JDN_23NL_Aug2021

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 23
August 2021
ISSN (print) 2415-1122
ISSN (online) 2312-220X
Junior Doctors Leadership 2020-2021
Junior Doctors Network Newsletter
Issue 23
August 2021
CHAIRPERSON
DEPUTY
CHAIRPERSON
SECRETARY
SOCIO-MEDICAL
AFFAIRS OFFICER
EDUCATION
DIRECTOR
MEDICAL ETHICS
OFFICER
MEMBERSHIP
DIRECTOR
PUBLICATIONS
DIRECTOR
COMMUNICATIONS
DIRECTOR
IMMEDIATE PAST
CHAIRPERSON
Dr Yassen Tcholakov
Canada
Dr Julie Bacqué
France
Dr Wunna Tun
Myanmar
Dr Manon Pigeolet
Belgium
Dr Helena Chapman
Dominican Republic
Dr Lyndah Kemunto
Kenya
Dr Lwando Maki
South Africa
Dr Uchechukwu Arum
Nigeria/United Kingdom
Dr Maki Okamoto
Japan
Dr Chukwuma
Oraegbunam
Nigeria
Page 2
Editorial Team 2020−2021
Junior Doctors Network Newsletter
Issue 23
August 2021
Dr Victor Animasahun
Nigeria
Dr Nishwa Azeem
Pakistan
Dr Sejin Choi
Republic of Korea
Dr Ricardo Correa
Panama/United States
Dr Giacomo Crotti
Italy
Dr Mashkur Isa
Nigeria/United Kingdom
Dr Jooyoung Moon
Republic of Korea
Dr Jeazul Ponce H.
Mexico
Dr Parth Patel
Malawi
Dr Vandrome Nakundi
Kakonga
Dem. Rep. of Congo
Dr Mellany Murgor
Kenya
Dr Suleiman A. Idris
Nigeria
Page 3
Table of Contents
TEAM OF OFFICIALS’ CONTRIBUTIONS
07 Words from the Chairperson
By Dr Yassen TCHOLAKOV (Canada)
08 Words from the Communications Director
By Dr Maki OKAMOTO (Japan)
09 Words from the Medical Ethics Working Group Chair
By Dr Lwando MAKI (South Africa)
11 Words from the Medical Ethics Working Group Project Co-Lead
By Dr Aashish KUMAR SINGH (India)
12 Words from the Medical Ethics Working Group Project Co-Lead
By Dr Uchit THAPA (Nepal/United States)
13 Words from the Publications Director
By Dr Helena CHAPMAN (Dominican Republic)
REFLECTIONS
14 Reflections about Promoting Medical Ethics
By JDN Publications Team
18 Reflections about Promoting Medical Ethics
By JDN Members of the Medical Ethics Working Group
JUNIOR DOCTORS’ PERSPECTIVES
AFRICA
20 Ethical Dilemmas during the COVID-19 Pandemic: Reflections from
the Frontline
By Dr Mellany MURGOR (Kenya), Dr Joshua OTIENO (Kenya), and Dr Robert
OKINYI (Kenya)
23 COVID-19 Protocol in Implementation: ‘The Insignificant Contacts’
By Dr Habeeb OGUNDIPE (Nigeria)
Junior Doctors Network Newsletter
Issue 23
August 2021
Page 4
Table of Contents
27 Confidentiality: Until Death Do Us Part?
By Dr Mary Adaeze UGAH (Nigeria) and Dr Kelechukwu ORANU (Nigeria)
30 Signing against Medical Advice in the Emergency Room: An Ethical
Dilemma
By Dr Dabota Yvonne BUOWARI (Nigeria)
32 A Cursory Look at the Ethical Challenges of Surgical Residency and
Fellowship Training
By Dr Musliu Adetola TOLANI (Nigeria)
AMERICAS
35 COVID-19 and Bioethical Challenges: The Limits of Professional
Autonomy
By Dr Andrey OLIVEIRA DA CRUZ (Brazil) and Dr José GUILHERME DE
OLIVEIRA (Brazil)
38 Ethics in Public Health: Commentary from a Junior Doctor
By Dr Rujvee PATEL (India/United States)
40 The Blame Game: Providers under Pressure
By Dr Uchit THAPA (Nepal/United States)
ASIA
42 A Pandemic and Fractured Mental Health
By Dr Aashish KUMAR SINGH (India)
44 Involving Medical Students as COVID-19 Warriors: An Ethical Critique
By Dr Shiv JOSHI (India)
48 Ethical Issues on Task Shifting in the Healthcare System: Observed
Practices in the Republic of Korea
By Dr Jihoo LEE (Republic of Korea)
Junior Doctors Network Newsletter
Issue 23
August 2021
Page 5
Table of Contents
52 Myanmar Junior Doctors Uphold the Physician Pledge while Defying
the Coup
By Dr Wunna TUN (Myanmar)
EUROPE
54 COVID-19 and Mental Health
By Dr Francesco ROSIELLO (Italy)
MULTIPLE REGIONS
57 Racism: The Insidious Social Determinant of Health
By Dr Eleleta Surafel ABAY (Ethiopia), Dr Ian PEREIRA (Canada), Dr Mellany
MURGOR (Kenya), Dr Merlinda SHAZELLENNE (Malaysia), Dr Shiv JOSHI
(India), Dr Wunna TUN (Myanmar), and Dr Flora KUEHNE (Germany)
WMA DECLARATIONS
62 WMA Declaration of Geneva
63 WMA International Code of Medical Ethics
65 WMA Declaration of Helsinki – Ethical Principles for Medical Research
Involving Human Subjects
69 WMA Declaration of Cordoba on Patient-Physician Relationship
Junior Doctors Network Newsletter
Issue 23
August 2021
Page 6
Dear colleagues,
It is my pleasure to introduce this special edition of the Junior Doctors Network (JDN)
Newsletter. Congratulations are in order for the Medical Ethics Working Group, with a
dynamic team that has supported JDN contributions on this important theme for the second
year in a row! Also, we recognize the hard-working and always reliable Publications Team
that has guided the editorial process and worked closely with JDN members!
Ethics is a core tenet of the medical profession, which is why doctors are among the most
trusted individuals in many societies. Nevertheless, this past year has proven fraught with
ethical dilemmas, from prioritising resources during the worst times of this pandemic, to
adapting new ways of practicing medicine while trying to preserve quality of care,
confidentiality, and patient trust. This year was also marked by a series of disruptions in
training programs by re-deployments, where junior doctors were sometimes asked to
perform care in less than optimally supervised settings outside their field of expertise.
Finally, the topic of racism, gender inequity, and other injustices are of foremost concern,
with respect to how we treat patients and how we manage collegial interactions within our
profession. While we try to hold ourselves to high standards of civility and respect, there is
evidence of sexism and discrimination within our own profession. Women and other
marginalized groups are often underrepresented in medical leadership, despite
representing a major portion of the global health workforce. As the next generation of
medical professionals, we must promote improved working conditions and encourage
inclusive workplace environments for all health professionals.
Enjoy the read!
Sincerely,
Yassen Tcholakov
Junior Doctors Network Newsletter
Issue 23
August 2021
Words from the Chairperson
TEAM OF OFFICIALS’ CONTRIBUTIONS
Yassen Tcholakov, MD MScPH MIH
Chairperson (2020−2021)
Junior Doctors Network
World Medical Association
Page 7
It is my pleasure to welcome you to the Medical Ethics Special Edition of the Junior Doctors
Network (JDN) Newsletter.
In their daily clinical practice, junior doctors encounter workplace situations that require the
application of medical ethics principles for difficult decisions. The decision-making process
in medical ethics is complex and challenging as there are no absolute answers. It is further
compounded by a lack of comprehensive or clear guidelines which cover the unique
situations that junior doctors encounter each day in their workplace.
Under these circumstances, it is important to promote positive communication with patients
and their families, where junior doctors actively listen to patients, provide adequate
information, and support their decisions. As JDN members, we play a significant role in
direct patient care during our training. Our empathetic listening and understanding is
essential, especially during difficult life decisions such as the management of severe
coronavirus disease 2019 (COVID-19) infections and end-of-life care.
Please enjoy reading this Special Edition and be inspired by your JDN colleagues who
share their various experiences and perspectives on medical ethics topics. We hope that
this resource offers valuable ideas that can guide you during your training.
Sending love from Berlin,
Maki Okamoto
Junior Doctors Network Newsletter
Issue 23
August 2021
Words from the Communications Director
Maki Okamoto, MD
Communications Director (2020−2021)
Junior Doctors Network
World Medical Association
Dear colleagues,
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 8
On behalf of the Medical Ethics Alive Team (2020−2021) of the Junior Doctors Network
(JDN) Medical Ethics Working Group, it is with great pleasure that I introduce the 2nd
annual Medical Ethics Special Edition of the JDN Newsletter.
In the World Medical Association (WMA)’s Medical Ethics Manual (2015), medical ethics is
recognised as the branch of ethics that examines moral issues in medical practice, with
strong connections to biomedical ethics. It clarifies that medical ethics primarily addresses
issues that originate in medical practice, whilst biomedical ethics focuses on moral issues
that arise from the biological sciences. Medical ethics forms the foundation of the medical
profession and comprises an integral part of global health.
Over the past decades, medical ethics has been brought into the limelight, as a result of
the active participation of health professionals in national and international discussions on
clinical competencies and responsibilities, human and animal research, patient
confidentiality and autonomy, and end-of-life care. The current coronavirus disease 2019
(COVID-19) pandemic has highlighted the importance of medical ethics as well as the
urgent need for medical curricula reform. As such, it behooves junior doctors to take the
lead in championing efforts to increase awareness about medical ethics topics in clinical
practice amongst the global health workforce.
This 2nd annual Medical Ethics Special Edition of the JDN Newsletter marks the first
anniversary of the historic milestone recognized as the first JDN officer collaboration. This
collaboration between the JDN Publications Team and the JDN Medical Ethics Working
Group is a symbol of the leadership, synergy, and enthusiasm of junior doctors who share
their experiences and expertise on topics that affect junior doctors in the clinical and
community workplace.
Junior Doctors Network Newsletter
Issue 23
August 2021
Words from the Medical Ethics Working Group Chair
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 9
Lwando Maki, MD
Medical Ethics Officer (2020−2021)
Medical Ethics Working Group Chair (2020−2021)
Junior Doctors Network
World Medical Association
Dear Junior Doctors, Members of the WMA, and Colleagues in health,
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
Lwando Maki
Junior Doctors Network Newsletter
Issue 23
August 2021
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 10
In this era of globalisation and capitalism, where the world is mostly driven by financial
gain, ethics is often overlooked. We observe this scenario within the medical community,
where hospitals often disregard the rights of health care workers and exploit them to the
point of burnout. Similarly, medical students are not universally taught about ethical
principles and challenging clinical scenarios, which can impact their clinical training and
doctor-patient rapport and communication.
As Junior Doctors Network (JDN) members, we must collaborate on initiatives that promote
the understanding of ethical principles in the health professions. By better understanding
the role of medical ethics in clinical and community health practice, we will be prepared to
highlight unethical practices, advocate for improved workplace conditions, and contribute
significantly to global health discussions on best approaches for the future of health care
service delivery.
It has been an honor to serve as project co-lead on the innovative development of this
second Medical Ethics Special Edition with my colleagues, Dr Uchit Thapa (Project Co-
Lead, Medical Ethics Working Group) and Dr Lwando Maki (Chair, Medical Ethics Working
Group). Likewise, I appreciate the leadership of Dr Helena Chapman (Director, Publications
Team), who has led the editorial process with utmost sincerity and dedication for this
unique collaboration. I also recognize the editorial expertise of the JDN Publications Team,
who has supported this collaboration and editorial tasks to completion. Finally, I thank all
JDN member 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 Kumar Singh
Junior Doctors Network Newsletter
Issue 23
August 2021
Words from the Medical Ethics Working Group Project Co-Lead
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 11
Aashish Kumar Singh, MBBS
Medical Ethics Working Group Project Co-Lead (2020−2021)
Junior Doctors Network
World Medical Association
Dear colleagues,
Medical ethics defines us as physicians, guides us towards perfecting our medical practice,
and helps us find the correct path in times of dilemma. During our medical training,
although we are trained to solve medical mysteries, little emphasis is placed on
understanding our patients as individuals and family members. We also learn the essential
skills of empathetic listening and communication throughout our clinical rotations.
