
Junior Doctors Network Newsletter
Issue 17
March 2020
Worker Health: The Priority in the Workplace
As junior doctors treat the occupational injuries and diseases of
worker patients, we should advocate for a healthy workplace for
patients that can reduce risk of occupational disease or injury.
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 10
Lwando Maki, MD
Medical Ethics Officer (2019−2020)
Medical Ethics Work Group Chair(2019−2020)
Junior Doctors Network
World Medical Association
The burden of occupational injuries and deaths in the employment sectors worldwide is
among the highest in the construction industry, attributing to over 50% of all global
occupational injuries and deaths (2−5). According to the International Labour Office (ILO),
the construction industry was responsible for 60,000 annual fatal accidents – or one death
every 10 minutes – and approximately 30% of construction workers suffered from back
pain or other musculoskeletal disorders (4). In fact, in the United Kingdom (UK), the burden
of occupational diseases and injuries in the construction industry was one of the highest in
the UK employment sectors for 2017−2018. The construction industry was responsible for
38 fatalities and 82,000 work-related ill health cases, where 51,000 (62%) cases were
musculoskeletal disorders and 14,000 (25%) cases were related to stress, depression or
anxiety (5). Notably, there is a paucity of occupational health-related data of the
construction industry from developing countries.
Globally, literature has shown that Occupational Health Services (OHS) were established
as a cost-effective measure to prevent workplace morbidity and mortality due to
occupational diseases and injuries (4). OHS consist of 1) performing the Hazard
Identification Risk Assessment (HIRA), 2) controlling the identified risk, and 3) monitoring
that control of the risk has not been lost. The risks identified by the HIRA are controlled
through risk reduction, risk removal, and risk avoidance. OHS also require the
establishment of OHS committees and representatives that further improve efforts to
maintain a healthy work environment and prevent negative impacts to health. With limited
availability and accessibility of OHS in the construction industry, employers place workers’
health and well-being at risk so that they can maximise company profits rather than
expenditure on OHS services (2−5).
Junior Doctors Network Newsletter
Issue 17
March 2020
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Evidence-based guidelines have demonstrated that early
detection and management of adverse health effects – such
as musculoskeletal disorders, mental health complaints, and
skin disorders – can substantially decrease work-related
injuries and illnesses.
In conclusion, there is a need for improved availability of OHS in the global construction
industry, especially in developing countries. All employers, government leaders, and worker
unions must work together to address this ethical challenge in the construction industry. As
junior doctors, we must continue to remain updated on the latest occupational health
practices and legislation of our country. Moving forward, we can advocate for healthy
workplaces for all patients that emphasize health and well-being and reduces risk of
occupational disease or injury.
References
1) Economics T. GDP from construction. 2018 [cited 2020 Jan 31].
2) Choi SD, Guo L, Kim J, Xiong S. Comparison of fatal occupational injuries in construction industry in the
United States, South Korea, and China. International Journal of Industrial Ergonomics. 2019;71:64−74.
3) Construction Industry Development Board. Labour & work conditions in the South African construction
industry − status and recommendations. 2015 [cited 2020 Feb 23].
4) Construction Research Education and Training Enterprises. Construction health and safety in South
Africa: status and recommendations. South Africa: Construction Industry Development Board; 2009.
5) Office of National Statistics (UK). Construction statistics, Great Britain, 2018. United Kingdom: United
Kingdom Government; 2018.
Junior Doctors Network Newsletter
Issue 17
March 2020
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Termination of pregnancy is a surgical procedure that consists of the premature and
provoked expulsion of the fetus from within the woman, either by internal or external
physical or chemical means (1). This practice, despite being legislated and decriminalized
in some countries, remains a taboo for society, even among health workers.
Conscientious objection is when an individual refuses to act under a legal mandate or
obligation, based on beliefs, morality or religion. This action commonly arises in the health
sector when health professionals are required to assist or perform a termination of
pregnancy for medical purposes (1).
Global research shows that there is variation in the number doctors who practice the legal
termination of pregnancy (1%) versus doctors who choose conscientious objection (>50%)
(2). In Italy, where termination of pregnancy has been legal since 1978, more than 69% of
doctors choose conscientious objection (2). High rates of doctors choosing conscientious
objection has been attributed to doctors perceiving that medical ethics has been violated,
especially disrespecting the life of the embryo, using the Hippocratic oath as justification.
The alternative view of not choosing conscientious objection, however, focuses on the
priority of the health and well-being of pregnant mothers.
