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Prisoners of conscience in Sudan
1448
Self-experimentation by doctors SIR,-As Dr Forrester shows (Sept 29, p 798), we only hear of heroic self-experiments. There also seems to be an anonymous army of self-experimenters among clinical researchers, since most physicians mask the fact that they do experiments on themselves. We have investigated the frequency of self-experimentation in clinical researchers in the Netherlands and the outcome of such research. A questionnaire, to be completed anonymously, was sent to 250 members of the Dutch Society of Clinical Pharmacology. Questions were asked about the nature of the experiment, the side-effects, and the perceived benefits. In addition we asked if the experiment had been submitted to an ethics committee. 102 (41 %) people responded. Of these, 55 had done experiments on themselves between 1960 and 1989. A wide range of experiments was reported-for example, intra-arterial blood pressure recordings, prolonged gravitational stress in a centrifuge, and bronchial lavage. Many experiments were pharmacological, reflecting the interests of our study group. One respondent had done an experiment on his own children. Nine experiments were submitted to an ethics committee. Reported side-effects were headache, sinus arrest, nausea, vomiting, diarrhoea, fever, ataxia, tremor, confusion, hallucinations, orthostatic hypotension, and thrombophlebitis. One subject had a myocardial infarction.1 22 people published their results. 1 person managed twenty publications with himself as the only subject. 7 researchers reported results in theses. 8 of these publications were mentioned and could be traced. The results of one publication only could be identified as a self-experiment.2 All other workers described themselves as "human volunteers". Haldane,3perhaps the most prolific self-experimenter of all, remarked, "The experimental pathologist is apt to miss the less obtrusive symptoms when working on other animals and in the long run he is driven to use his own body as an instrument of research...". With increasingly complex and objective methods of scientific research this does not sound a convincing argument. Some might argue that the experimenter should have undergone unpleasant procedures before subjecting his patients to them: unfortunately patients would probably have a different perception of the discomfort involved. Self-experiments are clearly not without danger and do sometimes (but rarely) yield spectacular results. It seems that many self-experiments are mainly done for convenience. Department of Medical Psychology, Academic Medical Centre, Amsterdam, Netherlands
J. J. E. VAN EVERDINGEN
Centre for Human Drug Research, Leiden University Hospital
A. F. COHEN
Dantzig JM, Duren DR, ten Cate JW. Desmopressin and myocardial infarction. Lancet 1989; i: 664. 2 Agoston S, Salt PJ, Erdmann W, Hilkemeijer T, Bencmi A, Langrehr D. Antagonism of ketamime-diazepam anaesthesia by 4-aminopyridine in human volunteers. Br J Anaesth 1980; 52: 367. 3. Haldane JBS. Possible worlds and other papers. Freeport, NY. Books for Libraries, 1971: 84. 1.
van
Prisoners of conscience in Sudan SIR,-Your Round the World correspondent’s piece on repression of doctors in Sudan (Nov 24, p 1307) draws much-needed attention to the gross abuses of professionals in Sudan since the military coup of June 30, 1989. Researchers at Amnesty International have difficulty in verifying and updating reports. There are thought to be more than 250 prisoners of conscience in detention in Sudan. The names of 19 doctors are on the current list, but this number is probably an underestimate. A report by prison doctors on 19 prisoners whom they found on examination to show evidence of torture, has been dismissed by the Ministry of the Interior as "communist allegations". 2 prisoners of conscience at Shala prison whose health is of grave concern are Abdulmoneim Salman, a 65-year-old teacher, who is a diabetic with hypertension and peripheral vascular disease, and Samir Girgis, a 60-year-old pensioner, who is reported to be very ill but receiving no medical treatment. Although the present regime in Sudan seems to be resistant, it is not entirely immune to appeals for humanity, as
suggested by the case of Dr Hussein, whose death sentence was commuted and who was subsequently released after international protest. Letters expressing concern at the detention of doctors purely for their beliefs and at reports of torture and ill-treatment of detainees should therefore be sent to: His Excellency, LieutGeneral Omar Hassan al-Bahir, Head of State and Chairman, National Salvation Revolution Command Council, Peoples’ Place, PO Box 281, Khartoum, Sudan. Medical Group, British Section,
Amnesty International, 99-119 Roseberry Avenue,
DUNCAN FORREST
London EC1R 4RE, UK
Medical aspects of torture SiR,—I refer to your note on the medical aspects of torture (Aug 25, p 498) and Mr Summerfield and Mr Toser’s article (Sept 15, p 678), and would bring to your attention the fact that the World Health Organisation Panafrican Centre for Emergency Preparedness and Response has published and distributed to all the African member countries a special report on the public health effects of situations of insecurity, tyranny, wars, civil strife, and political violence in Africa. A compte-rendu was annexed on the fourteen statements by professional associations about the "Hippocratic oath of health officers during warfare and under tyrannies", "International instruments that prohibit torture", the "Standard minimum rules for the treatment of prisoners", the "Principles of medical ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel inhuman or degrading treatment or punishment", and other relevant documentation on the topic. Panafrican Centre for
