Human Rights Violations & The Rise of Universal Ethics Guidelines
By: D. S. Nelson
Tags: Politics, Disability, Medicine, Health, Ethics

ENFORCEMENT OF ETHICAL PRACTICE: A PERILOUS DOWNWARD TREND — PART I

Human Rights Violations & The Rise of Universal Ethics Guidelines

What is the purpose of ethics guidelines?

Physicians have a duty to practice medicine within ethical guidelines and there are steep penalties for violations of accepted universal ethical norms, however, there have been many in the public eye of late who have been misleading the culture in regard to certain public health crises and not abiding by universal ethics principles. One example would be the overdose crisis and subsequent policies that were introduced and implemented to ‘correct course,’ many of which appear to be part of a systematic dismissal of human suffering once recent events, policy developments, etc., are compared in-depth.

In this series, we’re going to dig into some nuances in regard to ethics along with providing an overview for why ethics standards were required to begin with, a summation of federal overreach, and then tie in recent actions of some of the architects of the new status quo in medicine, public health practice, and some pockets of the political landscape.

Some bureaucrats, physicians, nurses, and others are responsible for much avoidable death and unnecessary human suffering in the United States (and elsewhere), and it’s time we began asking:

Why it took so long to codify ethical practices and guidelines considering the abuses that the government knew were taking place (historically). Why it now appears that enforcement of subsequently codified ethical practices are on a dangerous decline.

Before we can dig into any of that, we first need to define ethics.

The AMA Code of Medical Ethics

The American Medical Association’s (AMA) Code of Medical Ethics is an extensive document that discusses how to handle ethical issues for just about any topic that may come up in the course of providing care, as well as for ethical considerations for medical research among other things.

The AMA says they are the ‘guidance that identifies the essentials of ethical behavior for physicians,’[1] but what are ethics exactly and what are ethics guidelines for?

Ethics are, according to the dictionary definition ‘moral principles that govern a person’s behavior or the conducting of an activity.’

To ensure that using the AMA code as an example of strong guidelines for ethical behavior was appropriate, I asked Dr. Chad Kollas for his opinion regarding the code from the perspective of a physician. His response was that ‘while some states apply the AMA Code of Ethics as the standard of care, others view them as guidelines, albeit relatively strong ones.’ While physicians need to abide by ethical guidelines at all times, they don’t necessarily have to abide by the AMA’s guide. However, we’re going to use the AMA’s Code of Medical Ethics as a jumping-off point since they’re pretty well ingrained and familiar.

Medical Ethics, An Overview — Ethical Guidance for All Physicians

According to the AMA:

‘The AMA Code provides ethical guidance for all physicians, regardless of specialty. The AMA recognizes that other physician organizations may also have codes of ethical behavior and that physicians may, at times, have to balance guidance of other professional codes.’ ‘Conduct that violates these expectations or specific duties and obligations is not acceptable ethically and is unprofessional.’ ‘The relationship between ethics and law is complex. Ethical values and legal principles are usually closely related, but ethical responsibilities usually exceed legal duties. Conduct that is legally permissible may be ethically unacceptable. Conversely, the fact that a physician who has been charged with allegedly illegal conduct has been acquitted or exonerated in criminal or civil proceedings does not necessarily mean that the physician acted ethically.’ ‘In some cases, the law mandates conduct that is ethically unacceptable. When physicians believe a law violates ethical values or is unjust they should work to change in law. In exceptional circumstances of unjust laws, ethical responsibilities should supersede legal duties.’[1]

The AMA (among others), takes an intense stance when it comes to professionalism, and violations of ethical duties, likewise, have severe consequences. We’ll explore unjust laws and the physicians’ duty to challenge them a little later, but this should give you an overview of how important the ethical practice of medicine is to the AMA, and really, the entire culture surrounding the field of medicine and for society as a whole. If you’re not convinced of its importance yet, keep reading.