Junior Doctors Network Newsletter
Issue 17
March 2020
Termination of Pregnancy and Conscientious Objection:
A Confrontation between Science and Beliefs
Jeazul Ponce Hernández, MD MPH MSc
Predoctoral Fellow in Public Health
Complutense University of Madrid
Madrid, Spain
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 13
As these two polar views bring an ethical challenge to the health
sector, junior doctors should review the evidence-based literature
on the burden, morbidity, and mortality related to the termination
of pregnancy and reflect on their personal beliefs on the topic.
Their clinical decision can clarify offered medical services, minimize delay in service
delivery, and confirm the presence of continuum of care. This article aims to provide an
overview of this medical ethics debate and encourage junior doctors to understand their
potential role if requested to assist in or perform a termination of pregnancy.
Conscientious objection is a right for doctors, access to safe abortion is a right for women,
and both actions should have federal regulation and oversight; so that doctors can object
and women can have access to safe options. In some countries, the lack of regulation of
such procedures can place women in danger, where they seek illegal backstreet
procedures and face social stigma by their communities. It can also extend to doctors as
conscientious objectors who do not have clear guidelines or responsibilities to refer patients
who seek these procedures for medical purposes. Although individual autonomy must be
respected, conscientious objection is an individual right, as it relates to doctors and other
health care providers. However, the term conscientious objectors serves as direct evidence
of moral convictions, which can lead to abuse and imposition of ideas based on beliefs
rather than scientific evidence.
Although no reliable statistics on abortions exist, due to the illegal nature of the procedure
in some countries, the World Health Organization (WHO) estimates that approximately 19–
20 million unsafe abortions occur annually, with 97% in developing countries (3). In
contrast, liberal laws for access to termination of pregnancy are found throughout Europe
and Northern America as well as several countries in Asia (3). In Mexico, one research
study reported that the legalization of termination of pregnancy in 2016 protected lives,
where the case-fatality rate (per 100,000) declined from 54 deaths in 2000 to 33 deaths in
2016 (4). However, the legalization of termination of pregnancy does not guarantee the
provision of health care services nor that doctors will not choose conscientious objection.
Some South American countries have reported that a substantial number of countries have
developed legislation on conscientious objection without ensuring access to alternative and
safe options (5).
Junior Doctors Network Newsletter
Issue 17
March 2020
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 14
One common question remains: What happens when
conscientious objection hinders women’s sexual and
reproductive rights?
Over the past few decades, three key international activities have propelled the momentum
and discussion about women’s rights. In June 1993, the United Nations’ World Conference
on Human Rights was held in Vienna, Austria. Representatives of 171 states agreed to
consider any violation of specific women’s rights as a violation of human rights, recognized
as the Vienna Declaration and Programme of Action (6). In September 1995, the Fourth
World Conference on Women was held in Beijing, China. Representatives of 189 states
participated and recognized reproductive rights and noted that women’s human rights
included their right to have control over issues related to their sexual and reproductive
health, without being subject to coercion, discrimination or violence (7).
In October 2018, the 69th World Medical Association (WMA) General Assembly was held
in Reykjavik, Iceland. WMA representatives adopted a statement on medically-indicated
termination of pregnancy, proposing that physicians should continue to have a right to
conscientious objection to perform a termination of pregnancy, while ensuring the continuity
of medical care by qualified health professionals. Notably, it added that in all cases
physicians must perform those procedures necessary to save a woman’s life and to
prevent serious injury to her health and well-being (8).
In Latin America, legislation on conscientious objection has resulted in unclear public health
policies from a gender perspective, which have violated women’s sexual and reproductive
health rights. In turn, this has caused significant barriers to access to sexual education,
safe termination of pregnancy, and other reproductive health care services. These
regulations can be counterproductive for health professionals, where there may be
misunderstanding or misconceptions of vulnerability related to women’s rights.
In conclusion, the decriminalization of abortion is a battle between ideologies and scientific
evidence. By recognizing this global medical ethics debate and being aware that doctors
may have different viewpoints, governments should recognize conscientious objection so
that it respects human rights and advocates for enough non-objector doctors to provide
necessary health services.
Junior Doctors Network Newsletter
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March 2020
Junior doctors should reflect upon the choice to
conscientious object or not to conscientious object, which
can enhance health systems and protect patients’ health.
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 15
References
1) Turner KL, Börjesson E, Huber A, Mulligan C. Why focus on young women and abortion? Abortion care
for young women: a training toolkit. Chapel Hill, NC: Ipas; 2011.