Emergency Preparedness and Response, UN ECA Building, Addis Ababa, Ethiopia
SANDRO CALVANI, Director
Ethics committees SIR,-Dr Walshe (Nov 10, p 1194) delivers a stinging rebuke to ethics committees. I declare my interest as the chairman of such a committee. Walshe’s strictures are all the more uncomfortable because several of his points are true. Many of today’s medical benefits would, indeed, not have been sanctioned by ethics committees as constituted. In addition, I can assure Walshe that consideration of the increasing numbers of observational and questionnaire studies is a tedious practice. Walshe, however, fails to recognise that important changes have taken place during the 35 years of his clinical practice. Firstly, he does not distinguish between treatment (no matter how untried or experimental) and research: there is no reason to submit a new form of treatment, particularly when faced with life-threatening disease, to a committee. The onus is surely on the doctor to explain risk-benefit to the patient, just as in all proposed treatment, and let the patient decide. Ethics committees exist specifically and only for research projects. Walshe also fails to take into account a shift in public perception. Society is now, rightly or wrongly, suspicious of what may be seen as medical paternalism with a diminution of the patient’s rights and autonomy. Some notoriously ill-advised trials on ill-informed patients have given credence to this view. Surely, in the face of this, it is our duty as doctors to be seen to be acting first and last in the patient’s interest. The financial benefits that may accrue to individuals or departments from a multitude of drug trials which purport to demonstrate nuances of benefit compared with the last variation of the same drug are also of relevance. These trials often specify significant payments for enrolment and the carrying out of procedures. Recent television exposes (see Lancet Nov 17, p 1245) have shown the profession in an embarrassing light. Finally, there is no reason why medical research should be "retarded by such bureaucracy". Walshe’s swipe at lay and legal members being "as much interested in their own reputations as in the safety of the patient" is unworthy, and serves to justify the suspicions of which Walshe seems oblivious. It also undermines the
Self-experimentation by doctors SIR,-As Dr Forrester shows (Sept 29, p 798), we only hear of heroic self-experiments. There also seems to be an anonymous army of self-experimenters among clinical researchers, since most physicians mask the fact that they do experiments on themselves. We have investigated the frequency of self-experimentation in clinical researchers in the Netherlands and the outcome of such research. A questionnaire, to be completed anonymously, was sent to 250 members of the Dutch Society of Clinical Pharmacology. Questions were asked about the nature of the experiment, the side-effects, and the perceived benefits. In addition we asked if the experiment had been submitted to an ethics committee. 102 (41 %) people responded. Of these, 55 had done experiments on themselves between 1960 and 1989. A wide range of experiments was reported-for example, intra-arterial blood pressure recordings, prolonged gravitational stress in a centrifuge, and bronchial lavage. Many experiments were pharmacological, reflecting the interests of our study group. One respondent had done an experiment on his own children. Nine experiments were submitted to an ethics committee. Reported side-effects were headache, sinus arrest, nausea, vomiting, diarrhoea, fever, ataxia, tremor, confusion, hallucinations, orthostatic hypotension, and thrombophlebitis. One subject had a myocardial infarction.1 22 people published their results. 1 person managed twenty publications with himself as the only subject. 7 researchers reported results in theses. 8 of these publications were mentioned and could be traced. The results of one publication only could be identified as a self-experiment.2 All other workers described themselves as "human volunteers". Haldane,3perhaps the most prolific self-experimenter of all, remarked, "The experimental pathologist is apt to miss the less obtrusive symptoms when working on other animals and in the long run he is driven to use his own body as an instrument of research...". With increasingly complex and objective methods of scientific research this does not sound a convincing argument. Some might argue that the experimenter should have undergone unpleasant procedures before subjecting his patients to them: unfortunately patients would probably have a different perception of the discomfort involved. Self-experiments are clearly not without danger and do sometimes (but rarely) yield spectacular results. It seems that many self-experiments are mainly done for convenience. Department of Medical Psychology, Academic Medical Centre, Amsterdam, Netherlands
J. J. E. VAN EVERDINGEN
Centre for Human Drug Research, Leiden University Hospital
A. F. COHEN
Dantzig JM, Duren DR, ten Cate JW. Desmopressin and myocardial infarction. Lancet 1989; i: 664. 2 Agoston S, Salt PJ, Erdmann W, Hilkemeijer T, Bencmi A, Langrehr D. Antagonism of ketamime-diazepam anaesthesia by 4-aminopyridine in human volunteers. Br J Anaesth 1980; 52: 367. 3. Haldane JBS. Possible worlds and other papers. Freeport, NY. Books for Libraries, 1971: 84. 1.