The Medical Ethics Working Group of the Junior Doctors Network (JDN) aims to highlight
the importance of medical ethics through our clinical activities. We guide individuals in
different phases of medical practice, identify challenges facing young physicians, answer
questions through our collective experiences, and make our voices heard on an
international platform. The JDN has played a crucial role in promoting the value of junior
doctors, including advocating for pressing ethical issues such as gender equity in medical
leadership and the impacts of climate change. Over the years, these achievements have
been successful in bridging the gap between young doctors and audiences worldwide.
The JDN Newsletter has served as a perfect platform where young physicians can raise
their voices about health challenges, advocate for vulnerable populations, and present
solutions to authorities. This resource has always provided young doctors with a voice
without discrimination and highlighted issues of utmost importance on the international
stage. I believe that this Special Edition will continue to provide valuable information to
young doctors around the world.
I would also like to take this opportunity to applaud Dr Lwando Maki for the highly
recommendable work put forth in the field of medical ethics, leading the JDN Medical
Ethics Working Group to new heights, and bestowing confidence in myself as the Project
Co-lead. Also, I offer my utmost respect to Dr Helena Chapman and the JDN Publications
Team for their relentless efforts and time invested for years devoted to JDN activities.
Lastly, I would like to thank all authors who have contributed to the JDN Newsletter and all
readers who will gain insight from included scientific perspectives and clinical experiences.
Sincerely, Uchit Thapa
Junior Doctors Network Newsletter
Issue 23
August 2021
Words from the Medical Ethics Working Group Project Co-Lead
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 12
Uchit Thapa, MBBS
Medical Ethics Working Group Project Co-Lead (2020−2021)
Junior Doctors Network
World Medical Association
Dear respected junior doctors,
Dear JDN colleagues,
On behalf of the Publications Team (2020-2021) of the Junior Doctors Network (JDN), we
are excited to share the Medical Ethics Special Edition of the JDN Newsletter with junior
doctors across the world.
This 23rd issue of the JDN Newsletter marks the second collaborative effort between the
JDN Publications Team and the JDN Medical Ethics Working Group to develop a joint
Special Edition issue. This collaboration exemplifies the enthusiasm, passion, and
leadership of junior doctors who share key clinical and community health experiences and
perspectives on topics related to medical ethics.
The JDN Newsletter offers a global stage for junior doctors across the globe to contribute
and disseminate updates on JDN activities, critical analyses on emerging health issues,
and reflections on clinical and community experiences. Their inspirational activities can
empower other junior doctors to seek opportunities to share their expertise and
experiences, engage in valuable collaborations, and strengthen communication between
JDN members and the World Medical Association (WMA).
We recognize the dedicated efforts of all leaders of the Medical Ethics Working Group and
editors of the JDN Publications Team 2020-2021, as we finalized this 23rd issue. We
greatly appreciate the continued support of the JDN Management Team and WMA
leadership as our team refined the content of this high-quality resource for junior doctors.
We appreciate the support of our JDN family and hope that you enjoy reading about junior
doctors’ experiences in this 23rd issue!
Together in health,
Helena Chapman
Junior Doctors Network Newsletter
Issue 23
August 2021
Words from the Publications Director
Helena Chapman, MD MPH PhD
Publications Director (2020−2021)
Junior Doctors Network
World Medical Association
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 13
Junior Doctors Network Newsletter
Issue 23
August 2021
Reflections on Promoting Medical Ethics
by the JDN Publications Team (2020−2021)
PUBLICATIONS TEAM’S CONTRIBUTIONS
Dr Helena Chapman (Dominican Republic)
As junior doctors, we must promote high-quality principles of
medical ethics in our daily clinical and community practice. By
reviewing the principles of medical ethics through case studies, we
can enhance our analytical skills and be prepared on how to best
manage and communicate ethical challenges with our colleagues
as well as patients and families. Together, we can advocate for
best clinical practices that prioritize medical ethics across our
health systems.
Dr Victor Animasahun (Nigeria)
Medical ethics is the standard code of conduct that guides our daily
clinical practice. It is the unbiased framework for making fair and
safe clinical decisions and forms the blueprint for navigating ethical
dilemmas.
Dr Nishwa Azeem (Pakistan)
I believe that the basis of medical ethics in practise is respect. We
must view our patients as enabled and equal individuals, who we
seek to serve as a part of our duty.
Page 14
Junior Doctors Network Newsletter
Issue 23
August 2021
PUBLICATIONS TEAM’S CONTRIBUTIONS
Dr Ricardo Correa (Panama/United States).
Medical ethics offers a framework for the best practice of medicine
in a humane and empathetic manner. The principles of medical
ethics should govern our clinical practice, and we should advocate
that ethical practices should be widely applied across health
systems.
Dr Suleiman Ahmad Idris (Nigeria)
As a thin line exists between ‘Medical Doctor’ and ‘Doctor
Frankenstein’, medical ethics ensures that we do not cross this line
while delivering our services to humanity. We should create time to
learn the ethics of medical practice and advocate for its consistent
application in our daily clinical responsibilities.
Dr Giacomo Crotti (Italy)
The COVID-19 pandemic and resulting public health measures –
social distancing and vaccination efforts – have uncovered a
defining dilemma of public health ethics: the complex balance
between individual rights and public interest. In light of the
pandemic response efforts, the need to alternatively compress
autonomy over utility forces us to reflect: Can increased community
awareness of this dilemma improve adherence and participation?
As doctors, we can advocate for in-depth discussions that lead to
community action.
Page 15
Junior Doctors Network Newsletter
Issue 23
August 2021
PUBLICATIONS TEAM’S CONTRIBUTIONS
Dr Mashkur Abdulhamid Isa (Nigeria/United Kingdom)
To me, Medical Ethics refers to the moral codes and values that
guide the practice and conduct of medical professionals, based on
the principles of autonomy, beneficence, non-maleficence, and
justice. In a rapidly changing world, ethics is invaluable to ensure
that medical professionals are able to fulfill their obligations in
patient care.
Dr Jooyoung Moon (Republic of Korea)
As physicians, we often have to make difficult health care decisions
for our patients. While everyone may have a different set of moral
values, we cannot make such decisions based on our emotions or
personal preferences. It would help to remember that, in any case,
we must always act in the best interests of our patients.
Dr Mellany Murgor (Kenya)
Medical ethics guides the practice of medicine and offers a platform
for the continued discussion of evolving topics in clinical practice. It
is shaped by various internal and external determinants in health,
with various perspectives that should be understood. As junior
doctors, we have the opportunity to advocate for high ethical
standards that shape the future of medical practice. We must
continue to share our experiences, learn from past mistakes, and
prioritize ethical principles throughout our training.
Page 16
Junior Doctors Network Newsletter
Issue 23
August 2021
PUBLICATIONS TEAM’S CONTRIBUTIONS
Dr Vandrome Nakundi Kakonga
(Democratic Republic of the Congo)
Many ethical questions are raised by health systems in low-income
countries, including challenges faced by patients who cannot afford
medical care for their families. Doctors, who accept their
professional devotion to patient care, may face significant
limitations when providing clinical care. Universal health coverage is
a global priority, as doctors are trained to care for all individuals, not
only those who are financially secure to afford care.
Page 17
Junior Doctors Network Newsletter
Issue 23
August 2021
WORKING GROUP MEMBERS’ CONTRIBUTIONS
Dr Dabota Yvonne Buowari (Nigeria)
The practice of medicine is guided by the application of the
principles of medical ethics. In our clinical practice, we can promote
high-quality ethical practices that can prevent misunderstanding and
potential litigation, enhance patient-doctor rapport, and manage
ethical dilemmas.
Dr Shiv Joshi (India)
As doctors, our actions and approaches in medicine reflect our
identity, priorities, and underlying values. We must continue to
promote the practise of ethically competent medicine in our daily
clinical practice.
Dr Kelechukwu Oranu (Nigeria)
Medical ethics offers a check in medical practice for health
professionals. It ensures that patients’ decisions for management
plans are respected and that treatment protocols result in maximum
benefit with minimal harm.
Page 18
Reflections on Promoting Medical Ethics
by JDN Members
Junior Doctors Network Newsletter
Issue 23
August 2021
WORKING GROUP MEMBERS’ CONTRIBUTIONS
Dr Jasmine Shrestha (Nepal)
When the difference between right and wrong becomes blurred or
complicated, our application of medical ethics based on moral
principles and values can guide our clinical decisions.
Dr Mary Adaeze Ugah (Nigeria)
Medical ethics is a career-long process of understanding, analysing
and properly managing a plethora of distinct clinical scenarios that
usually occur. As doctors, we must use the basic tenets of ethics –
autonomy, do good, do no harm, and be just – while seeking
clarification or assistance during challenging scenarios in clinical
practice.
Page 19
In medical practice, it is a general rule that the first few years after medical school
graduation are usually the most challenging time for junior doctors. As they are supervised
in their clinical training, their senior colleagues, supervisors, and teachers provide essential
guidance and recommendations. However, during the coronavirus disease 2019 (COVID-
19) pandemic, junior and senior doctors have navigated uncharted waters, pushed to the
limits with minimal time and flexibility as they deliver medical care.
First, Do No Harm: The System Fails the Hippocratic Oath
Patient A, a 65-year-old man, experienced chest pain and immediately scampered to the
nearest hospital. As a spirited fight against his diabetes and hypertension, aided by a
cocktail of medication, he knew that his ailments were well controlled. Still, he knew that he
had a heightened cardiovascular disease risk, and this chest pain did not bode well with
him. On initial assessment, we evaluated the chest pain by conducting a complete blood
Junior Doctors Network Newsletter
Issue 23
August 2021
Ethical Dilemmas during the COVID-19 Pandemic:
Reflections from the Frontline
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA
Mellany Murgor, MD
Medical Officer
Nairobi, Kenya
Joshua Otieno, MBCh.B
Medical Officer
Nairobi, Kenya
Robert Okinyi, MBCh.B
Medical Officer
Nairobi, Kenya
Page 20
This article recounts two reflections from our clinical
experiences, as we worked tirelessly on the frontline during the
ongoing COVID-19 pandemic in Kenya.
count and electrocardiogram (EKG). We noted that his oxygen saturation was teetering
between 85-90% on room air, causing slight breathlessness. His radiographic imaging
resulted in a diagnosis of atypical pneumonia. As the COVID-19 inpatient isolation unit was
almost full, he secured the last bed in the unit.
Patient B, a 38-year-old female with no known chronic illnesses, experienced rapid
breathing and traveled to the hospital. A rapid medical evaluation concluded that her
oxygen saturation was 60% on room air. Her radiographic images concluded pneumonia,
most likely due to COVID-19, and with this COVID-19 wave, facilities lacked space for
hospital admissions.
Since Patient A had registered before Patient B, Patient A was prioritized for the COVID-19
inpatient isolation unit ward bed, although Patient B had a more clinical severe COVID-19
presentation. However, Patient A had multiple risk factors that could not be ignored,
including his advanced age and other co-morbidities.
Physician, Heal Thyself
As we completed our duties during the peak periods of the pandemic in Kenya, we recall
when we were overwhelmed by COVID-19 cases for three weeks. Our clinical schedules
started at 7AM, and we would still be conducting ward rounds at 5PM. During our night
shifts, we would have to be alert all night, vigilantly caring for our COVID-19 patients. It was
often impossible to take any breaks, since we were fully donned in personal protective
equipment (PPE), which we would only remove when exiting the isolation unit. Other less
urgent albeit important tasks – such as updating patients’ next of kin – were often delayed
due to the demanding workload and worsened by visiting restrictions to maintain infection
control measures.