2) Balzano A. [The Italian case: reproductive medicine and conscientious objection]. Revista de Bioética y
Derecho. 2013;0:11–23. Italian.
3) Singh S, Remez L, Sedgh G, Kwok L, Onda T. Abortion worldwide 2017: uneven progress and unequal
access. New York: Guttmacher Institute; 2017.
4) Darney BG, Fuentes-Rivera E, Polo G, Saavedra-Avendaño B, Alexander LT, Schiavon R. Con la ley y
sin la ley/With and without the law: utilization of abortion services and case fatality in Mexico, 2000-2016.
Int J Gynecol Obstet. 2020;148:369-374.
5) Ester B, García NC. [The question of abortion in Latin America]. 2019 [cited 2020 Mar 1]. Spanish.
6) United Nations. Vienna Declaration and Programme of Action. 2003 [cited 2020 Mar 1].
7) United Nations. [Report of the Fourth World Conference on Woman]. 1996 [cited 2020 Mar 1]. Spanish.
8) World Medical Association. WMA statement on medically-indicated termination of pregnancy. 2018 [cited
2020 Mar 1].
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Clinical practice guidelines are evidence-based recommendations that have been
developed by expert medical panels to standardize infectious and chronic disease
management and support clinical decision-making (1). These guidelines aim to optimize
patient care and minimize morbidity and mortality rates across the patient population. The
importance of these scientific recommendations was noted by the Institute of Medicine
(now, the National Academies of Medicine) in the 1990s, which led to the widespread
development, dissemination, and use of clinical practice guidelines for patient-centered
care across the world (1). Over time, sophisticated appraisal techniques were implemented
to strengthen the systematic review of evidence-based research, evaluate the risks and
benefits of alternative care options, and enhance the trustworthiness of clinical practice
guidelines.
As new scientific evidence emerges on clinical topics, an exhaustive systematic review of
the literature by selected advisory boards of federal agencies and professional medical
associations is indispensable to maintain up-to-date clinical practice guidelines. Some
examples of such agencies and associations are the Centers for Disease Control and
Prevention, American Academy of Family Physicians, European Society of Cardiology, and
Infectious Diseases Society of America. As medical curricula have adopted problem-based
learning approaches to stress the practice of evidence-based medicine, physicians are
responsible to remain up-to-date and adhere to clinical practice guidelines as essential
elements of clinical practice.
Junior Doctors Network Newsletter
Issue 17
March 2020
Clinical Practice Guidelines: Exploring the
“Knowledge–Action” Gap in the Dominican Republic
Scientific research aims to advance the current knowledge base
by exploring complex clinical questions, examining associations
between epidemiologic variables, and assessing the effectiveness
of current standard practices.
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 17
Helena Chapman, MD MPH PhD
Publications Director (2019−2020)
Junior Doctors Network
World Medical Association
Clinicians, although with genuine intentions to follow medical ethics principles – autonomy,
beneficence, justice, and non-maleficence – may be unable to apply the respective clinical
practice guidelines in their workplace.
For example, if selected pharmaceutical agents, laboratory diagnostics or other
technological advancements are in limited quantity or inaccessible – due to inadequate
funding or resources within the institution – then the prompt and appropriate delivery of
health care services to patients and resulting clinical outcomes may be significantly
impacted (3). These limitations can conflict with physicians’ education and training, adding
to their frustration and inability to provide optimal patient care.
Example: Tuberculosis Control in the Dominican Republic
Tuberculosis (TB), transmitted through aerosol droplets infected with Mycobacterium
tuberculosis, remains a significant global health burden, causing 10 million new infections
and 1.5 million deaths in 2018. In the Dominican Republic (DR), a country of approximately
11 million residents, the incidence of TB per 100,000 persons has continued to decline over
the past three decades, from 91 cases in 1990 to 60 cases in 2015 to 45 cases in 2018
(4,5).
This decline is attributed to the DR Ministry of Health leadership and support of the
National Tuberculosis Control Program, including gratuitous TB treatment through directly
observed treatment short-course (DOTS), capacity building for health professionals,
educational outreach at primary care centers (Unidades de Atención Primaria, UNAP), and
hospital-level patient-centered care. In efforts to reduce risk of M. tuberculosis transmission
and protect patient and employee health, international clinical practice guidelines for TB
diagnosis, management, and prevention are widely disseminated across DR health
institutions.