Historic Human Rights & Ethics Violations by the US Federal Government & Physicians

Many of the ideas and values surrounding the ethical practice of medicine are now universal in the wake of quite a few infamous research studies. One example of this is the impetus for the Research Act of 1974 and the Belmont Report among other important ethics guidelines and regulations. However, some of these values are currently in danger of eradication if current trends are any indication of future harm. It is the author's opinion that they’re a strong indicator of future harm and patterns in events (both recent and historical) appear to support that assertion.

Recently and inexplicably, bureaucrats made sweeping changes to ethics regulations that were implemented because of unethical studies, some of which were carried out in the not too distant past, that denied basic human rights to vulnerable human beings and populations. Now, the little oversight that exists as it relates to federal health agencies and those with whom they collaborate is being systematically eroded, as is the culture of ethics in the United States generally.

Image by Mick Sylvestre from Pixabay

While public health bureaucrats are typically not doctors and not many doctors intentionally cause harm, some of them are responsible for much unnecessary suffering and death in the US. This is primarily due to overzealous curiosity and a lack of oversight. This is hardly a new development considering that the Department of Health & Human Services (HHS) itself (as well as agencies under its purview) have been caught repeatedly engaging in harmful practices due to a lack of supervision, and it appears it may be happening again despite control systems that were put in place decades ago in an attempt to mitigate risks to human health and to maintain individual autonomy.

The common rule is a regulation that governs ethical practices for trials involving human research subjects. Unfortunately, in 2018 HHS made sweeping changes to the common rule which now provides certain exemptions for important aspects of the rule, like obtaining informed consent, as well as other exemptions. The common rule was based on the Belmont Report which was required and implemented as an ethics guideline after human rights abuses came into sharp focus via media coverage of the Tuskegee Experiment in the early 1970s.

The infamous Tuskegee Experiment ran from 1932 to 1972. The study was carried out by the U.S. Public Health Service (PHS), which is a division within HHS and the purpose of the experiment was to study the untreated course of syphilis.

To provide you with an idea of the flippant attitudes that existed within the team that conducted this experiment, here is a quote by Dr. Taliaferro Clark to another physician:

‘We have not yet commenced the spinal punctures. This operation will be deferred to the last in order not to unduly disturb our field work by any adverse reports by the patients subjected to spinal puncture because of some disagreeable sensations following this procedure. These negroes are very ignorant and easily influenced by things that would be of minor significance in a more intelligent group.48’[2]

It’s also of import to note that the men never truly received treatment, even after penicillin was proven as an effective treatment and had become widely available:

‘At the end of this project we shall have a considerable number of cases presenting various complications of syphilis, who have received only mercury and may still be considered untreated in the modern sense of therapy. Should these cases be followed over a period of from five to ten years many interesting facts could be learned regarding the course and complications of untreated syphilis.50'[2]

The PHS carried out the study for decades on an extremely vulnerable population and likely would have continued had media not exposed the abuses taking place and had Americans not demanded that human rights protections be put in place. If we aren’t careful, it could happen again. In fact, it may already be happening again. It’s of import to note that no one was ever held accountable for the immoral and heinous practices that were forced on human beings during the Tuskegee Experiment at the hands of bureaucrats, scientists, physicians, and others; nor were they held accountable for the avoidable deaths and unnecessary human suffering that those practices resulted in.

National Archives Atlanta, GA (U.S. government) originally from National Archives (The Tuskegee Experiment)

Unfortunately, this was not the only unethical human experiment conducted by the PHS. There was also a Guatemalan study that the PHS collaborated on with Guatemalan Health Ministries that was just as bad as the Tuskegee Experiment:

‘The experiments were led by the United States Public Health Service physician John Charles Cutler, who had earlier participated in the similar Terre Haute prison experiments, in which volunteer prisoners were infected with gonorrhea. Cutler also later took part in the late stages of the Tuskegee syphilis experiment. While the Tuskegee experiment followed the natural progression of syphilis in those already infected, in Guatemala, doctors deliberately infected healthy people with the diseases; some of which can be fatal if untreated.’[3]

Image: Learning History[2]

Oversight is Again Lacking

As I mentioned in The Emerging Surveillance Model of Medicine, HHS is responsible for updates and revisions to the common rule, and they’re also ‘bound’ by the common rule. So essentially, HHS governs, is ‘bound’ by, and ‘oversees’ itself. Additionally, it can change the regulations under its purview whenever it suits their agenda with absolutely no oversight, at least not as far as I can discern.