This scenario offers junior doctors several important reflections: Was there ever a time, in
the middle of our busy clinical shifts, when we should have prioritized our well-being over
our patients’ care? Even if we should prioritize our well-being, how could we apply this step
in practice? With rising COVID-19 cases and few medical staff, should we have bypassed
some of our institutional processes to recruit new staff and risk inadequately inducted
frontline workers on the medical team? How much harm occurred when we had barred
interactions between patients and families or delayed our clinical updates to families?
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 21
Notably, this clinical scenario of two sick patients presented an
ethical dilemma: Who should be hospitalized?
We Strive to do Better
Many global healthcare workers have provided clinical and community care, as they
continue to advance their knowledge about this novel coronavirus. Bedside clinicians have
had to engage in difficult decision-making, where each decision has benefits and risks.
Often, some decisions have already been made, due to health system inadequacies. The
price paid in these less-than-perfect circumstances include undermining patients’ care,
harming the physical and psychological well-being of healthcare workers, patients, and
families, loss of family income, risking inadequate vaccine coverage in lieu of individual
autonomy, deploying ill-trained and ill-equipped caregivers, and contributing to adverse
outcomes of patients or caregivers.
In anticipation of future pandemics and for the benefit of expanding the knowledge base of
medical ethics, it is important that junior doctors share the ethical issues that they have
faced during the COVID-19 pandemic.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 22
These collective experiences can help future doctors and
decision-makers in their clinical and community practice, as we
shape future response efforts to pandemics and other
emerging health threats.
The coronavirus disease 2019 (COVID-19) pandemic has continued to evolve since its
onset in December 2019, and signs of a third wave have already been observed (1).
Several countries and agencies have developed protocols for infection control, including
early case identification, isolation, treatment, contact identification, and quarantine. These
policies have helped control the spread of this virus, whose replication rate is higher than
previous coronaviruses of epidemiological importance, such as the severe acute respiratory
syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus
(MERS-CoV) (2). As of July 23, 2021, 192,284,207 confirmed cases and 4,136,518 deaths
due to COVID-19 have been reported (1).
Following emergency approval of several vaccines against SARS-CoV-2, many countries
are implementing vaccination programs that prioritize healthcare workers and vulnerable
populations. As of July 25, 2021, 3,646,968,156 vaccine doses have been administered
worldwide (1). This leaves a significant proportion of the population, especially in low- and
middle-income countries, largely undervaccinated.
Defining and Managing COVID-19 Contacts
Case definition. According to the World Health Organization (WHO), a COVID-19 contact is
defined as: 1) a person who has had direct physical contact or exposure within 1 meter and
for at least 15 minutes with a probable or confirmed case of COVID-19; or 2) a person who
has been involved in the direct care for a patient with probable or confirmed COVID-19
disease without the use of recommended personal protective equipment (PPE), with
exposure occurring between two days before and 10 days after the onset of symptoms (3).
Isolation. The WHO recommends that all contacts of confirmed or probable COVID-19
cases should be quarantined in a designated facility or at home for 14 days from their last
exposure (4). The Centers for Disease Control and Prevention (CDC), however, excludes
individuals who have recently been diagnosed with COVID-19 (preceding three months)
and persons fully vaccinated against COVID-19 (5).
Junior Doctors Network Newsletter
Issue 23
August 2021
COVID-19 Protocol in Implementation:
‘The Insignificant Contacts’
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA
Habeeb Ogundipe, MBBS
Junior Resident, Department of Surgery
University College Hospital
Ibadan, Oyo State, Nigeria
Page 23
The Challenge
One significant challenge in the control of this infection is the failure to follow established
protocols for COVID-19 prevention and management. The following case scenario
describes the situation of a patient with symptoms suggestive of COVID-19 in a typical
public hospital in a low-income country (Box 1).
This case scenario marks the potential exposure risk of three categories of individuals:
❑ Hospital staff: Doctors and nurses provide direct clinical care to patients.
❑ Relatives: Family members help their sick loved ones by buying medications and food,
spending time to comfort them during visiting hours, and offering additional errands.
❑ Surrounding patients and families on hospital ward: Although there is minimal direct
contact with non-relative patients, other individuals on the hospital ward may be in
contact.
If this case scenario occurs in resource-constrained settings, diagnostic testing or isolation
may not be available for close contacts of the index case, as they continue their regular
daily activities. As these COVID-19 contacts are erroneously treated as ‘insignificant
contacts’, there is an increased risk of SARS-CoV-2 transmission, especially by
asymptomatic carriers.
Clinical Evidence
One study noted that persons who directly care for individuals with the viral infection have
an increased risk of COVID-19 disease and hospitalization (6). This suggests that
healthcare workers and relatives of newly diagnosed COVID-19 cases are at the highest
risk of infection. Another study concluded that COVID-19 contact tracing is fundamental to
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 24
In some settings, a hospitalized patient with symptoms suggestive of COVID-19 is
assigned to a bed in an open general ward with other patients. In the best-case
scenario, the patient is immediately moved to a designated COVD-19 isolation
ward, and nasal swab testing is conducted. In the worst-case scenario, nasal
swab testing is conducted, and the patient remains in the open general ward until
the result is available. If the result is positive, then the patient would be relocated
to a designated COVID-19 isolation ward.
Box 1. Case scenario.
Ongoing research studies have demonstrated that infection
control measures are key to mitigate exposure risk to
susceptible individuals.
treat contacts and reduce community transmission (7). Additional infection prevention and
control measures include extensive screening for SARS-CoV-2, quarantining patients on
affected hospital wards, and use of PPE during all patient contacts. However, compliance
may be limited in certain settings, due to the health worker shortage, limited capacity on
hospital wards and quarantine facilities, and constant need of relative support to offer
support and accompaniment.
However, these considerations have been counteracted by other scientists. Another study
reported that the logistic and economic impact of implementing the protocols for COVID-19
contacts should be prioritized (8). Authors highlighted that of the 376 health workers in this
study, 94 symptomatic COVID-19 cases and 81 asymptomatic contacts of COVID-19
cases were quarantined for 10 to 14 days, and 201 health workers remained to provide
medical care. The implementation of these quarantine measures led to a depleted health
workforce for direct medical care and economic loss to the hospital (8). However, authors
failed to consider the possible role of asymptomatic individuals on COVID-19 transmission
(8). Furthermore, the CDC has provided interim guidance for individuals with high-risk
exposure in non-U.S. healthcare settings, where the decision for quarantine measures
should be balanced against several factors, including the ability to maintain staffing levels
to provide adequate care to all patients (9). This guidance, however, has led health workers
to fear for their safety as well as the safety of other health workers, patients, and families.
Although vaccination programs are ongoing and expanding to cover the entire population,
vaccination does not guarantee full immunological protection, especially with the evolving
SARS-CoV-2 strains. Thus, continued virus transmission and increased COVID-19-related
mortality may persist even when persons are fully vaccinated, suggesting the need for
additional protection, irrespective of vaccination status. All COVID-19 contacts are at risk of
viral infection, constitute a significant vehicle for disease transmission, and should be
protected irrespective of logistical constraints.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 25
Irrespective of our challenges to implement standard quarantine
protocols for COVID-19 contacts, there is a clear need to protect
patients, contacts, and society from continued disease transmission.
The continued enforcement of non-pharmacologic preventive measures – such as the use
of facemasks and handwashing hygiene – should always be emphasized. Augmenting
these measures with safe and effective chemoprophylaxis will go a long way in helping all
COVID-19 contacts. There is a need to evaluate available data on COVID-19
chemoprophylaxis and consider emergency authorization for the most promising and safe
candidates.
Conclusion
COVID-19 is still around, and no one should be considered an insignificant COVID-19
contact, irrespective of management challenges as a key factor in disease control. While
countries aim to adhere to existing hospital protocols and guidelines, there is a need to
strengthen immunological protection against COVID-19 beyond vaccination and non-
pharmacologic preventive measures. A viable and safe option remains chemoprophylaxis
against SARS-CoV-2 in both vaccinated and unvaccinated groups.
References
1) World Health Organization. WHO Coronavirus (COVID-19) Dashboard. 2021 [updated 2021 Jul 23; cited
2021 Jul 25].
2) Petrosillo N, Viceconte G, Ergonul O, Ippolito G, Petersen E. COVID-19, SARS and MERS: are they
closely related? Clin Microbiol Infect. 2020;26:729-734.
3) World Health Organization. Considerations for quarantine of contacts of COVID-19 cases. 2021 [updated
2021 Jun 25; cited 2021 Jul 25].
4) World Health Organization. Contact tracing in the context of COVID-19. 2021 [updated 2021 Feb 1; cited
2021 Jul 25].
5) Centers for Disease Control and Prevention. COVID-19: when to quarantine. 2021 [updated 2021 Jul 21;
cited 2021 Jul 25].
6) Shah ASV, Wood R, Gribben C, et al. Risk of hospital admission with coronavirus disease 2019 in
healthcare workers and their households: nationwide linkage cohort study. BMJ. 2020;371:m3582.
7) Karlsson U, Fraenkel C-J. COVID-19: risks to healthcare workers and their families. BMJ.
2020;371:m3944.
8) Uçkay I, Steinwender L, Burkhard J, Holy D, Strähl M, Farshad M. Outcomes of asymptomatic hospital
employees in COVID-19 post-exposure quarantine during the second pandemic wave in Zurich. J Hosp
Infect. 2021;113:189-191.
9) Centers for Disease Control and Prevention. COVID-19: managing exposed healthcare workers. 2021
[updated 2021 Feb 23; cited 2021 Jul 25].
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 26
Confidentiality begets trust. As an underlying principle of medical ethics, it behooves every
medical practitioner to ensure that trust is never tampered with or disregarded (1,2).
Although it is a non-negotiable tenet of medical practice, there are exceptional situations
where patient information may be disclosed. For instance, the law may require the release
of patient information when preparing a coronary report or death certificate for the Ministry
of Health records. It also may occur when meeting a statutory duty of candour, described
when there is imminence of harm to identifiable individuals or public health (e.g. disease
outbreak) or when there is potential benefit to at-risk individuals or public health (e.g.
genetic disease) (2,3). However, some patient deaths can lead to a multiplex state, where
healthcare providers must decide whether and which information to share with family
members and health authorities.
Clinical Scenario 1
An Instagram video surfaced of the family member of a deceased patient (Patient A) who
was treated in a public hospital prior to his death. The hospital management were
implicated for the death of Patient A by the relatives. They claimed that they were unaware
of the kind of care given to Patient A, who was frequently left unattended. As the social
media video went viral, people expressed shock at the alleged hospital negligence. In
response to these allegations, the hospital’s next action was intriguing: The hospital
directors revealed classified medical records of the Patient A, noting that these records had
already been publicized by the relatives (4).
Junior Doctors Network Newsletter
Issue 23
August 2021
Confidentiality: Until Death Do Us Part?
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA
Mary Adaeze Ugah, M.B.S.S.
Medical Officer
Benin City, Nigeria
Kelechukwu Oranu, M.B.B.S.
Medical Officer, Police Clinic Abakpa
Enugu, Nigeria
Page 27
The question remains: Can confidentiality be respected when
patients die? Let’s take a closer look at two real-life ethical
scenarios that occurred in Nigeria in May 2021.
Clinical Scenario 2
A prominent female (Patient B) had an elective surgery, but later died as a result of
unexpected surgical complications (5). The public was agog and called for serious
sanctions of all responsible individuals. Her family conducted a public interview and shared
medical information about Patient B. The hospital management, however, only made a few
comments about this case, which the public viewed as a passive act to facilitate damage
control. Later, in a letter shared with the public, the hospital management explained that
they did not provide full details about Patient B’s medical records, due to patient
confidentiality (6).