Recently, the DR Ministry of Health investigated the high-risk occupations for M.
tuberculosis transmission in tertiary-level health institutions between 2005 and 2012.
Physicians and nurses were the top occupations of the 111 total health care workers who
developed TB disease (5). To explore the “knowledge−action” gap, researchers designed a
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This “knowledge−action” gap, defined as the inability to
consistently apply knowledge to practice, may reflect knowledge
barriers of the individual practitioner or health system level (2).
qualitative study to explore clinicians’ decision-making processes as they were able to
apply TB infection control practices in the workplace. Through interviews with TB experts
and focus group discussions with physicians and nurses in primary care and emergency
medicine, clinicians expressed feeling powerless in clinical practice. Although they were
trained in clinical knowledge of TB, they expressed intrinsic (e.g. general sense of
invincibility) and extrinsic (e.g. no isolation ward, limited supply of protective equipment)
barriers to adhering to recommended TB infection control practices (5).
Some interventions may include strengthening capacity-building activities for all health care
workers, requesting increased national health budgets to allocate for essential medical
equipment and supplies, and modifying physical infrastructure to provide airborne infection
isolation (e.g. negative pressure) rooms in health institutions.
Evidence-based clinical guidelines represent high-quality scientific tools to prioritize patient-
centered care during ambulatory or hospitalized settings. Junior doctors must remain up-to-
date on clinical recommendations and be aware of the “knowledge−action” gap in clinical
practice. Their global leadership in organizations, conferences, and small work groups can
advocate for the proper application of clinical practice guidelines to strengthen patient care
outcomes.
References
1) Institute of Medicine (US). Committee on Standards for Developing Trustworthy Clinical Practice
Guidelines. Editors: R. Graham, M. Mancher, D. Miller Wolman, S. Greenfield, E. Steinberg. Clinical
practice guidelines we can trust. Washington DC: National Academies Press; 2011.
2) Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull
World Health Organ. 2004;82:724–731; discussion 732.
3) Farmer PE. Shattuck Lecture. Chronic infectious disease and the future of health care delivery. N Engl J
Med. 2013;369:2424–2436.
4) Pérez-Then E, Acosta I, Marcelino B, Espinal M. Tuberculosis in the Dominican Republic: addressing the
barriers to sustain the achievements. Bull World Health Organ. 2007;85:384−385.
5) Chapman HJ, Veras-Estévez BA, Pomeranz JL, Pérez-Then EN, Marcelino B, Lauzardo M. The role of
powerlessness among health care workers in tuberculosis infection control. Qual Health Res.
2017;27:2116−2127.
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This exact scenario, which may be experienced by clinicians
across the globe, offers a call to action for medical ethics on
identifying where interventions can empower clinicians in their
clinical practice and minimize this “knowledge−action” gap.
Establishing a close, positive rapport between a physician and a patient has always been
an important element of the physician-patient relationship. Successful establishment of
rapport, well supported by evidence-based research, can lead to high levels of compliance
and successful treatment outcomes (1).
In the current era, cataclysmic changes have been made to the physician-patient
relationship. Although significant strides in technology, such as the internet, allow patients
to easily access information that they think that they need, whether that information is
indeed accurate and necessary to patients comes into question. Physicians sometimes feel
that patients who obtain inappropriate amounts of health information can minimize the
authority entrusted to physicians (2). As such, they may consider themselves as
customers, rather than patients, who seek the highest cost-effectiveness. Physicians’
traditional and authoritative voice can no longer be sustained in this kind of environment.
Although this situation may differ among countries, the status quo of the physician-patient
relationship in the Republic of Korea has taken a more undesirable turn, notably with the
recent attempt to revise the Medical Law in 2019.
In May of 2019, the ruling Democratic Party of Korea submitted a bill that proposed the
mandatory installation of closed-circuit television cameras (CCTV) in hospital operating
rooms after strings of preventable medical malpractice (3). Recent medical malpractice
incidents included proxy surgeries by unlicensed medical equipment salespeople,
completion of inappropriate medical procedures among medical personnel, and reported
Junior Doctors Network Newsletter
Issue 17
March 2020
Patient-Physician Relationships Need Doctors’ Self-regulation
Jihoo Lee, MD
Internal Medicine Resident, Seoul National University
Director, Korean Intern Resident Association
Seoul, Republic of Korea
Yujin Song, MD
Intern, National Medical Center
Executive Member, Korean Intern Resident
Association
Seoul, Republic of Korea
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 20
The medical profession must strive to form a trustworthy
physician-patient relationship, preferably based on strong
mutual respect.
sexual harassment of patients under anesthesia. The passage of this bill is currently
pending for two reasons. First, the financial and administrative challenges hinder the real-
world application. Second, more crucially, a conflicting view exists between medical
professionals and the general public on this issue.
