more_vertThe study of a phenomenon as complex as the impact of gun laws requires strong theory and study designs capable of untangling causal pathways, attention to implementation, and precision in the measurement of legal variables. Other scholars have criticised the study by Bindu Kalesan and colleagues (April 30, p 1847)1 in those regards—the cross-sectional design, absence of theoretical framework, and failure to observe that some of the laws studied had not actually been implemented.2 We note another weakness that is all too common in legal evaluations: imprecise and opaque measurement of legal variables.
Preference: Law
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[Correspondence] Gun violence prevention
Analyses of the effects of gun policy on firearm deaths by Bindu Kalesan and colleagues1 received widespread attention for surprising findings, including that if three specific policies became federal law, US firearm deaths could be reduced by 98%. We examined these data and identified methodological problems in the original analyses.
Minnow ‘stares down’ Big Tobacco
Tobacco giant Philip Morris has been ordered to pay Uruguay US$7 million in damages and court costs after it lost a legal challenge to the South American country’s anti-smoking laws.
In a ruling hailed as a landmark outcome by public health advocates, the International Centre for the Settlement of Investment Disputes (ICSID) early this month rejected a claim by Philip Morris that Uruguay laws banning smoking indoors, increasing tobacco taxes and requiring cigarette packets carry prominent health warnings breached the terms of a 1998 trade agreement between the Latin American country and Switzerland.
The ICSID, a branch of the World Bank, judged that “the responsibility for public health measures rests with the government, and investment tribunals should pay great deference to governmental judgments of national needs in matters such as the protection of public health”.
Public Health Association of Australia past President Professor Mike Daube said the case was “a historic win for global public health”.
“It confirms the sovereign rights of all governments to protect the public’s health,” Professor Daube said. “Uruguay refused to be intimidated by Big Tobacco and has been completely vindicated.”
Under the Uruguayan laws, the Government ordered manufacturers of 12 different brands of cigarettes to increase the size of the health warnings on their packaging by 80 percent. The resulting costs forced Philip Morris to withdraw seven of the 12 types of cigarettes that it sold in Uruguay.
The case had been watched closely by health advocates worldwide. It was feared an adverse outcome for the Uruguayan government would have been a major setback for tobacco control measures, particularly in the developing world where smoking rates are continuing to increase.
Instead, the judgement has emboldened activists and policymakers to intensify their efforts to control tobacco.
Welcoming the tribunal’s decision, Uruguayan President Tabare Vazquez said that, “we have proved before the ICSID that our country, without violating any treaty, has met its unwavering commitment to the defence of the health of its people”.
In a statement following the ruling, Philip Morris Vice President Marc Firestone said his company had “never questioned the authority of Uruguay to protect public health and this case did not address broad issues on tobacco policies”.
But the case is expected to provide a boost to plans for countries such as Canada to follow Australia in introducing tobacco plain packaging laws.
Rob Cunningham, a senior policy analyst with the Canadian Cancer Society, told CTV News that the Uruguay case provided a very useful precedent for countries like Canada because the issues raised were similar.
“The tobacco industry claims these measures are invalid, but they keep losing these cases,” Mr Cunningham said. “That’s going to provide encouragement to governments to make sure their regulations are not only adopted but they are as comprehensive as possible.”
The ICSID ruling is the latest setback for the tobacco industry in its attempts to frustrate tobacco control measures and overturn plain packaging laws.
A legal challenge to Australia’s world-first plain packaging laws was thrown out by the High Court in 2012, and last year the Permanent Court of Arbitration rejected a claim by Philip Morris Asia that the legislation impinged on investor rights under the terms of a trade deal between Australia and Hong Kong.
Uruguay’s fight to control tobacco drew international support.
The US-based Campaign for Tobacco-Free Kids established a fund to help Uruguay and other small countries to fight legal challenges to anti-smoking laws, and drew contribution from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.
“It shows countries everywhere that they can stand up to tobacco companies and win,” Bloomberg Philanthropies founder Michael Bloomberg said. “No country should ever be intimidated by the threat of a tobacco company lawsuit, and this case will help embolden more nations to take actions that will save lives.”
Adrian Rollins
Where to from here for the review of AMA policy on euthanasia and physician assisted suicide?