Analysis
Second, the relatives had observed the kind of medical care that was provided to patients
(7). When patients and caregivers are not aware of medical management, the health team
frequently receives blame when any adverse outcome occurs.
Third, purported details of patients’ ailments were already in the public domain, courtesy of
the relatives who breached ethical protocol. Medical practice, which involves establishing
trust and rapport with patients and society, entails maintaining privacy and confidentiality of
entrusted health information (2). Although doctors must adhere to these ethical principles,
there are reasonable exceptions to overlook such confidentiality, as noted in instances
where public safety is threatened. Doctors may be tempted to divulge health information,
especially in the face of denunciation due to inaccurate and misleading details of medical
diagnosis, treatment or behavior. However, a moral doctor should always comply with
ethical and legal principles, and where in doubt, seek advice of experienced colleagues,
professional bodies or legal counsel.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 28
Photo 1. Bedside.
Credit: Bret Kavanaugh on Unsplash.
Public opinion believed that doctors of patient A, not patient
B, acted correctly. However, how did these cases escalate
to this point (Photo 1)?
First, by virtue of their caregiving roles, relatives of Patients
A and B had access to their health records as well as the
issued death certificates. They may have also received
information from known breaches, such as other medical
personnel or side comments from doctors, which is a
common occurrence in low- and middle-income countries
(1).
By analyzing these two clinical scenarios, we emphasize that confidentiality, as a
fundamental requirement of medical practice, should be protected at all times. Healthcare
providers should prioritize effective communication skills with patients and family members
about medical management at every step of clinical care. There are situations, however,
where doctors may be swayed by public sentiments to disclose patient information,
especially in the advent of death, as noted in these described scenarios. These actions can
be averted by applying the basic principles of ethics, respecting the rule of law, and
seeking counsel.
References
1) Beltran-Aroca CM, Girela-Lopez E, Collazo-Chao E, Montero-Pérez-Barquero M, Muñoz-Villanueva MC.
Confidentiality breaches in clinical practice: what happens in hospitals? BMC Med Ethics. 2016;17:52.
2) General Medical Council (United Kingdom). Confidentiality: good practice in handling patient information.
General Medical Council. 2017 [cited 2021 Jun 8].
3) Subramani S. The uninformed spouse: balancing confidentiality and other professional obligations. Indian
Journal of Medical Ethics. 2019;4:211-215.
4) Adeyemo WL. LUTH: Ukato was well attended to before he died. The News Nigeria. 2021 [cited 2021 Jun
7].
5) Adelagun O. Family accuses hospital of negligence in death of Lagos chef. Premium Times. 2021 [cited
2021 Jun 7].
6) Kenechukwu S. ‘We can’t breach client confidentiality’ — hospital declines enquiries on Peju Ugboma’s
death. The Cable Lifestyle. 2021 [cited 2021 Jun 7].
7) Petronio S, Sargent J, Andea L, Reganis P, Cichocki D. Family and friends as healthcare advocates:
dilemmas of confidentiality and privacy. Journal of Social and Personal Relationships. 2004;21:33-52.
Junior Doctors Network Newsletter
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August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 29
As junior doctors, we can advocate for confidentiality and the use
of ethical principles as we care for and communicate with our
patients and their family members.
Signing against medical advice (SAMA) is also known as leaving against medical advice
(LAMA), discharge against medical advice (DAMA), or leaving before the visit or admission
is complete (LBVC). SAMA occurs when hospitalized patients who are mentally and
psychologically stable decide to discharge themselves and discontinue treatment. They
sign a formal document that confirms that they have been counselled by healthcare
professionals about their illness and willingly decide to forego further treatment and accept
any consequence of their actions. Hence, healthcare professionals would no longer be held
responsible for any future health complication.
Globally, DAMA patients may decide to leave the hospital prior to admission or while being
managed as in-patients, accounting for 1% of the total number of in-patients (1,2).
Adequate definitive care and treatment is the principle behind hospitalization, in order to
reduce risk of life-threatening consequences (2). If DAMA patients seek medical care after
discharge, it may impose additional stress, health risks, and financial costs to patients and
health facilities (2,3).
In the emergency department, SAMA patients represent a high-risk population, irrespective
of their illness. Patients decide to leave the hospital for various reasons, affected by cultural
or religious beliefs, traditions, and disagreement with hospital regulations (4). Hospitals
have established several measures to document the request by SAMA patients, and
attending physicians counsel patients about their health conditions and must attest that
patients are mentally and psychologically stable (5).
Junior Doctors Network Newsletter
Issue 23
August 2021
Signing against Medical Advice in the Emergency Room:
An Ethical Dilemma
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA
Dabota Yvonne Buowari, MD
Department of Accident and Emergency
University of Port Harcourt Teaching Hospital
Port Harcourt, Rivers State, Nigeria
Page 30
This is a significant burden in low- and middle-income countries,
where citizens have limited access to health insurance and most
patients have to pay out-of-pocket expenses.
Ethical Implications of Signing against Medical Advice
Since doctors must respect the autonomous decisions of SAMA patients, there are
potential ethical implications that expose physicians to litigations of SAMA (5). For
example, if patients’ health deteriorates after leaving the hospital, they may sue physicians
for authorizing their discharge home or disagree with the DAMA signed by relatives or
caregivers (6,7). This can subsequently cause a disruption in patient-doctor relationships,
affecting the ethical principles of autonomy and beneficence (6,7). Due to communal living
in low- and middle-income countries, the decision-making process is often made by other
family members, rather than individual patients – whether the head of the family, oldest
male family member, husband or father-in-law, financially responsible family member or
religious leader.
Conclusion
Patients who seek medical care in the emergency room may decide to discharge
themselves against medical advice, which can lead to ethical dilemmas and exposure of
physicians to litigation.
References
1) Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp
Med. 2008;3:403-408.
2) Ismail AK, Mohamad AS, Che’ Man Z. Factors associated with discharge against medical advice from the
emergency department, Universiti Kebangsaan Malaysia Medical Centre. Med & Health. 2016;11:29-37.
3) Oyira EJ, Mgbekem M, Edet OB. Factors associated with discharge against medical advice among
patients in University of Calabar Teaching Hospital Calabar (UCTH). Global Journal of Pure and Applied
Sciences. 2016;22:91-100.
4) Abuzeyad FH, Farooq M, Alam SF, et al. Discharge against medical advice from the emergency
department in a university hospital. BMC Emerg Med. 2021;21.
5) Akinbodewa AA, Adefumo OA, Adejumo OA, et al. Evaluation of administration of discharge against
medical advice: ethico-legal considerations. Nig Postgrad Med J. 2016;23:141-145
6) Fadare JO, Jemilohum AC. Discharge against medical advice ethico-legal implications from an African
perspective. South African Journal of Bioethics and Law. 2012;5:1-9.
7) Bohara TP. Ethical and legal issues of left against medical advice discharge. Journal of Society of
Surgeons of Nepal. 2015;17:1-2.
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August 2021
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To minimize potential risks, physicians should take measures
to document their clinical management as well as counselling
efforts with patients in their clinical notes, especially for
SAMA, DAMA, and LBVC patients.
Surgical education is complex and requires the theoretical application of clinical knowledge
for patient management. Hands-on skills are obtained and refined through years of training
in surgical residency and fellowship programs.
Patient Consultations for Surgical Procedures
As trainees prepare for surgical procedures, especially trainees in the early curve of their
learning, peri-operative safety and surgical outcomes are of significant concern. As such,
training centers have a structured system to supervise procedures. For example, trainees
are initially introduced to simple and isolated tasks during the surgical procedure before
they are certified to be competent to handle more technically challenging and complete
procedures. Notwithstanding, conflict can ensue between teams’ internal control to
maintain beneficence and non-maleficence in a training setting and ensure social justice.
Future surgeons are trained to provide in-depth descriptions of the surgical intervention,
including the composition of the surgical team, and encourage patients’ autonomy as they
make decisions for their care. They must gain rapport with patients, in efforts to eliminate
any erroneous perception of being experimented upon and any concerns about the level of
patient-centered care (1).
Application of Surgical Simulations and New Technologies
This ethical dilemma to maintain professional education has indeed led to the increased
adoption of simulation for surgical training. As practice is said to lead to improvement and
subsequent perfection, it cannot be overemphasized in surgical training. This innovative
technology has been used to enhance technical skills education through augmented
perception of the sense organs via haptic feedback, mastery of hand-eye coordination, and
Junior Doctors Network Newsletter
Issue 23
August 2021
A Cursory Look at the Ethical Challenges of Surgical
Residency and Fellowship Training
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 32
Musliu Adetola Tolani, MBBS PGCertPH(Liv) FWACS FMCS
Department of Surgery, Ahmadu Bello University
Zaria, Kaduna State, Nigeria
Shurhabil Tahir Mustapha
Ahmadu Bello University
Zaria, Kaduna State, Nigeria
This training comes with unique ethical considerations, especially
with patient consultations for surgical procedures and the
application of surgical simulations and new technologies.
the perfection of surgical skills with optimal speed and minimal errors. Today, its application
ranges from use in simple procedures, such as bowel anastomosis and excision of soft
tissue swelling, to more complex surgeries, like hepatic resection and laparoscopic
operations (2).
Animal and Computer-based Models. Live animals have been used in wet laboratories as
models for simulation training. Ethical concerns have been centered on the potential
benefits and risks of these invasive procedures conducted on animals during the simulation
training. With technological advances leading to the emerging use of virtual and augmented
reality for training purposes, some issues associated with animal rights have been
obviated. Others have argued, however, that this new training method may have
challenges related to integrating non-technical skills, which are germane to the value-based
system of ethics (3). Furthermore, the predictive validity of this tool in real practice and its
capability to completely assess competence need further research.
Artificial Intelligence. The emerging trend of the use of artificial intelligence in surgery may
simplify decision making in patient management. Implications, however, may include a
deficit in the comprehension of core pathophysiological principles by trainees. Another
critique of this pathway is the notion that this technology does not incorporate the factor of
empathy in the provision of care (4).
Virtual Technology. First, many health institutions have integrated online data systems to
manage medical records. Although privacy rules on the handling of medical information
exist, any data breach can result in significant consequences for patient care and the
healthcare system. Second, video-based teaching has the potential to expand instructional
content as well as create a community of practice. However, strict rules must caution
trainees about the legal implications of posting uncensored information without patient
consent.
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Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 33
In addition to traditional hospital-based records, the internet has
provided tremendous opportunities to advance surgical training.
Additional Ethical Considerations
A few other ethical issues remain in relation to the use of surgical simulations. First,
conflicting interests of surgical innovators with dual affiliations to industries and healthcare
institutions could affect robust validation before its incorporation into training. Second, the
costs of surgical education tools and the overall benefits to trainees and patients may be
unknown and contentious (5). Third, there are disproportionate levels of access to high
fidelity simulation systems between low-, middle-, and high-income countries, which
stresses the need to promote global surgery education, research, and training.
Some activities are limited, however, by the ethical requirements of medical licensing for
practice within specific countries (6).
To conclude, surgical training in residency and fellowship programs is complex and is
supported by various educational aids and faculty supervision. As junior doctors, we should
recognize the ethical considerations that impact surgical training as well as patient
management. After all, it is important to consider the thin line between clinical training and
breaching one of the basic tenets of clinical practice, primum non nocere (first, do no
harm).
References
1) Brenna C, Das S. Imperfect by design: the problematic ethics of surgical training. J Med Ethics.
2021;47:350-353.
2) Agha RA, Fowler AJ. The role and validity of surgical simulation. Int Surg. 2015;100:350-357.
3) Pinar G, Peksoy S. Simulation-based learning in healthcare ethics education. Creat Educ. 2016;7:131-
138.
4) Elnikety S, Badr E, Abdelaal A. Surgical training fit for the future: the need for a change. Postgrad Med J.
2021;0:1-4.
5) Satava RM. Laparoscopic surgery, robots, and surgical simulation: moral and ethical issues. Semin
Laparosc Surg. 2002;9:230-238.