In 2019, the Korean Intern Resident Association (KIRA) conducted a survey to examine the
perceptions related to installing CCTVs in operating rooms of 866 resident physicians at 90
training hospitals. A total of 81.3% of respondents believed that installing CCTVs in
operating rooms was an unnecessary measure, and 15% replied that this installation
should be an optional, not mandatory, measure. The main reasons for opposing CCTVs
included the possibility of violating patients’ privacy and doctors’ autonomy (Figure 1).
Despite this ongoing dispute, pilot practices of CCTV monitoring systems are already in
operation by the Gyeonggi provincial government (4). Six provincial hospitals have started
to record surgeries with enthusiastic community support. In 2019, the Gyeonggi province
conducted a survey to explore community support of CCTV monitoring systems in
operating rooms of 1,000 community residents. A total of 91% of local residents supported
the monitoring system in operating rooms (Figure 1). Under CCTV installation, the public’s
main rationale is rather simple: patients want protection when related to medical disputes.
In other words, the commotion surrounding CCTVs is only a facade of the crumbling
physician-patient relationship in the Republic of Korea.
Junior Doctors Network Newsletter
Issue 17
March 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 21
Figure 1. KIRA survey of 866 medical residents (left) and
1,000 Gyeonggi-do Province residents (right) on perceptions
regarding CCTV installation in operation rooms.
Credit: KIRA/Gyeonggi-do province, 2019.
However, the general public favors
the passage of this submitted bill.
The Gyeonggi provincial government
and lawmakers are actively taking
action to answer public demands for
CCTV installation. They claim that
CCTVs can help patients and their
families collect data and identify
causal relationships if a medical
dispute occurs. Hence, they believe
that the CCTV installations can close
the information gap between
physicians and patients, restoring
patients’ confidence in physicians
over time.
The Central Ethics Committee of the Korean Medical Association (KMA) is responsible for
executing effective discipline for impaired members and providing prompt ethical guidelines
(5). The weak binding power, however, challenges a shared consensus about whether the
Committee functions properly and gains patients’ trust. Although the Committee acts as the
initial gateway to identify individuals who tarnish the medical profession through
misconduct, it does not possess any means to inflict actual penalties. Frequently, the
Committee submits formal reports to the Ministry of Health and must wait for the
appropriate administrative measures within an extended time limit.
The Central Ethics Committee’s limitations to secure physician-patient trust have led to the
development of additional Committees that are more focused on investigating and
penalizing impaired physicians. These changes are slow but demonstrate forward
movement.
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Issue 17
March 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 22
Figure 2. KMA survey of 500 patients on perceptions
regarding their trust in physicians.
Credit: KMA Research Institute for Healthcare Policy, 2011.
We believe that this emphasizes the
importance of physician’s self-regulation.
No matter how many medical cases result
without errors, only a handful of cases
with poor outcomes are sensationalized
by the media and promote distrust and
misunderstanding by the general public
(Figure 2). Therefore, physicians should
express their efforts to maintain high
moral standards through self-regulation.
The collective behavior of this self-
regulation leads physicians to demand the
participation of high-level bodies and
organizations, such as medical ethics
committees.
Medical interns and residents stand at the forefront of
patient care, making their role pivotal in rebuilding the
broken trust between patients and physicians.
Over the next few years, KIRA envisions the development of their own Ethical Committee.
Although the gap in knowledge and practice of medical ethics has hindered this plan,
KIRA’s recent interest in Junior Doctors Network (JDN) Medical Ethics Committee (MEC)
will offer a lively discussion of physicians’ self-regulation and surveillance among junior
doctors.
References
1) Kelley J, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician
relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled
trials. PLoS ONE. 2014;9:e94207.
2) Kim J, Kim S. Physicians’ perception of the effects of Internet health information on the doctor-patient
relationship. Inform Health Soc Care. 2009;34:136−148.
3) Kim A. Doctors resist bill requiring cameras in operating rooms. Koreaherald.com. 2019 [cited 2020 Feb
10].
4) He-rim J. Gyeonggi province to introduce first surveillance cameras inside operating rooms.
M.koreaherald.com. 2019 [cited 2020 Feb 10].