On 27 May Dr Michael Gannon (who would be elected AMA President two days later) chaired a forum on assisted dying (euthanasia and physician assisted suicide) at the 2016 AMA National Conference in Canberra.
The session, moderated by Tony Jones of the ABC’s Q&A program, included contributions from a panel of four medical practitioners, Emeritus Professor Bob Douglas, Dr Karen Hitchcock, Professor Malcolm Parker and Associate Professor Mark Yates, as well as AVANT medico-legal expert Georgie Haysom.
The session was well-received. Both panellists and members of the audience passionately but respectfully expressed views both supporting, and opposing, doctor involvement in assisted dying.
Discussion focussed on a broad spectrum of issues including:
- the role of patient autonomy, choice and individual rights;
- the treatment of the elderly, the disabled and others requiring care;
- the perception of becoming a ‘burden’ to others in relation to disease progression, disability or ageing;
- the concept of ‘suffering’, the fear of dying ‘badly’ and the effect a ‘bad’ death has on family members;
- the difficulty of distinguishing euthanasia and physician assisted suicide from suicide generally;
- the role of palliative care in supporting patients and families, the need for more education and training, and recognition of the wider health care team, including pastoral and spiritual care;
- the impact on community perception of the medical profession should the role of the doctor allow for providing euthanasia and/or physician assisted suicide;
- different models of assisted dying legislation such as the Oregon law (based on physician assisted suicide); and
- the need to improve doctor knowledge of the law in relation to end of life care; for example, it is within the law for a doctor to provide treatment to a patient with the primary intention of alleviating the patient’s suffering that has a secondary effect of hastening death.
While opinions clearly diverged on whether or not doctors should be involved in euthanasia and/or physician assisted suicide, there appeared to be consensus on at least one major issue – the medical profession can do better to support patients and their family members at the end of life.
For those who would like to view the National Conference session, it can be accessed on YouTube at https://www.youtube.com/watch?v=eQGNkOGpuUw.
Where to from here for the review of AMA policy on euthanasia and physician assisted suicide?
The results of the recent AMA member survey on euthanasia and physician assisted suicide are being collated and will initially be discussed by the AMA’s Federal Council at its upcoming meeting in August. Members will be informed of the survey results when Federal Council has had sufficient opportunity to review them.
Along with the survey, Federal Council will consider the issues raised during the other major member consultation initiatives – the 2016 National Conference session and last year’s Australian Medicine consultation on the current AMA policy.
Federal Council will also consider background information on national and international opinions and relevant legislative initiatives before making a policy decision in relation to euthanasia and physician assisted suicide. Federal Council is likely to undertake these deliberations over their next two meetings.
The AMA has endeavoured to make this policy review transparent and inclusive to allow a wide range of member views to be heard.
We will keep members informed of the review’s progress and appreciate your patience and participation throughout the review process.
[Perspectives] Politics: for sickness or for health?
Human rights lawyer Reed Brody, Counsel and Spokesperson for Human Rights Watch and long-time “dictator hunter”, has mordantly argued: “If you kill one person, you go to jail; if you kill 20, you are committed to an institution for the criminally insane; if you kill 20 000, you go into comfortable exile with political asylum.” But what if your country’s (or a corporation’s) policies and practices are responsible for the chronic illness and premature deaths of millions? Following Brody’s logic, as a politician you will earn fame and a handsome living; as a corporate CEO you will enjoy a life of luxury and impunity as a 0·01 percenter.
World told to get ready for plain packaging
Australia has received a big filip in its fight to protect its tobacco plain packaging laws after the World Health Organisation launched an international campaign declaring that all governments had to “get ready” plain packaging.
Since it introduced the world’s first plain packaging laws in 2012, Australia has been playing virtually a lone hand in a global battle with major tobacco companies determined to have the laws overturned.
So far, Britain, Ireland and France have joined Australia in passing plain packaging legislation, and both, Canada and New Zealand have announced plans to introduce plain packaging legislation.
Tobacco companies have failed in successive bids to have the laws overturned by national courts and international tribunals.
The latest setback came last month when the highest court of the European Union ruled in favour of regulations that give its member states the option of implementing plain packaging for tobacco products.