6) Cunningham AJ, Stephens CQ, Ameh EA, Mshelbwala P, Nwomeh B, Krishnaswami S. Ethics in global
pediatric surgery: existing dilemmas and emerging challenges. World J Surg. 2019;43:1466-1473.
Junior Doctors Network Newsletter
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August 2021
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To address these challenges, the twinning model – or
partnerships among academic institutions in low- and middle-
income countries and high-income countries – has been
employed as a means to expose surgeons to surgical procedures.
The World Medical Association (WMA) recognizes professional autonomy and clinical
independence as “essential elements in providing quality health care to all patients and
populations” (1). Professional autonomy, which is defined as the state of being independent
and self-directing in making decisions, secures the freedom to exercise professional
judgement. When applied to medical practice, it defines conduct regarding the care and
treatment of patients “without undue or inappropriate influence by outside parties or
individuals” (1).
During the coronavirus disease 2019 (COVID-19) pandemic, health professionals faced
numerous challenges in daily clinical practice, including limitations in adequate health
infrastructure (e.g. personal protective equipment, excess work load and schedules), bad
remuneration, and lack of continuing medical education platforms. These experiences
emphasize the presence of bioethical conflicts in light of rapid transmission of a novel
pathogen.
In April 2020, the Brazilian Federal Council of Medicine (CFM, in Portuguese) published the
Technical Report that allowed the use of chloroquine and hydroxychloroquine, under
exceptional conditions, for the treatment of COVID-19 (2). As this report was disseminated,
physicians across Brazil adopted the “off-label use” of diverse drug therapies to manage
COVID-19 cases. Now, in 2021, this report remains valid, although new high-impact
research and consensus studies by national and international agencies and medical
associations have concluded the ineffective use of chloroquine and hydroxychloroquine for
COVID-19 treatment. On this basis, Brazilian medical doctors can administer their therapy
Junior Doctors Network Newsletter
Issue 23
August 2021
COVID-19 and Bioethical Challenges:
The Limits of Professional Autonomy
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS
Andrey Oliveira da Cruz, MD
Physician in Family and Community Medicine
São Paulo, Brazil
José Guilherme de Oliveira, MD
Resident in Family and Community Medicine
Santa Marcelina Hospital
São Paulo, Brazil
Page 35
In Brazil, health professionals across the country were dedicated to
providing medical care as they aimed to combat COVID-19.
of choice to COVID-19 patients, regardless of the new scientific evidence. Although these
actions prioritize medical autonomy in a clear bioethical conflict, they juxtapose the
principles of non-maleficence and patient autonomy. For example, some doctors have
administered nebulizer treatments with crushed hydroxychloroquine pills, without support
from clinical guidelines or ethical research protocols. This scenario highlights the existing
technical and political challenges to adopt therapies – with unproven clinical benefit – as
public health policies.
Taking a closer look at the WMA declarations, the WMA Declaration of Geneva requires
doctors to maintain the utmost respect for human life (3). The WMA Declaration of Helsinki
defines that the medical intervention involving human subjects “must be evaluated
continually through research for their safety, effectiveness, efficiency, accessibility and
quality” and that “physicians should consider the ethical, legal and regulatory norms and
standards for research involving human subjects in their own countries as well as
applicable international norms and standards” (4).
Despite ensuring medical autonomy as a fundamental principle, the Brazilian Code of
Medical Ethics states that “medicine will be exercised using the technical and scientific
means available aimed at achieving the best results” (5). It also limits the process of
professional decision-making to informed consent and patients’ autonomy on choosing
diagnostic and therapeutic procedures, as long as they are appropriate and scientifically
recognized. For this reason, we should be aware of three ethical considerations related to
understanding medical autonomy for our clinical practice.
First, we should recognize that medical autonomy does not conflict with other bioethical
principles, such as nonmaleficence, beneficence, and justice (Table 1) (6).
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 36
Table 1. Definitions of three ethical principles (6).
Second, medical autonomy is not a “free-pass” for human experiments, as the conditions
for medical research are well established by international standards. The WMA Declaration
of Helsinki clearly stated that medical research involving human subjects must follow
accepted scientific principles and be conducted only by individuals with the appropriate
scientific training and qualifications (4). Even in exceptional circumstances, such as the
COVID-19 pandemic, informed consent must be obtained, and strict ethical protocols must
be followed.
Third, the conflict between “science” and “non-science” should be examined on the global
platform. The current models of health professions education can be revised and adapted
to incorporate the importance of the scientific method and evidence-based medicine across
curricula. Likewise, scientific results should be disseminated in a clear manner to the
general public. These actions can directly impact society by increasing access to scientific
findings, enhancing understanding, and dispelling myths.
In conclusion, medical autonomy is an important principle that can benefit patients’ care. As
junior doctors, we can promote medical autonomy in our clinical practice and mitigate
potential bioethical conflicts during clinical treatment.
References
1) World Medical Association. WMA Declaration of Seoul on Professional Autonomy and Clinical
Independence. 2006 [cited 2021 Jun 6].
2) Brazilian Federal Council of Medicine. [CFM Technical Report No. 4/2020: Treatment of patients with
COVID-19 with chloroquine and hydroxychloroquine]. 2020 [cited 2021 Jun 6]. Portuguese.
3) World Medical Association. WMA Declaration of Geneva. 2018 [cited 2021 Jun 6].
4) World Medical Association. WMA Declaration of Helsinki: Ethical Principles for Medical Research
Involving Human Subjects. 2018 [cited 2021 Jun 6].
5) Brazilian Federal Council of Medicine. [CFM Resolution No. 2217/2018: Code of Medical Ethics, modified
by CFM Resolution No. 2.222/2018 and 2.226/2019]. Brasilia, Brazil: Brazilian Federal Council of
Medicine; 2019. Portuguese.
6) Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-498.
Junior Doctors Network Newsletter
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August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 37
We should seek up-to-date scientific findings to guide our
clinical training and prioritize our application of evidence-based
medicine across our clinical and surgical disciplines.
The current coronavirus disease 2019 (COVID-19) pandemic has emphasized the role of
public health as a scientific discipline connected with administrative and policy decision-
making. While the promotion of population health has been the classic goal of public health
practice and policy, new objectives connecting autonomy and equality have been
introduced in recent decades (2). As public health considers the health and well-being of
communities and populations collectively, the principles of medical ethics should be
incorporated into decision-making activities, especially since ethical dilemmas can arise
from intersectoral collaborations and stakeholder engagement.
By definition, we can observe that ethical principles focus on theoretical reflections, and
health policies direct concrete courses of action. However, ethics can lose its purpose if it
does not guide specific, practical policies (3). Public health ethics highlights the moral
implications that drive these policies and influence a wide range of interventions aimed at
maintaining and improving population health (4). As such, the adoption of community
measures and strategies – such as the allocation of medical-surgical supplies, workforce
staff, and economic support – must be efficient and comprehensive, while benefiting the
maximum portion of the population. The equitable distribution and allotment of these
resources determine the outcomes of a particular public health measure, success or failure,
and the extent.
Junior Doctors Network Newsletter
Issue 23
August 2021
Ethics in Public Health: Commentary from a Junior Doctor
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 38
Public health is “the science and art of preventing disease,
prolonging life, and promoting health through the organized efforts
and informed choices of society, organizations, public and private
communities, and individuals.”
− CEA Winslow (1)
Rujvee P. Patel, M.B.B.S.
General Physician
Surat, India
Graduate student, School of Public Health, Yale University
New Haven, Connecticut, USA
During the COVID-19 pandemic, public health ethical frameworks have been designed and
implemented in public health practice, yielding substantial reflections for discourse. First,
rapid decisions and emergency authorisation procedures have rested on the support of
ethical frameworks that guide health policies within the national and international context.
Second, the global debate of public interests and individual liberty, autonomy and priority
setting, and allocation of scarce resources, has raised key questions related to ethical
implications (4).
Conclusion
As the evolution of public health ethical frameworks signifies the need to focus on collective
values, greater discussion should incorporate a variety of ethical concepts. These concepts
include utility, evidence-based effectiveness, distributive justice and fairness, solidarity and
social responsibility, community empowerment and participation, transparency,
accountability, and trust (4). Recognizing public health ethics as an opportunity − not an
obstacle − is therefore fundamental for public health policy because the implementation of
effective “policy analysis lies squarely (if uncomfortably) between science and ethics” (6).
References
1) Centers for Disease Control and Prevention. Introduction to Public Health. In: Public Health 101 Series.
Atlanta, GA: CDC; 2014.
2) Munthe C. The goals of public health: an integrated, multidimensional model. Public Health Ethics.
2008;1:39-52.
3) Petrini C. Ethics-based public health policy? Am J Public Health. 2010;100:197-198.
4) Abbasi M, Majdzadeh R, Zali A, Karimi A, Akrami F. The evolution of public health ethics frameworks:
systematic review of moral values and norms in public health policy. Med Health Care Philos.
2017;21:387-402.
5) Baylis F, Kenny NP, Sherwin S. A relational account of public health ethics. Public Health Ethics.
2008;1:196-209.
6) Fischer F, Forester J. Confronting values in policy analysis: the politics of criteria. Newbury Park, CA:
Sage; 1987.
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August 2021
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This observation highlighted that pandemic planning must
be squarely situated in the larger realm of public health, and
an ethical framework for public health should recognize
vulnerable populations in society (5).
In this article, I present a hypothetical scenario faced by healthcare providers and my
analysis based on my clinical experiences during my training in Nepal (Photo 1).
Clinical Scenario
One early morning (6AM), a 57-year-old man complained of chest pain to his wife. He
expressed a distressing pain, where he was unable to breathe but did not want to seek
medical care. He waited a few hours for the symptoms to resolve, but there was no
improvement. Then, by mid-morning (10AM), he called the ambulance, but due to traffic,
the ambulance reached his home one hour later (11AM) and then the hospital (12PM).
That day, the emergency room had reached full capacity, and there was a sudden staff
shortage with many providers calling in sick. Within the next 30 minutes, the patient was
assigned a bed and evaluated by the physician, who quickly realized the possibility of a
myocardial infarction and ordered an electrocardiogram (EKG) and troponin tests. Although
the EKG did not reveal any acute ST-T wave changes, he awaited the laboratory test
before he could confirm or exclude the diagnosis of myocardial infarction.
Junior Doctors Network Newsletter
Issue 23
August 2021
The Blame Game: Providers under Pressure
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 40
Uchit Thapa, MBBS
Internal Medicine Resident
Mary Imogene Bassett Hospital
Cooperstown, New York, USA
Photo 1. Dr. Uchit Thapa on his
clinical rotation at the hospital.
Credit: Dr. Uchit Thapa.
The laboratory tests were delayed by one hour, due to
technical difficulties in the medical equipment. In the
meantime, the patient had suffered a sudden cardiac arrest,
and despite the best efforts from the medical team, he was
unable to be resuscitated. In response, the patient’s family
was furious, physically assaulted the medical staff, and
destroyed hospital property.
Analysis
This unfortunate reality across some Asian countries highlights multiple faults in the health
system, although ultimately an individual is blamed (1). In this case scenario, the question
remains: Who is to blame? Is it the patient who delayed seeking medical care, the
ambulance driver stuck in traffic, nursing staff for bed management, laboratory staff for
delayed laboratory results, hospital administration for staffing issues or the physician who
waited for laboratory results to avoid misdiagnosis? The “blame game” begins, and
physicians are frequently the scapegoat for any unexpected event or complication.
In previous decades, this “blame game” was observed in the U.S. health system. In this
case, health leaders realized that blaming the medical staff neither improved the quality of
medical care nor decreased the risk of adverse events. As they realized that medical staff
made errors due to the intrinsic weaknesses of the health system, they identified and
subsequently reduced systemic errors, leading to declining rates of medical errors (2,3).