5) Jung JT, Lee MJ, Lee IH, Gang HR. Research on the development plan for the Central Ethics Committee
of the Korean Medical Association. Yongsan-gu (KOR): Research Institute for Healthcare Policy; 2011.
Junior Doctors Network Newsletter
Issue 17
March 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 23
These efforts will provide insight to future steps that will
progress the advancement of the field of medical ethics.
I was born and raised in a sub-metropolitan city located in the far eastern region of Nepal.
This city is recognized for the enormous British establishment (Ghopa Camp) and a major
tertiary-level health center for eastern Nepal. Within this establishment, I completed my
high school education in an international branch of a highly reputed private school.
My memories of observing medical students in their bright white coats are vivid. It would be
the most awaited moment of my day, watching them from the window of my school bus. I
wondered how prestigious their lives would be, feeling fulfilled through their clinical practice.
I have always aspired to have the same feeling of gratification and happiness and
wondered if I would ever be able to experience it.
As I entered medical school, I quickly realized that the reality was far different from what I
had imagined. The influence of highly powerful people in the medical sector − commonly
referred to as Medical Mafias − was apparent early during my medical journey. The bribe
charged under the table, their influence on education, and the future towards becoming a
doctor were clearly apparent. Limitations included a lack of teaching faculty, inadequate
infrastructure, and substandard educational curriculum. For decades, the educational
system had been executed with every raised voice silenced by the influence of money and
power.
After completing medical school, my belief that the phase of domination and monopoly
would end was incorrect. In the private sector, financial gain from the patient population is
typically prioritized over the concern for patient betterment or safety. Since junior doctors
must complete a one-year post-graduate clinical clerkship before applying to medical
residency, job opportunities were only limited to small private hospitals. However, without a
Junior Doctors Network Newsletter
Issue 17
March 2020
Support Us: A Plea from Young Nepali Doctors
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 24
Uchit Thapa, MBBS
General Physician, Kantipur Hospital Pvt. LTD.
Kathmandu, Nepal
There are certain memories, moments, and experiences that guide
our personal development and inspire us to act in new ways.
powerful influence – whether political or hospital administration contacts – new medical
graduates were rarely able to enter the reputed private sector or government-run hospitals.
They often acquired employment in the poorly-run hospitals of the private sector.
Junior doctors also received an unreasonable financial reimbursement and faced serious
security issues in the workplace (1). Challenges included caring for family needs at home in
addition to their own safety concerns from angry mobs at the hospital. At the same time,
they may experience significant stress as the media portrays the false image of doctors as
unprofessional and solely motivated by financial gain. Doctors have pleaded for help from
institutional and government authorities, but they have received no assistance to date.
Over the past five years, doctors have fought and protested for reasonable rights, but there
has been minimal support from the government, senior health authorities, and general
population. Considered a soft target, the media views this resistance for rights and justice
as a nuisance and negligence towards this noble profession. However, what is truly heart-
breaking is the fact that the senior health authorities, recognized as the pioneers of
medicine in Nepal, have ignored this suffering and consequences of the corrupt system.
For this reason, as this article can only touch upon the tip of the iceberg, a subsequent
article could further elaborate on the specific details of this situation.
A few questions remain: Is this the life that junior doctors understand and accept? Is it
wrong to fight for our rights and pride? Are we the true villains of this society portrayed by
authorities? Do we regret our decision to become doctors?
As they are passionate about clinical care, they observe the value and personal satisfaction
of their doctor-patient interactions which cannot be measured with monetary compensation.
This may serve as an example of why doctors serve humanity and encourage future
generations to follow a career path that results in self-satisfaction.
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Issue 17
March 2020
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Although these questions require in-depth reflections, junior
doctors continue to inspire colleagues, exhibiting passion and
dedication for the medical profession albeit significant hardships.
In the end, junior doctors have experienced this challenging journey, investing their time
with the promise of devoting their future career to medicine. They only request a workplace
environment where they can learn and practice medicine without fear, receive appreciation
for their efforts, and attain financial stability. Doctors need their patients to trust them, their
mentoring physicians to provide guidance, and the government to support health care
service delivery.
Reference
1) Thapa U. Untold stories of young doctors from the land of the Himalayas. JDN Newsletter. 2019;0:38−39.
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March 2020
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These action steps may take years to accomplish, but
junior doctors can start taking the first steps together as a
family unit, supporting each step of this journey.