This followed the acceptance of the Permanent Court of Arbitration sitting in Singapore of Australia’s argument that it did not have jurisdiction to hear a claim by Philip Morris Asia that the legislation breached trademark protection laws.
The WHO used World No Tobacco Day to join the fight, launching its “Get ready for Plain Packaging” campaign for more effective health warnings on tobacco products around the globe.
The WHO said tobacco packaging was a form of advertising and promotion, often misled consumers and served to hide the deadly reality of tobacco use.
Plain packaging requires tobacco products be sold without marketing gimmicks and with clearly displayed health warnings. Australia was the first country in the world to introduce the legislation. Introduced in 2012, research has indicated that Australia has seen a reduction of 100,000 fewer smokers as a direct result from the plain packaging legislation.
The AMA has been a loud supporter of plain packaging legislation. Past AMA President Dr Andrew Pesce was alongside Federal Health Minister Nicola Roxon as she released the world-first draft Bill and the proposed design for the plain packaging packs.
The WHO said that plain packaging built upon other measures as part of a comprehensive multi-sectoral approach to tobacco control. For more information about the campaign, visit http://www.who.int/campaigns/no-tobacco-day/2016/en/
Kirsty Waterford
[Perspectives] Action against body shaming
Fatphobia is one of the last acceptable prejudices in public spaces. Fat people endure outright abuse, not-so-covert photography/filming, and assumptions about their intelligence and education. Although workplace equal opportunities policies technically outlaw discrimination based on difference, there are many ways to express prejudice other than abuse or obvious criticism.
Global emergency call on yellow fever outbreak
The World Health Organisation has been urged to take emergency action over a rapidly spreading yellow fever epidemic that has so far infected more than 2000 people in Africa and Asia.
Health experts at Georgetown University’s Institute for National and Global Health Law, writing in the Journal of the American Medical Association, have warned that “quick and effective action” is needed to halt the spread of the disease, which has already killed more than 250 people in Angola and has appeared in Congo, Kenya and China.
The experts, Dr Daniel Lucey and Professor Lawrence Gostin, said that shortages in the supply of the yellow fever vaccine raised the risk of a “health security crisis” if the disease spreads through Africa and reaches Asia (which has never experienced a yellow fever epidemic) or the Americas (where the mosquito that can transmit yellow fever is endemic).
“The WHO should urgently convene an emergency committee to mobilise funds, coordinate an international response, and spearhead a surge in vaccine production,” they said.
Dr Lucey and Professor Gostin said delays in the international community’s response to the 2014 Ebola outbreak that eventually infected 28,646 people and claimed 11,323 lives should serve as a salutary lesson of the costs of a tardy response.
“Prior delays by the WHO in convening emergency committees for the Ebola virus, and possibly the ongoing Zika epidemic, cost lives and should not be repeated,” they said. “Acting proactively to address the evolving yellow fever epidemic is imperative.”
Yellow fever kills around 30,000 people a year, mostly in Africa, and the latest outbreak has added impetus to mass vaccination programs. More than 7 million Angolans have been immunised against yellow fever, and in May the Democratic Republic of Congo Government announced plans to vaccinate 2 million of its citizens.
Dr Lucey and Professor Gostin warned that these mass immunisation campaigns “could be a tipping point in exhausting global vaccine supplies”.
Medical experts have already advised that just one-fifth of normal vaccine dose be administered to avert the risk of an acute shortage if the disease spreads, but Dr Lucey and Professor Gostin said it was time for the WHO to step in.
They said the world health body should invoke procedures similar to those used during the Ebola epidemic to safeguard vaccine supplies.
“Stewardship of scarce vaccine supplies is essential, but requires the WHO’s Director-General to declare a public health emergency of international concern,” they wrote. “[But] it is only by convening an emergency committee that the Director-General could declare a public health emergency of international concern.
“Given the world’s vital health security interest, the WHO’s Director-General should use [the procedures] to authorise a reduced vaccine dose to control the epidemic in Angola.”
Dr Lucey and Professor Gostin said the yellow fever outbreak, combined with the experiences of the Ebola and Zika epidemics, showed that the WHO needed to have a standing emergency meeting that met regularly, rather than having to be formed each time a serious global health threat arose.