While HHS and federal agencies, in general, are only part of what we’ll be looking at in regard to issues concerning ethics and their apparent decline, the recent drastic changes to the common rule are one important example that demonstrates a downward trend in the enforcement of ethical practice post-Tuskegee. Generally, it appears this trend is partially due to the changing political landscape, the regulatory environment, and the dominant zeitgeist of the culture that’s emerged in recent years. This isn’t a good development by any means and it will absolutely have a trickle-down effect that affects industry, academia, and other important sectors that collaborate with federal agencies and that creates grave concerns, especially considering our history as a nation as it relates to the ethical practice of medicine and current trends.

In Part II of this series, we’ll focus on how serious the need for medical ethics is for Americans and the world, and the fact that despite their rather short history, as far as being codified into the regulatory apparatus in the US, we’re already beginning to see the rotten fruit of their decline in the way of current events.

We’ll also discuss the trickle-down effect and how all of these sectors end up shaping the dominant culture as far as what’s considered ‘acceptable’ a little later, but right now we’re going to focus on how federal overreach causes an environment that’s ripe for ethics violations and human rights abuses.

Photo by Jacob Morch on Unsplash

Historical Overreach Juxtaposed with Recent Overreach & How This Creates an Environment That’s Ripe for Human Rights Abuses & The Collapse of the Principles of Medical Ethics

A long pattern of coercive tactics has been employed as it relates to the so-called ‘war-on-drugs’ and overreach by the Drug Enforcement Agency (DEA) spans many decades, but we’re going to touch on the last two decades here for brevity.

One historical example of questionable tactics is a FAQ and ‘agreement’ that the DEA circulated via a press release back in 2002, which was subsequently retracted by the DEA not long after indicating their intention to implement a less punitive environment for physicians who treat severe physical pain with analgesic medications.

See Siohban Reynolds’ statement, Founder, and President of the Pain Relief Network, to the Committee on the Judiciary back in July of 2007.[4]

Unfortunately, instead of the agency dedicating itself to actually creating that less punitive environment for prescribers that they claimed they intended to help facilitate, the DEA retracted its collaboration with academic pain medicine, possibly due to fear that ‘physicians might rely on it in Federal courtrooms,’[5] which of course could set a precedent that included a ruling that barred continued DEA overreach into the practice of medicine.

Consider U.S. Code § 1395.Prohibition against any Federal interference:

‘Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.’[6]

The result of the DEA’s withdrawal of this agreement was that regulatory agencies and others doubled down on punitive restrictions that eventually ended up being a catalyst to the current status quo surrounding analgesic medications in the US, which as I pointed out in Unscientific Guidelines Are Being Peddled As ‘Evidence-Based’ Medicine, is harming unsuspecting Americans who trust their physicians to act in their best interest.

Unfortunately, for many physicians in this new and more punitive climate, it’s simply not possible for them to adequately treat their patients or act in their best interest because of the coercive practices of the DEA among other agencies and issues, and while we can argue that physicians still have an ethical duty to attempt to effect change in this regard for their patients and the good of the public health, that isn’t within the scope of this particular piece to explore.

What is within scope and relevant here is that the DEA does not regulate the practice of medicine and even made recent admissions to that effect in October of 2019 to Newsweek.[7] However, if you look at their recent or even their historical interventions, it’s clear that they’ve put themselves into a de facto position of doing just that.

Patterns, Patterns, EVERYWHERE

I touched on recent DEA overreach in Policies Fail on Small Scale, Yet Forced Nationally and detailed cases of their de facto regulation of medicine just in this last year, but since just last week when that article was published, there are yet more developments that need to be considered.

The DEA is a rogue federal agency in need of supervision, much like HHS. Between their overreach into America’s doctor’s offices, as well as its interference in the supply chain for certain medications, the DEA is now making its intention of forcing medication manufacturers to limit their inventory of analgesic medications clear.