Historically, doctors have been viewed as a respected working class in society. However,
people may disregard the fact that this respect comes with an enormous cost, which can
drain physical health and mental peace. Society may admire the white ward coats and
stare wistfully at the neatly tucked-in shirts with ironed trousers and shining shoes.
Although they may wish that they were part of this hallowed profession, they may overlook
the sacrifices of dedicated patient care, including extended work hours, increased stress,
and sleepless nights. With hectic clinical schedules, doctors may frequently return home at
late hours and miss family events, such as family birthday celebrations and wedding
anniversaries. Although doctors have adapted to this work routine, they may reflect on how
society prioritizes patients’ health over doctors’ well-being.
Doctors often work long clinical shifts, which sometimes extend to 36 hours without proper
rest. This can be described as burnout, where physical and emotional fatigue or exhaustion
is accompanied by feelings of limited personal achievements and depersonalization (1). As
global medical councils recognize this burden, health leaders hold open discussions where
they discuss challenges and advocate for improved working conditions for all health care
workers. Although an essential call to action, these described recommendations have been
inconsistently integrated into clinical practice.
Recent research studies have demonstrated the reality of burnout among doctors across
the globe. In 2019, the British Medical Association conducted a survey among doctors,
reporting the risk of burnout to be as high as 80% (1). In 2018, the Physician Foundation, a
national non-governmental organization in the United States, administered a survey among
doctors, showing that 78% expressed feelings of burnout (2). In 2018, a study conducted in
India concluded that the rate of depression among resident doctors was 28%, which was
higher than the prevalence in the general population (3).
Junior Doctors Network Newsletter
Issue 17
March 2020
Physician Burnout
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 27
Aashish Kumar Singh, MBBS
Medical Ethics Work Group Project Lead (2019−2020)
Junior Doctors Network
World Medical Association
These fora provide opportunities to voice recommendations
that can be adopted into national guidelines and policies.
In 2019, doctors in India launched a public awareness campaign titled, I am Overworked, to
raise awareness about the unregulated duty hours and increasing rates of depression and
suicide among doctors. As part of the campaign, doctors wore the I am Overworked badge
during their clinical responsibilities, hoping that their voices would reach the Minister of
Health (4).
Numerous research studies have concluded that an overworked mind can result in
unintentional clinical errors, suggesting that doctors’ actions directly affect patients’ health
outcomes (5). Moving forward, global medical regulatory professional councils and
governments should continue to hold open fora with stakeholders on emerging issues like
burnout, organize meetings between physicians and other health care providers, and adopt
appropriate and timely interventions. For example, work hours can be regulated and not
exceed a total of 12 hours in one single clinical shift, in order to allow sufficient time to rest.
In conclusion, it is evident that human beings are happier with a healthy body and a
peaceful mind. As B.K.S. Iyengar, one of the foremost yoga teachers in the world, stated,
When your body, mind, and soul are harmonious, you will bring health and harmony to the
world. In efforts to optimize doctors’ health and well-being, the medical community should
stress the need to address burnout among doctors and mitigate risk though prompt and
appropriate interventions.
References
1) The Lancet. Physician burnout: a global crisis. Lancet. 2019;394:93.
2) The Physicians Foundation. 2018 Survey of America’s physicians: practice patterns & perspectives. 2018.
3) Dave S, Parikh M. Depression, anxiety, and stress among resident doctors of a teaching hospital. Indian
Journal of Social Psychiatry. 2018;34:163–171.
4) Perappadan BS. When stressed doctors seek better care for themselves. The Hindu. 2019 [cited 2020
Feb 24].
5) Michel A. Burnout and the brain. Association for Psychological Science. 2016 [cited 2020 Feb 24].
.
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March 2020
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These global statistics are alarming as burnout can lead to
depression, anxiety, and in some cases, suicide.
Moving forward, global medical regulatory professional councils
and governments must understand that a healthy doctor is key to
a healthier and more productive society.
Mental health is one of the fields that has continuously evolved over the last century. Long
neglected, it has emerged as one of the main health, societal, and economic challenges.
Reports by the World Health Organization (WHO) (2001) and the World Bank (2002) have
placed mental health as one of the pillars that must be targeted to improve the most
disadvantaged economies (1). Mental health disorders are one of the main causes of
declining human productivity. Its direct and indirect financial costs are estimated at more
than 450 billion Euros per year in the European Union (2).