“The complexities and apparent increased frequency of emerging infectious disease threats, and the catastrophic consequences of delays in the international response, make it no longer tenable to place the sole responsibility and authority with the WHO’s Director-General to convene currently ad hoc emergency committees,” they said.
Adrian Rollins
Leaving Australia
There are restrictions on what medicines and medical devices you can take with you when you leave Australia, and countries may have different laws on what you can bring in.
On assisted dying
The AMA National Conference hosted a special policy session on the highly contentious issue of assisted dying as part of an on-going AMA policy review.
The session, moderated by ABC presenter Tony Jones, brought together a panel of doctors, ethicists and lawyers with a range of views on whether doctors should be involved in assisted dying.
The debate began with an account of the death of an elderly patient who had had a breathing tube removed without anaesthetic because the treating doctor was fearful that if they administered a drug they might be charged with causing their death.
The scenario prompted discussion of the degree to which doctors were uncertain about the law around assisted dying and the so-called double effect doctrine.
Professor of Ethics at the University of Queensland, Malcolm Parker, said it was “widely understood the doctor knowledge of the law in all sorts of areas is not particularly good,” and many doctors were worried that if the treatment they provided had the effect of causing death, “they will get into trouble”.
Avant Head of Advocacy, Georgie Haysom, said the issue hinged around intent: “If you intend to cause someone’s death, that is murder”.
Dr Karen Hitchcock, who works in acute and general medicine at Melbourne’s Alfred Hospital and last year wrote a Quarterly Essay on caring for the elderly, said there needed to be much greater education around the double effects doctrine, under which the death of a patient is a side effect of treatment.
“Double effect is the bedrock of medicine, which is to treat symptoms,” Dr Hitchcock said. “We never treat life, we treat symptoms. So hastening death is not an issue. [Doctors] do not set out to kill; alleviating symptoms is the aim.”
Associate Professor Mark Yates, a geriatrician at Ballarat Health Services, said the double effects doctrine “is used on a day-today basis”, and rather than changing its position on assisted dying, the AMA should devote its efforts to promoting good palliative care.
But Emeritus Professor Bob Douglas from the Australian National University said the double effects doctrine was “a nonsense”, and was causing serious concern for both doctors and the broader community.
Professor Douglas agreed that there needed to be greater investment in palliative care and advance care planning, but said patients should have the choice of assisted dying.
“From the perspective of a patient, my concern is that when I get to the point of incurable illness and inevitable death, I don’t want to put all my relatives through the pain and suffering of an unnecessarily elongated process,” he said.
Professor Douglas said laws similar to those enacted in the US state of Oregon, which allow terminally ill adults to obtain and use prescriptions from their physicians for self-administered, lethal doses of medications, would “give a lot of people comfort”.
Dr Hitchcock said, however, that Oregon-style laws were unnecessary and could actually be harmful, by making the elderly and disabled feel pressured into seeking assisted dying, such as because of the fear of being a burden to their relatives.
“Every patient [already] has a right to choose to have treatment withdrawn,” she said. “The main reason people request physician-assisted suicide is because of feelings of uselessness and hopelessness. If we give people the choice, it will influence them.”
Dr Hitchcock disputed claims that Oregon-style laws put doctors at arms’ length from killing their patients, arguing it was “ridiculous” to pretend that writing a prescription for a lethal dose of medicine was not an act.
“What we are proposing is that instead of [a palliative care team], doctors can give a patient a prescription to go ahead and kill themselves,” she said. “We are talking about replacing the palliative care team with a script.”
But Professor Douglas countered that just knowing assisted dying was an option could bring people enormous comfort, and experience showed that far from all who acquired a prescription for lethal medication went on to use it.
Figures published by the Oregon Public Health Division show that from the time the laws were introduced in 1997 and the end of 2013, 1173 had obtained prescriptions and 752 had used them. During 2013, 122 people were provided a prescription, and 71 had killed themselves.
AMA President Dr Michael Gannon, who initiated the policy review as Chair of the AMA Ethics and Medico-legal Committee, said the National Conference session would, along with 3500 responses to an AMA member survey, be used to help inform the AMA Federal Council’s deliberations on the issue.
Adrian Rollins