As a call to action, It is time that physicians accept that our health system in Asia is broken
and needs repair. Physical assault and property damage are barbaric approaches to
display dissatisfaction and frustration with medical care. These hideous acts lead to
increased fear and uncertainty among physicians to take risks, save lives, and serve the
sick. Health leaders should together work to strengthen the health system infrastructure,
invest in the health system, and avoid the “blame game” against the medical team (4).
References
1) Ambesh P. Violence against doctors in the Indian subcontinent: a rising bane. Indian Heart J.
2016;68:749-750.
2) Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med.
2003;18:61-67.
3) Rodziewicz TL, Houseman B, Hipskind JE. Medical error reduction and prevention. In: StatPearls.
Treasure Island, FL: StatPearls Publishing; 2021.
4) Bornstein B. Medical mistakes: human error or system failure? Momentum (Emory University). 2000;3.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 41
Moving forward, global health leaders should actively identify
systemic errors in health care infrastructure and seek to
improve health care service delivery for all patients.
In June 2020, I was on call for my first duty in the intensive care unit (ICU) for patients with
coronavirus disease 2019 (COVID-19). That morning, I received a call that a 40-year-old
male patient was admitted to the COVID-19 ICU with dyspnoea and hypoxia, with blood
oxygen saturation of 40%. As I donned my personal protective equipment (PPE), I
observed the patient with severe respiratory distress, including unstable vital signs and
blood oxygen saturation of 20%. Immediately, I called for assistance to implement the
clinical protocol to intubate the patient. I noted that clinical staff were reluctant to assist, as
they passed instruments from afar. Although the intubation was successful, his health
declined, and he suffered fatal consequences the following day due to acute respiratory
distress syndrome. To address the observed challenges, I requested a meeting with clinical
staff to discuss their reluctant behavior. Their collective response was related to their fears
of developing COVID-19.
Since March 2020, the COVID-19 pandemic has affected all populations, but notably
placing health professionals at high risk on the frontline. With a substantial number of
medical colleagues who have lost their lives in the line of duty, their mental health has been
significantly impacted, including new fears of becoming infected and losing one’s life or the
lives of loved ones (1).
One recent systemic review conducted during the peak of the pandemic showed high
prevalence of depression, anxiety, and insomnia among healthcare workers involved in
COVID-19 duties (2). These mental health issues can be attributed to long working hours
without breaks, post-exposure isolation and quarantines, and ineffective communication
with patients due to PPE. Social stigma was also observed regarding those who were
infected or recovered from COVID-19 as well as the inability to meet with family and friends
due to social distancing restrictions (2,3).
Junior Doctors Network Newsletter
Issue 23
August 2021
A Pandemic and Fractured Mental Health
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 42
Aashish Kumar Singh, MBBS
Junior Resident Doctor
Neigrihms, Shillong, India
Their dedicated efforts in providing clinical care to COVID-19 patients
has taken a heavy toll on their physical and mental well-being (1).
Sadly, when I look around my workplace, I observe limited actions by hospital management
to develop plans that address the mental health impacts of COVID-19. As we seek
guidance from the evidence-based literature, there are numerous activities that can benefit
the mental health of healthcare workers (4,5). Some of these approaches include: 1) early
assessments of medical staff for mental health and timely psychiatric interventions; 2)
counselling services by multidisciplinary mental health teams; 3) continued education on
mental health and stress management; and 4) standardised work hours with appropriate
breaks.
Since junior doctors are the backbone of any health delivery system, it is our responsibility
to look for signs of depression and anxiety among our fellow colleagues and encourage
them to seek help. Although the described recommended actions are not a comprehensive
list, they can relieve stress, improve overall functioning, and ultimately lead to enhanced
delivery of high-quality patient care. Moving forward, the medical community must first
openly accept that mental health woes among healthcare workers – including burnout – are
common challenges. Together, we must work towards creating an environment where
healthcare workers are comfortable to share their mental health issues without fear of
judgment.
References
1) Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers
during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care. 2020;9:241-247.
2) Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression,
anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review
and meta-analysis. Brain Behav Immun. 2020;88:901-907.
3) Mohd Fauzi MF, Mohd Yusoff H, Muhamad Robat R, Mat Saruan NM, Ismail KI, Modh Haris AF. Doctors’
mental health in the midst of COVID-19 pandemic: the roles of work demands and recovery experiences.
Int J Environ Res Public Health. 2020;17:7340.
4) Vizheh M, Qorbani M, Arzaghi SM, Muhidin S, Javanmard Z, Esmaeili M. The mental health of healthcare
workers in the COVID-19 pandemic: a systematic review. J Diabetes Metab Disord. 2020;19:1-12.
5) Xiang YT, Yang Y, Li W, et al. Timely mental health care for the 2019 novel coronavirus outbreak is
urgently needed. Lancet Psychiatry. 2020;7:228-229.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 43
This pandemic will pass, but its effect on mental health will haunt
us for years to come, unless we embrace the issue and act now.
However, one question remains: What are we doing to tackle mental
health challenges due to COVID-19 in the clinical workplace?
The decision to include medical students in the fight against the coronavirus disease 2019
(COVID-19) is thought to have a utilitarian ethical justification, with the public health
manager using the utilitarian approach to maximize the benefit to the greatest number of
people possible (1). However, because of the uncertainties and lack of evidence, countries
are free to respond in their own way. Due to the inherent urgency of the situation, this may
facilitate the approval of public measures without adequate ethical analysis.
The Risk-benefit Debate
Before finalizing any decisions, it is necessary to assess the risks inherent in the proposed
measures to maximize their beneficial effects as well as identify and minimize any harmful
exposures of medical students, as stated in Articles 4 and 20 of the Universal Declaration
of Bioethics and Human Rights (UDBHR) (2) (Table 1). This increased risk of
contamination is inherent when working on the frontlines, as observed and supported by
the evidence from the current COVID-19 pandemic (3). As such, the inclusion of medical
students may increase the work capacity of health systems and offer students with unique
opportunities for clinical learning.
Junior Doctors Network Newsletter
Issue 23
August 2021
Involving Medical Students as COVID Warriors:
An Ethical Critique
JUNIOR DOCTORS’ PERSPECTIVES: ASIA
Shiv Joshi, MBBS PGDGM
Medical Resident in Community Medicine
Mahatma Gandhi Institute of Medical Sciences
Sewagram, India
Founder, Working Group for Research in Bioethics, International
Chair in Bioethics
Page 44
The current pandemic, however, has not provided the same medical
education and training as it once did, as a result of overworked
health workers and the suspension of outpatient services (4).
This article will examine the inclusion of medical students in
COVID-19 response efforts from an ethical viewpoint.
According to the public health acts and legislatures of each country, the provision of
medical services has become mandatory (obligation) for the majority of these students (5).
As such, any attempt to undermine individual liberties and autonomy is unethical and
violates Articles 3 and 5 of the UDBHR, which describe human dignity and individual
responsibilities (2) (Table 1). Also, the dedicated hours of these medical services represent
a substitute for the required coursework of medical curricula (6). While the exemption from
mandatory coursework may seem like a “fair” reward for students who volunteered to help
with the pandemic, there is evidence that socio-demographic factors may influence medical
student engagement and volunteerism during a public health crisis (7). This infringes upon
the equal treatment and participation of rights, reinforced by Article 10 of the UDBHR (2)
(Table 1). The long-term implications of such substitution measures necessitate an in-
depth discussion among experts.
The Ethical Approach
Considering the logic of applying utilitarian ethics (1), all consequences of these actions
must be evaluated before implementation. After a detailed analysis of the risk-benefit ratio,
a series of risk mitigation measures should be confirmed after deliberations. This would
ensure the personal integrity of medical students involved and encourage the prudent use
of their intellectual capacity with adequate compensation, as supported by Articles 8 and 18
of the UDBHR (2) (Table 1). Therefore, alternatives to direct assistance to patients
suspected of COVID-19 infection should be evaluated. Some activities – such as the
creation of digital content aimed at educating the medical community and the general public
– can be conducted remotely. Additional tasks can include the development of platforms
with up-to-date scientific evidence and social networks for disseminating accurate health
information, dispelling myths through fake news (infodemic), and resolving local and
national community concerns. Medical student volunteers could also collaborate with
management and regulatory teams to develop safety protocols and train professionals in
the proper use of personal protective equipment.
Conclusion
For an effective response to the COVID-19 pandemic, the adopted measures must be
collectively structured, taking advantage of students’ existing capabilities and respecting
their limitations, vulnerabilities, and freedoms.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 45
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 46
Ethical decisions made in the context of medicine and future
generations of health professionals can have far-reaching
implications for these individuals, their patients, and communities.
Article Resolution
Article 3:
Human dignity and
human rights
1) Human dignity, human rights and fundamental freedoms are to be fully
respected.
2) The interests and welfare of the individual should have priority over
the sole interest of science or society.
Article 4:
Benefit and harm
In applying and advancing scientific knowledge, medical practice and
associated technologies, direct and indirect benefits to patients, research
participants and other affected individuals should be maximized and any
possible harm to such individuals should be minimized.
Article 5:
Autonomy and
individual responsibility
The autonomy of persons to make decisions, while taking responsibility
for those decisions and respecting the autonomy of others, is to be
respected. For persons who are not capable of exercising autonomy,
special measures are to be taken to protect their rights and interests.
Article 8:
Respect for human
vulnerability and
personal integrity
In applying and advancing scientific knowledge, medical practice and
associated technologies, human vulnerability should be taken into
account. Individuals and groups of special vulnerability should be
protected and the personal integrity of such individuals respected.
Article 10:
Equality, justice and
equity
The fundamental equality of all human beings in dignity and rights is to
be respected so that they are treated justly and equitably.
Article 18:
Decision-making and
addressing bioethical
issues
1) Professionalism, honesty, integrity and transparency in decision-
making should be promoted, in particular declarations of all conflicts of
interest and appropriate sharing of knowledge. Every endeavour should
be made to use the best available scientific knowledge and methodology
in addressing and periodically reviewing bioethical issues.
2) Persons and professionals concerned and society as a whole should
be engaged in dialogue on a regular basis.
3) Opportunities for informed pluralistic public debate, seeking the
expression of all relevant opinions, should be promoted.
Article 20:
Risk assessment and
management
Appropriate assessment and adequate management of risk related to
medicine, life sciences and associated technologies should be promoted.
Table 1. Relevant articles from the Universal Declaration of Bioethics and Human Rights (2).
References
1) Mandal J, Ponnambath DK, Parija SC. Utilitarian and deontological ethics in medicine. Trop Parasitol.
2016;6:5-7.
2) United Nations Educational, Scientific and Cultural Organization. Universal Declaration on Bioethics and
Human Rights. 2005 [cited 2021 Jun 28].
3) World Health Organization. Health workers exposure risk assessment and management in the context of
COVID-19 virus: interim guidance, 4 March 2020. 2020 [cited 2021 Jun 28].
4) Seifman MA, Fuzzard SK, To H, Nestel D. COVID-19 impact on junior doctor education and training: a
scoping review. Postgrad Med J. 2021;0:1-11.
5) Ministry of Health (Brazil). (2020, March 23). The Strategic Action “O Brasil Conta Comigo”, aimed at
students of health courses, to cope with the coronavirus pandemic (COVID-19). Ordinance No. 492-20-
MS. 2020 [cited 2021 Jul 25]. Portuguese.
6) Office of the Prime Minister (Government of India). Press Information Bureau: PM authorises keys
decisions to boost availability of medical personnel to fight COVID-19. 2021 [cited 2021 Jul 25].
7) Appelbaum NP, Misra SM, Welch J, Humphries MH, Sivam S, Ismail N. Variations in medical students’
educational preferences, attitudes and volunteerism during the COVID-19 global pandemic. J Community
Health. 2021:1-9.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 47
In 2020, the United Nations (UN) Millennium Declaration was formally signed by global
leaders, recognizing the seven Millennium Development Goals (MDG) to improve diverse
aspects of population health. Notably, one MDG included targets to combat human
immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS), malaria, and
tuberculosis. However, the world, especially in low- and middle-income countries, was
facing a chronic shortage of health workers. To address this global health worker crisis, the
UN held a special session on HIV/AIDS and the World Health Organization (WHO)
launched the Treat, Train, Retain (TTR) plan.