As reported by Pat Anson, an award-winning journalist, and editor in chief of Pain News Network:

‘The U.S. Drug Enforcement Administration has announced plans to significantly reduce inventories of opioid pain medication and other controlled substances that drug manufacturers are allowed to maintain. The inventory reductions are in addition to cuts in the production of opioids that the DEA is seeking in 2020. The proposed regulations, published this week in the Federal Register, would limit “excess quantities of medications” being stored in inventory that might be vulnerable to diversion. Other rule changes would tighten DEA oversight of the manufacturing and distribution of controlled substances.’[8]

This despite hospitals running into shortages for trauma and surgical patients the last time they interrupted the supply chain:

‘Last year the DEA allowed drug manufacturers to increase the production of injectable opioids after shortages developed at U.S. hospitals. The shortages became so acute that some hospitals were forced to use acetaminophen and muscle relaxants to treat surgery and trauma pain. The FDA still has of morphine, hydromorphone and fentanyl solutions on its list of drug shortages.’[8]

So now, not only must the manufacture of analgesics be limited by pharmaceutical companies, but the inventory for those analgesics that the DEA decides can be manufactured must be limited as well. If this isn’t considered regulating medicine under current definitions, then it’s due to a game of semantics, not reality. All of this despite the fact that the overdose crisis is the result of illegal fentanyl, its analogs, and heroin, drugs that are never prescribed by US physicians. Illegal fentanyl and heroin continue to proliferate on the streets of America and kill with impunity and all the while the DEA continues its misguided overreach and de facto regulation of medicine, despite a recent study showing that prescription analgesics were not to blame in the vast majority of overdose cases.

The study, which was released on October 2, 2019, showed that only 1.3% of opioid-related overdose decedents had active legal opioid analgesic prescriptions prior to death at the height of the overdose crisis (2013–2015). This information was confirmed via toxicology reports for these decedents[9] and the findings may very well be broadly representative.

The warnings by public health officials, federal agencies, physicians and other stakeholders regarding adverse health impacts due to policies such as an arbitrary dosing cap that isn’t based on any current scientific understanding and forced-tapers of patients off of their analgesic medications by their physicians who stand to lose everything if caught in the DEA’s crosshairs, will remain moot as long as DEA overreach continues.

The problem with perpetual, unchallenged overreach by the DEA is that it has continued to cause harm to Americans’ health, up to and including death, just as the CDC’s overreach by creating an unscientific ‘guideline’ did. This has been acknowledged by multiple federal agencies in the very recent past who are also culpable in the avoidable deaths and unnecessary suffering of American citizens that their policies catalyzed, and very recently at that. Unfortunately, these acknowledgments mean nothing for Americans as long as the DEA is allowed to maintain its rogue position and the DEA among other federal agencies are contributing to the creation of an environment where human rights abuses and ethics violations are ripe to occur.

Photo by Kuma Kum on Unsplash

We’ll discuss other actors who are contributing to this environment in Human Rights Violations Persist Despite Universal Ethics Guidelines, Part II of this series.

Conclusion

The overdose crisis, the engineered punitive climate surrounding pain medicine in general, the conflation of use with misuse and abuse, and the alarming pattern that’s emerged, could end up having systemic consequences for the US and the world.

Aside from HHS loosening its regulations on informed consent among other things, which contributes to creating an environment where human rights abuses and ethics violations can go unnoticed, especially considering the history that caused the need for ethics guidelines in the first place, and the fact that HHS really has no oversight once again, the DEA likewise is contributing to the creation of such an environment via SWAT-style force.

Between the AMA Code of Medical Ethics, the extreme import of ethical guidelines in general (due to the potential for harm), historical abuses by HHS with the Tuskegee Experiment (among others, where no one was held accountable), changes to regulatory requirements like the common rule that were required because of such unethical studies, federal overreach from agencies like the DEA, and the punitive and unscientific environment that’s being created due to overreach makes a compelling case that ethics & enforcement of ethical practice are experiencing a dangerous downward trend that is already resulting in more avoidable death and unnecessary human suffering. We’ll explore that more in Part II.