van
Prisoners of conscience in Sudan SIR,-Your Round the World correspondent’s piece on repression of doctors in Sudan (Nov 24, p 1307) draws much-needed attention to the gross abuses of professionals in Sudan since the military coup of June 30, 1989. Researchers at Amnesty International have difficulty in verifying and updating reports. There are thought to be more than 250 prisoners of conscience in detention in Sudan. The names of 19 doctors are on the current list, but this number is probably an underestimate. A report by prison doctors on 19 prisoners whom they found on examination to show evidence of torture, has been dismissed by the Ministry of the Interior as "communist allegations". 2 prisoners of conscience at Shala prison whose health is of grave concern are Abdulmoneim Salman, a 65-year-old teacher, who is a diabetic with hypertension and peripheral vascular disease, and Samir Girgis, a 60-year-old pensioner, who is reported to be very ill but receiving no medical treatment. Although the present regime in Sudan seems to be resistant, it is not entirely immune to appeals for humanity, as
suggested by the case of Dr Hussein, whose death sentence was commuted and who was subsequently released after international protest. Letters expressing concern at the detention of doctors purely for their beliefs and at reports of torture and ill-treatment of detainees should therefore be sent to: His Excellency, LieutGeneral Omar Hassan al-Bahir, Head of State and Chairman, National Salvation Revolution Command Council, Peoples’ Place, PO Box 281, Khartoum, Sudan. Medical Group, British Section,
Amnesty International, 99-119 Roseberry Avenue,
DUNCAN FORREST
London EC1R 4RE, UK
Medical aspects of torture SiR,—I refer to your note on the medical aspects of torture (Aug 25, p 498) and Mr Summerfield and Mr Toser’s article (Sept 15, p 678), and would bring to your attention the fact that the World Health Organisation Panafrican Centre for Emergency Preparedness and Response has published and distributed to all the African member countries a special report on the public health effects of situations of insecurity, tyranny, wars, civil strife, and political violence in Africa. A compte-rendu was annexed on the fourteen statements by professional associations about the "Hippocratic oath of health officers during warfare and under tyrannies", "International instruments that prohibit torture", the "Standard minimum rules for the treatment of prisoners", the "Principles of medical ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel inhuman or degrading treatment or punishment", and other relevant documentation on the topic. Panafrican Centre for
Emergency Preparedness and Response, UN ECA Building, Addis Ababa, Ethiopia
SANDRO CALVANI, Director
Ethics committees SIR,-Dr Walshe (Nov 10, p 1194) delivers a stinging rebuke to ethics committees. I declare my interest as the chairman of such a committee. Walshe’s strictures are all the more uncomfortable because several of his points are true. Many of today’s medical benefits would, indeed, not have been sanctioned by ethics committees as constituted. In addition, I can assure Walshe that consideration of the increasing numbers of observational and questionnaire studies is a tedious practice. Walshe, however, fails to recognise that important changes have taken place during the 35 years of his clinical practice. Firstly, he does not distinguish between treatment (no matter how untried or experimental) and research: there is no reason to submit a new form of treatment, particularly when faced with life-threatening disease, to a committee. The onus is surely on the doctor to explain risk-benefit to the patient, just as in all proposed treatment, and let the patient decide. Ethics committees exist specifically and only for research projects. Walshe also fails to take into account a shift in public perception. Society is now, rightly or wrongly, suspicious of what may be seen as medical paternalism with a diminution of the patient’s rights and autonomy. Some notoriously ill-advised trials on ill-informed patients have given credence to this view. Surely, in the face of this, it is our duty as doctors to be seen to be acting first and last in the patient’s interest. The financial benefits that may accrue to individuals or departments from a multitude of drug trials which purport to demonstrate nuances of benefit compared with the last variation of the same drug are also of relevance. These trials often specify significant payments for enrolment and the carrying out of procedures. Recent television exposes (see Lancet Nov 17, p 1245) have shown the profession in an embarrassing light. Finally, there is no reason why medical research should be "retarded by such bureaucracy". Walshe’s swipe at lay and legal members being "as much interested in their own reputations as in the safety of the patient" is unworthy, and serves to justify the suspicions of which Walshe seems oblivious. It also undermines the