Historically, little was known about health promotion, prevention, and treatment of
psychiatric diseases. For example, asylum psychiatry was the traditional approach to the
treatment of psychiatric diseases in the 19th century. Following scientific, technological,
societal, ethical, and demographic advances, a paradigm change has occurred in the
delivery of psychiatric health care.
During psychiatric treatment, numerous cases of human rights violations have been
reported to the European Court of Human Rights, mainly in large mental health institutions
and related to coercion (3). In response, over the past few years, patients’ representative
groups, physicians, and political figures have started public discussions on the use of
coercion in psychiatric treatment. How can we best address decision-making in medical
Junior Doctors Network Newsletter
Issue 17
March 2020
Medical Ethics Challenges Related to Mental Health in Europe:
Views from a French Junior Doctor
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 29
Audrey Fontaine, MD
Chair (2019−2020)
Junior Doctors Network
World Medical Association
Today, person-centred care has been integrated into health
care service delivery, recognised as more efficient and ethical
practices. However, services and practices do not always
reflect this knowledge.
cases when the distorted perception of reality and lack of insight are primary symptoms?
Why would we force patients to be treated against their will when they are suffering from a
psychiatric illness, but not if they were suffering from cancer? Is this an ethical approach?
Are we respecting human rights and dignity while administrating involuntary treatments,
such as prescribing pills, giving injections or placing patients in isolation or with restraints?
On June 26, 2019, the European Parliamentary Assembly adopted a resolution to end
coercion in mental health treatment and promote a human rights-based approach. In
reality, the slow implementation of these measures and limited community-based mental
health services across European countries encourages reorganization of health systems.
For example, France has initiated a major reform on mental health service delivery since
2018. The Ministry of Health issued a framework for action in order to improve prevention,
health promotion, and care of persons living with mental disorders. As this framework
highlighted the importance of community-based approaches, a working group was
developed to strengthen the health finance system.
Nevertheless, psychiatrists continue to be challenged in providing person-centred care, and
ethical questions remain. Last year, the French government issued a new bylaw regarding
the management of data collected on persons with involuntary hospitalization. This bylaw
allows the government to keep patients’ personal records for three years. Many French
psychiatrists have vocally disagreed with this bylaw as unethical and stigmatising for
patients, taking it to the European Court of Justice.
Psychiatric patients frequently face non-psychiatric illnesses that can be misattributed to
mental illness and lead to delayed treatments. It has been shown that health professionals
can demonstrate unconscious biases, hidden beliefs, and behaviours that may contribute to
stigmatizing experiences among patients (4). It can also serve as a barrier to recovery for
people seeking help for mental illnesses (5). Thus, health professions education should
focus on raising awareness and minimizing associated stigma through appropriate didactic
coursework and clinical rotations.
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March 2020
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Stigma and prejudice against mentally ill persons are
additional ethical challenges that can lead to reduced access
to health care services and higher mortality rates.
To conclude, mental health is one of the health fields where ethics, culture, and social
beliefs are interwoven and have a crucial impact on the delivery of health care services.
The nature of psychiatric illnesses raises challenging and fascinating questions about
human rights, patients’ autonomy, and health systems’ organizations. It is therefore
essential to create a fit-for-purpose workforce who would be fully aware of the emerging
challenges that mental health faces nowadays.
References
1) World Bank. World Development Report 2002: building institutions for markets. New York: Oxford
University Press; 2002.
2) Knapp M, McDaid D, Mossialos E, Thornicroft G; World Health Organization, Regional Office for Europe.
Mental health policy and practice across Europe: the future direction of mental health care. Maidenhead
[England]: Open University Press; 2007.
3) Niveau G, Materi J. Psychiatric commitment: over 50 years of case law from the European Court of
Human Rights. Eur Psychiatry. 2007;22:59–67.
4) Knaak S, Patten S. A grounded theory model for reducing stigma in health professionals in Canada. Acta
Psychiatr Scand. 2016;134:53–62.
5) Henderson C, Noblett J, Parke H, Clement S, Caffrey A, Gale-Grant O, Schulze B, Druss B, Thornicroft
G. Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry.
2014;1:467–482
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March 2020
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Ethical practices in the field of mental health require
awareness, sensitivity, and empathy for patients as
individuals, while respecting their cultural values and beliefs.
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March 2020
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WMA Declaration of Geneva
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WMA International Code of Medical Ethics
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WMA International Code of Medical Ethics
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WMA Declaration of Helsinki
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WMA Declaration of Helsinki
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WMA Declaration of Helsinki
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WMA Declaration of Helsinki