The basic goal of task shifting is the rational re-distribution of tasks (1). In fact, most of the
task shifting is traditionally unidirectional, from health professionals with higher levels of
training to those with lower levels of training. Task shifting is considered a necessary
ethical alternative to mitigate the health worker shortage, although accountability may be
questioned when physicians’ duties are placed upon the non-physician workforce.
However, task shifting can occur due to other factors in areas without any health worker
shortage (2). In these cases, the ethical aspect of task shifting should be managed since it
may jeopardize the quality of healthcare.
Junior Doctors Network Newsletter
Issue 23
August 2021
Ethical Issues on Task Shifting in the Healthcare System:
Observed Practices in the Republic of Korea
JUNIOR DOCTORS’ PERSPECTIVES: ASIA
Jihoo Lee, MD
Medical Resident in Internal Medicine
Seoul National University Hospital
Seoul, Republic of Korea
Page 48
The WHO later held the first global conference on ‘task shifting’ and
published global recommendations and guidelines for task shifting
to tackle the health worker shortage (1).
The role of physician assistants (PA), who are allowed to practice medicine under a
physician’s supervision, serves as a key example of task shifting. Established during the
mid-1960s in the United States, this medical occupation was created to broaden the
delivery of general medical services to the public (3). Numerous countries adopted the
occupation and assigned various jurisdiction and practical roles in efforts to improve
national health systems and expand coverage to citizens (4).
In the Republic of Korea, PAs, like nurse practitioners, represent a legitimate profession,
which was stated in Article 78 of the Medical Service Act and amended in February 2008.
However, there are discrepancies observed in practice. For example, the Medical Service
Act does not state the specific duties or range of duties that lead the judicial precedent to
conclude that medical practice beyond the regular nursing purview is illegitimate (5).
Nevertheless, PAs have worked anonymously in diverse medical fields. One Parliamentary
document (2014) reported that more than 500 PAs were working in national hospitals in
2014, doubling the number from 2010 (6). Another estimate has indicated that 10,000 PAs
are currently working throughout the Republic of Korea (7).
These PAs fill the physician shortage by conducting duties that are beyond their authority,
such as prescribing medications, writing medical records or handling surgical procedures
(6,7). Inappropriate medical practice conducted by unlicensed assistants as well as issues
of task shifting with PAs have been perpetually disclosed to the national platform.
In 2019, the Ministry of Health and Welfare (Republic of Korea) composed a consultant
group – with the Korean Medical Association and the Korean Intern Medical Association –
to specify the duties of each health occupation (8). Unfortunately, uncompromising conflict
of interests among stakeholders had deferred the initial meeting for several weeks, and the
consultant group subsequently produced a mere agreement without debate on the role of
PAs. Although under these indeterminable disputes, in May 2021, the Seoul National
University Hospital, one of the largest and most renowned hospitals in the country,
arbitrarily announced to officially approve the role of clinical practice nurses as PAs. This
alarming news has reawakened an embedded conflict among numerous stakeholders on
task shifting in the health system in the Republic of Korea.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 49
Since there is no special education or training program for
PAs in the Republic of Korea, currently employed PAs are
recognized as long-serving nurses.
Sadly, it appears that there are few ethical concerns regarding these countless arguments.
In the Republic of Korea, PAs are alleviating the physician shortage, which was commonly
placed on other health professionals with less training. Thus, the physician shortage is a
matter of balance, rather than an absolute number. The imbalance of specialties results
from the lack of compensation, including insufficient medical reimbursement rates, lack of
legal safeguards on unpreventable outcomes, and more arduous medical training. It is by
no means considered ethical to exploit medical professionals with less training to simply fill
the deficiency caused by complex factors. The truly ethical discussion for improving the
health system under the condition of sufficient capacity and resources is the integral
redistribution of health resources and tasks.
According to the WMA Resolution on Task Shifting from the Medical Profession (2019), the
effect of task shifting on the overall functioning of health systems remains unclear (2). In
spite of this uncertainty, task shifting in the health system will be inevitable as the world
faces diverse challenges beyond the health workforce shortage. This is a call to action
where the physician’s role should be revised, and duties should be reallocated to manage
emerging issues like new medical technologies, physician-patient rapport, and elevating
expectations of health care services.
Conclusion
Task shifting in the healthcare system continues to be a complicated and debated topic
across national health systems. Since physicians are recognized as highly trained health
professionals, they should lead local and national discussions and ultimately judge if patient
safety is threatened by task shifting. To date, the concept of task shifting has not been
widely discussed across global medical societies, albeit significant health challenges
including the coronavirus disease 2019 (COVID-19) pandemic. However, the WMA has
recently confirmed its interest to revise the WMA Resolution on Task Shifting from the
Medical Profession (2019) and establish a framework that can offer medical societies
appropriate guidelines to implement task shifting within their health systems.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 50
Considering the direct impact on quality of care, task shifting
should always be incorporated into ethical debates, recognizing
patient safety as a top priority.
References
1) World Health Organization. Task shifting: global recommendations and guidelines. 2007 [cited 2021 Jun
9].
2) World Medical Association. WMA Resolution on Task Shifting from the Medical Profession. 2019 [cited
2021 Jun 9].
3) Cawley JF. Physician assistants and their role in primary care. AMA Journal of Ethics. 2012;14:411-414.
4) Pasquini S. Where PAs and physician associates can work internationally. International Physician
Assistant. 2021 [cited 2021 Jun 9].
5) Legislation Research Institute (Republic of Korea). 대한민국 영문법령. 2019 [updated 2020 Mar 4; cited
2021 Jun 9]. Korean.
6) Choi GS. Bitter confessions by a PA, “I feel horrible because it feels like I’m doing something wrong”.
Korea Biomedical Review. 2016 [updated 2017 Feb 20; cited 2021 Jun 9].
7) Seon D, Hwang Y. [Reportage] Physician assistants required to roles of doctors amid medical staff
shortage. Hankyoreh. 2020 [cited 2021 Jun 9].
8) Ministry of Health and Welfare (Republic of Korea). 의료인 업무범위 논의 협의체」제1차 회의 개최. 2019
[updated 2019 Jun 5; cited 2021 Jun 9]. Korean.
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 51
As junior doctors, we can advocate for and participate in this
global dialogue, where we can continue to emphasize the delivery
of high-quality medical care, patient safety in clinical and surgical
procedures, and optimal work-life balance for all health workers.
More than six months has passed since the Myanmar military, known as the Tatmadaw,
staged a coup to depose the country’s democratically-elected government authorities. This
coup was in response to a democratic administration that was elected in 2015, after a
history of military dictatorship since 1962. Despite the continual threat of incarceration, the
majority of Myanmar junior doctors have joined the Civil Disobedient Movement (CDM) until
democracy is restored. Myanmar’s CDM protest is distinct from other nations’ strikes, which
are intended to improve doctors’ working conditions. In Myanmar, physicians, nurses, other
health professionals, and government employees are collectively participating in CDM
protests to enhance the national health system, which has been recognized with the
poorest health indicators across the world. Notably, under the democratic government led
by State Counsellor Daw Aung San Suu Kyi (2015−2021), Myanmar’s health system had
improved national health indicators at an exponential rate.
Resisting the coup, CDM doctors guarantee that critical and emergency health services as
well as continuity of treatment are delivered. They constantly offer continuous and up-to-
date information to their patients and the general public about the demands to remove
dictatorships and the measures that are being implemented. Myanmar citizens have
supported physicians’ decisions to leave state-run hospitals. Since the coup, however,
soldiers have been stationed across health facilities, discouraging Myanmar citizens from
seeking medical attention. In response, the general population has refused to seek medical
care or COVID-19 vaccinations at military-controlled facilities (2).
Junior Doctors Network Newsletter
Issue 23
August 2021
Myanmar Junior Doctors Uphold the Physician Pledge
while Defying the Coup
JUNIOR DOCTORS’ PERSPECTIVES: ASIA
Wunna Tun, MBBS MD
Secretary (2020−2021)
Junior Doctors Network
World Medical Association
Page 52
As junior doctors, we adhere to rigorous ethical norms and
prioritize the health and well-being of our patients as first
priority, as stated in the WMA Declaration of Geneva (1).
The Myanmar military junta has ordered the suspension of medical clinics, which are
depriving thousands of patients from receiving ongoing diagnosis and treatment for human
immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS) and
tuberculosis (3). As doctors treated patients at private hospitals or charity clinics for free,
their clinics were invaded, and they were kidnapped (4). Doctors who have participated in
strikes were considered ‘criminals’, and their photographs were widely disseminated across
state-run media like “Wanted” posters. As such, the military and police have declared war
on doctors of the health system, who were among the first and most vociferous opponents
of the coup in February 2021. Security forces are detaining, assaulting, and murdering
medical personnel, branding them as state enemies.
Currently, with doctors forced underground in the midst of a worldwide epidemic, the
country’s already precarious health system is collapsing (5). Nowadays, Myanmar junior
doctors treat patients in secret, risking their own lives while upholding their ethical
obligation to patients.
References
1) World Medical Association. WMA Declaration of Geneva. 2021 [cited 2021 Jul 11].
2) Paddock R. In Myanmar, health care’s collapse takes its own toll. New York Times. 2021 [cited 2011 Jul
11].
3) Mahase E. Myanmar: order to close clinics could be “life threatening” for thousands of people with HIV
and TB, says MSF. BMJ. 2021:n1512.
4) Jha P. ‘Life is at a turning point’: Inside Myanmar’s resistance. New Internationalist. 2021 [cited 2021 Jul
11].
5) Gelineau K, Milko V. In Myanmar, the military declares war on medical workers. Los Angeles Times. 2021
[cited 2021 Jul 11].
Junior Doctors Network Newsletter
Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 53
Junior doctors continue to be in grave trouble as they provide
essential medical care to the Myanmar people.
Although the scientific literature recognizes the severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) epidemic as a pandemic, this virus co-exists with other public
health challenges such as infectious (e.g. malaria, tuberculosis) and chronic diseases (e.g.
diabetes, obesity, hypertension). Like other countries, Italy has emerged with new public
health concerns that have challenged the health system over the past two years. Few
researchers, however, have correctly used the term syndemia in their reports. This article
aims to discuss four major ethical issues that can serve as a starting point in a discussion
that will hopefully lead to global debate and solutions.
Ethics and Public Misinformation
Some Italian media outlets exaggerated the severity of the adverse effects of the
coronavirus disease 2019 (COVID-19) vaccines in efforts to entice readers to buy their
articles (“clickbait”) (1,2). However, readers who purchased these click bait papers followed
a sequence of reactions – frightened, acceptance, and suspicious – to official sources of
information. Notably, this trend of public misinformation was observed across other
countries (3).
Junior Doctors Network Newsletter
Issue 23
August 2021
COVID-19 and Mental Health
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 54
Francesco Rosiello, MD
Department of Public Health and Infectious Diseases
Sapienza University of Rome
Rome, Italy
These public health challenges with major ethical issues
include public misinformation, vaccine delivery,
hospitalizations, and mortality.
Ethics and Vaccine Delivery
The introduction of vaccines during the COVID-19 pandemic has triggered several
questions: Is it right to subject all citizens to mandatory vaccination or is individual self-
determination more important? Should vaccines be prioritized for the most vulnerable
persons (e.g. elderly) or for the general workforce which can restart the economy? Do
healthcare personnel have an additional moral obligation toward vaccine acceptance than
the general population?
Ethics and Hospitalizations
The COVID-19 pandemic has been used as an excuse to justify the slow actions within the
political administration and healthcare system. With reduced funding and shortage of health
workers, access to local health facilities was reduced, leading to suspended health
screenings for the prevention or management of chronic diseases. Consequently, health
complications from poor pharmacological management of chronic diseases led to a surge
in capacity in emergency rooms that were already facing limitations before the pandemic.
On March 6, 2020, the Italian Society of Anesthesia, Analgesia Resuscitation, and
Intensive Care (SIAARTI, in Italian), published the consensus paper entitled,
“Recommendations of Clinical Ethics for Admission to Intensive Treatments and their
Suspension” (4). On November 24, 2020, the National Institute of Health and the National
Federation of Physicians and Dentists (highest body of all Italian doctors) published the
paper entitled, “Decisions for Intensive Care in the Event of Disproportion between Care
Needs and Resources Available during the COVID-19 Pandemic” (5). These two
publications aimed to use evidence-based criteria and create a hierarchy for patient care
when facing limited resources during the pandemic. This ranking system resulted in the
observed sacrifice of vulnerable patients, such as the elderly and patients with co-
morbidities. These clinical experiences make us reflect on history – back to the Napoleonic
wars – as triage (“triere” in French) referred to those patients who could be selected or
saved.
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Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 55
These questions are complex and have more than one right answer.
Ethics and Mortality
As Italy was one of the first countries to implement lockdown measures during the COVID-
19 pandemic, leaders aimed to reduce incidence and mortality rates. The ethical questions
behind the placement of lockdown measures are complex and multifactorial.
After a few months, the social pressures from the business and commerce world became
publicly evident. The Italian Government acknowledged the community need to balance
economic sustainability with an “acceptable” daily mortality rate. However, is there really an
“acceptable” daily mortality rate? What moral or ethical mechanism allows us to understand
and quantify the “acceptable” mortality rate? Unfortunately, there are no straightforward
answers to these questions.
In summary, the COVID-19 pandemic has triggered a series of questions among all health
care workers – including junior doctors – which can facilitate shared experiences, inputs,
and thoughts. Moving forward, we hope that this global dialogue will help shape the
response in the ongoing pandemic and as we prepare for any future response.
References
1) MacDonald NE. Fake news and science denier attacks on vaccines. What can you do? Can Commun Dis
Rep. 2020;46:432-435.
2) Marco-Franco JE, Pita-Barros P, Vivas-Orts D, González-de-Julián S, Vivas-Consuelo D. COVID-19, fake
news, and vaccines: should regulation be implemented? Int J Environ Res Public Health. 2021;18:744.
3) Wang Y, McKee M, Torbica A, Stuckler D. Systematic literature review on the spread of health-related
misinformation on social media. Soc Sci Med. 2019;240:112552.
4) SIAARTI-SIMLA Working Group. Decisioni per le cure intensive in caso di sproporzione tra necessità
assistenziali e risorse disponibili in corso di pandemia di COVID-19, 2021. 2021 [cited 2021 Jun 12].
Italian.
5) SIAARTI Working Group. Raccomandazioni per le cure intensive in caso di sproporzione tra necessità
assistenziali e risorse disponibili in corso di pandemia di COVID-19, 2021. 2021 [cited 2021 Jun 21].
Italian.
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Issue 23
August 2021
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 56
Clearly, it is not a simple task to balance autonomy (individual) with
the greater good of the community (public health).
Health is Largely Determined by Factors Outside our Current Healthcare Systems
Social Determinants of Health (SDH) drive over 30-50% of health outcomes. They dwarf
the healthcare sector, which accounts for under 25% of outcomes, despite consuming a
majority of health expenditures in most high-income countries (1). SDHs are non-medical
factors – social systems, economic policies, and political agendas – that influence health,
and they are exacerbated by economic crises, political unrest, and other social stressors
(Figure 1). Until recently, racism and other forms of discrimination have been largely
excluded from discussions (2).
Junior Doctors Network Newsletter
Issue 23
August 2021
Racism: The Insidious Social Determinant of Health
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS
Eleleta Surafel Abay, MD
General Practitioner, Ethiopia
Ian Pereira, MD
Resident in Radiology, Canada
Mellany Murgor, MD
Medical Officer, Kenya
Merlinda Shazellenne, MBBS OHD
Medical Officer, Malaysia
Shiv Joshi, MBBS PGDGM
Resident in Community Medicine, India
Wunna Tun, MBBS MD
Fellow in Medical Education, Myanmar
Flora Kuehne, MD
Resident in Family Medicine, Germany
Page 57
“Water-borne diseases are not caused by lack of antibiotics but by dirty water and
the political, social and economic forces that fail to make clean water available to all;
heart disease not by a lack of coronary care units but by the lives people lead
shaped by the environments in which they live; obesity not caused by moral failure of
individuals but by the excess availability of poor foods…”
−WHO Commission on Social Determinants of Health (2008)
Discrimination is defined as differential treatment based on actual or perceived
characteristics, such as race and ethnicity. One form is racism, described as a system of
practices at the individual, institutional, and structural levels to devalue, disempower, and
decrease opportunities to groups regarded as inferior, often according to skin color (e.g.
people of color) or numerical representation in a community (e.g. minorities) (Figure 2).
This inequity is deeply embedded in society historically and continually through its
interaction with social forces and their determinants of health. This threatens the health of
physicians, patients, and our healthcare systems.
Impact of Discrimination including Racism on Health
For Physicians
Reports of physician rudeness, emotional abuse, anger, toxicity, and physical harm are
rising (4). Often unreported, over 30-60% of young physicians face at least one episode of
violence in their careers, with increased prevalence in minority groups (5). The cost of such
incivility is high, including burnout and suicidal thoughts (6). This leads to unequal training
opportunities, research contributions, and career progression, including remuneration and
reputation that self-selects a health workforce vulnerable to perpetuating this trauma.
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August 2021
Page 58
Figure 1. Contributions to health outcomes.
Sources: Standing Committee on Social
Affairs, Canada, 2009; Noun Project.
Figure 2. The house that racism built
Source: Adapted from Williams, 2019 (3).
“Structural racism in health care and our society exists and it is incumbent on all of
us to fix it”
− Dr. James L. Madara, CEO of the American Medical Association (2021)
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS
For Patients
Discrimination threatens patient safety via several pathways, including emotional and
psychological distress, access to health education and care, participation in healthy
behaviors, and physical injury including racially-motivated attacks. Racism is consistently
linked to poor mental and physical outcomes (7). Drug development often sidelines
minorities for convenience, especially since some are not always informed of the true
nature of experiments (e.g. Tuskegee Study). While research policy such as the
Declaration of Helsinki helps prevent exploitation, vulnerable populations are routinely
excluded from clinical trials and the full benefit of discoveries. When the Sustainable
Development Goals counted metrics like maternal care, they highlighted inequities. For
example, black women across the United States and United Kingdom are 3-4 times more
likely to die from pregnancy-related complications than white women (8), with similar trends
for infant mortality, heart disease, stroke, cancer, and diabetes. Racism is the risk factor for
poor health outcomes that needs to be addressed, not race.
For Effective Health Systems
Discrimination erodes health systems and the economies supporting them. Members of the
healthcare workforce facing discrimination have worse productivity, capacity, and turnover.
Lack of diversity further compromises innovation and the quality of care. Disadvantaged
populations have worse health outcomes with increased costs of care. In the United States,
one study estimated that over 30% of direct medical costs faced by African Americans,
Hispanics, and Asian Americans were due to health inequities totaling over US$230 billion
over four years. By adding indirect costs, including lost productivity, wages, absenteeism,
family leave, and premature death, this total rose to US$1.24 trillion (9). High value care
requires controlling the costs of discrimination.
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Issue 23
August 2021
Page 59
Racism, which is historically engraved through systemic racial
profiling and discriminatory segregation, continues to persist
through self-perpetuating algorithms into the digital age.
Overcoming racism is needed to provide high-quality patient care,
engage in constructive learning, and uphold our pledge for
humanity in medicine.
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS
Why?
Discrimination, including racism, is not just one of the SDHs, but it also is the fundamental
determinant affecting all others. Structural racism is etched in historic and ongoing
legislative policies, hiring practices, resource distribution or other inequitable practices that
restrict access to education, job opportunities, safe housing and neighborhoods. It can also
hinder opportunities for some groups through their institutions, interpersonal relationships,
or ethnicity or race. Discrimination drives health inequities and is a barrier for a better future
of work, living and learning, and universal healthcare coverage.
What Can We Do?
The Primary Health Care (PHC) approach is recognized internationally as a powerful tool to
reduce health inequities (10). It includes integrated health services (including primary care
and essential public health), multisectoral policy, and empowerment of people and
communities towards comprehensive care − a promising approach to address
discrimination and SDHs.
Some targets include:
❑ Data-Driven Truths: Governments and health organizations must measure and report on
the impact of discrimination as a structural, institutional, and individual overarching SDH.
❑ Recognition and Justice: Country leaders, health ministries, and other stakeholders must
recognize discrimination in all health practices and develop stronger mechanisms to
ensure physical and psychological safety for disadvantaged groups.
❑ Peace through Health: Countries must deploy strong affirmative action to actively
increase inclusion of previously neglected groups and prevent the health consequences
of discrimination.
Role as Junior Doctors
As a networked and informed generation, we are positioned to break the cycle of
discrimination. We can improve the effectiveness of our healthcare systems, care of our
patients, and our own lived experiences by understanding, recognizing, and taking steps to
prevent discrimination. This means highlighting discrimination as an overarching SDH by
including it in all policy design, implementation, and evaluation for accountability
“upstream”. We must prevent it from negatively affecting how we care for each other and
our patients “downstream” as well as increase awareness of its direct and indirect health
consequences throughout. This will not be an easy task, but treading together safely we
can resonate.
Junior Doctors Network Newsletter
Issue 23
August 2021
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JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS
References
1) World Health Organization. Social determinants of health. Geneva: World Health Organization; 2021.
2) World Medical Association. WMA Declaration of Oslo on Social Determinants of Health. 2020 [cited 2021
Jul 25].
3) Williams DR, Lawrence JA, Davis BA, Vu C. Understanding how discrimination can affect health. Health
Serv Res. 2019;54:1374-1388.
4) Keller S, Yule S, Zagarese V, Henrickson Parker S. Predictors and triggers of incivility within healthcare
teams: a systematic review of the literature. BMJ Open. 2020;10:e035471.
5) Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic
review and meta-analysis. Acad Med. 2014;89:817-827.
6) Hu Y-Y, Ellis RJ, Hewitt DB, et al. Discrimination, abuse, harassment, and burnout in surgical residency
training. N Engl J Med. 2019;381:1741-1752.
7) Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-
analysis. PLoS One. 2015;10:e0138511-e.
8) Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020:58-61.
9) LaVeist TA, Gaskin D, Richard P. Estimating the economic burden of racial health inequalities in the
United States. Int J Health Serv. 2011;41:231-238.
10) Rasanathan K, Montesinos EV, Matheson D, Etienne C, Evans T. Primary health care and the social
determinants of health: essential and complementary approaches for reducing inequities in health. J
Epidemiol Community Health. 2011;65:656-660.
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“Of all the forms of inequality, injustice in health is the most
shocking and the most inhuman.”
−Martin Luther King, Jr.
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS
Junior Doctors Network Newsletter
Issue 23
August 2021
WMA DECLARATIONS
WMA Declaration of Geneva
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Junior Doctors Network Newsletter
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August 2021
WMA DECLARATIONS
WMA International Code of Medical Ethics
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August 2021
WMA DECLARATIONS Page 64
Junior Doctors Network Newsletter
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August 2021
WMA DECLARATIONS
WMA Declaration of Helsinki
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WMA DECLARATIONS Page 66
Junior Doctors Network Newsletter
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August 2021
WMA DECLARATIONS Page 67
Junior Doctors Network Newsletter
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August 2021
WMA DECLARATIONS Page 68
Junior Doctors Network Newsletter
Issue 23
August 2021
WMA DECLARATIONS
WMA Declaration of Cordoba on
Patient-Physician Relationship
Page 69
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August 2021
WMA DECLARATIONS Page 70