SHOULD INTERNATIONAL HUMAN RIGHTS SUBSUME MEDICAL ETHICS? REFLECTIONS ON THE CREATION OF AN INTERNATIONAL BIOETHICS CONVENTION.
THOMAS ALFRED FAUNCE *
ABSTRACT
Medical ethics encompasses the virtues and principles that doctors have developed over thousands of years to represent the ethos and standards behind their professional work. It reposes now in various local, national and international codes, oaths, guidelines and instruments and has been synthesized and categorized in numerous well-respected academic texts and articles. Medical ethics has played an historically resilient part in professional self- regulation. This article suggests, however, that medical ethics is now involved in a process that may eventually see it subsumed by universal norms of human rights. The reasons for this process and some of its more significant advantages and disadvantages are considered.
Key Words: Medical Ethics; Bioethics; Human Rights; History of Medicine; Doctor/Patient Relationship; Professional Regulation.
INTRODUCTION
The regulatory system known as medical ethics has been one of the most socially valuable creations of the medical profession. Its influence has extended beyond physician-patient relations to the shaping of many key humanistic and egalitarian features of the world's legal and political institutions.
Medical ethics has played inspirational, educative, disciplinary and normative roles from its location in traditional professional oaths, codes prepared by national and regional medical associations, guidelines and committees predominantly influenced by doctors, as well as influential texts and academic articles summarising and categorising its core professional virtues and principles. Bioethics, overlapping with medical ethics, is less directly concerned with regulation of the medical profession and the responsibilities of health professionals to patients. Involving application of the techniques of moral philosophy to ethical problems in the life sciences, it is an important non-legal regulatory feature in areas such as sexuality, reproduction and genetic choice and manipulation 1.
Medical ethics, however, should now be recognised as suffering severe deficiencies in relation to process of development, instruction, interpretation, implementation and credibility. To some extent these problems have been present throughout its history. Their existence is now of particular significance owing to increased transparency and expectations of quality and safety in doctor-patient relations.
An additional challenge, explored here, arises from the development of norms, many previously considered within the sole province of medical ethics, as binding, or potentially binding, obligations under the system of international human rights. These may manifest most clearly with the creation of United Nations Bioethics Convention.
International human rights have evolved from a tradition or moral and political discourse between citizens and the powers that govern and should protect, respect and fulfil them. It has come to aggregate most authoritatively around United Nations treaties aiming at worldwide membership amongst States. The term regulation here refers to the various mechanisms, both rule or esteem-based, that attempt to control the flow of events and outcomes in this area of human activity 2.
THE HIPPOCRATIC OATH'S FADED VIRTUE
Evaluations of medical ethics customarily begin with the virtues and principles allegedly originally found in documents such as the Oath and Epidemics attributed to Hippocrates of Kos, descendant of Asclepius, in the fourth century BCE. These include the virtues of professional self-respect, collegiality and competence, as well as principles of respect for patient confidentiality, beneficence, nonmaleficence, respect for life and, possibly, egalitarian treatment. Indeed, central to one dominant history of the medical profession has been the culture and gender-selective narrative that "through the long lapse of many centuries, in every land and age of civilisation" the Hippocratic Oath "has been the tutelary genius of our art, its guide and aegis, its pillar and cloud of fire." 3
Perhaps the most simplistic approach, then, to beginning a critique of the ongoing viability of medical ethics as a tool of professional regulation, would be to examine the continuing role of the Hippocratic Oath. Certainly the myth of its historical survival over millennia lies at the heart of much of the continuing authority of medical ethics. Like a sacred scroll, of the type sought by ancient Chinese pilgrim Hsuan-tsang (Tripitaka), the revered tenets of this Oath have been carefully passed from luminaries of the profession such as Scribonius Largus and the Benedictines at Salerno monastery, to the great codifiers, Gregory, Percival and Benjamin Rush 4.
Yet, for a minority, the Oath appears to have been not merely a carefully preserved antique, but a source of inspiration encouraging conscience to overcome professional etiquette or law for the benefit of patients. Ignaz Semmelweiss, for example, drew strength from it in his campaign to reduce fatal peri-natal infection by making obstetricians wash their hands after leaving the morgue 5. Dr Bourne relied similarly in openly performing an illegal abortion on a 14 year old girl who had been violently raped 6.
Proving breach of the Hippocratic Oath's ethical obligation to "do no harm" was central to the conviction at Nuremberg of four Nazi doctors for non-consensual, brutal experimentation, sterilization and active non-voluntary euthanasia. The Nuremberg Trial spurred creation of a tripartite collection of documents that remain central to medical ethics: the Declaration of Geneva, or modem restatement of the Hippocratic Oath, the Nuremberg Declaration on human experimentation and the International Code of Medical Ethics 7
Many medical schools continue to use the Hippocratic Oath as a graduation pledge, but not all 8. Inquiries such as that into paediatric cardiac surgery at the Royal Bristol Infirmary, confirm that most whistleblowers and few of the physicians and surgeons they confront are now so motivated by this document as to see, for example, its reference to "purity" of life and art as a powerful encouragement to professional character development 9.
PROBLEMS WITH DEVELOPMENT
The globalization of medical ethics has arguably been hampered by too great a reliance on its ancient, culture-specific origins in the Hippocratic Oath. Similar professionally significant documents, espousing like virtues and principles, have been ascribed to Buddhist, Hindu, Confucian and Islamic10 traditions. Further, there is a strong tradition of mutual influence between the authors of Islamic and Jewish medical ethics texts and the keepers of the Hippocratic corpus 11. Indeed, one of the great strengths in a regulatory sense, of medical ethics may be the authority its principles derive from generalised respect for individuals loyal to the relief of human suffering.
Contemporary medical ethics, however, is largely known by the principles and rules appearing in codes prepared by national and regional medical associations, or the guidelines and reports prepared for the profession by committees of eminent appointees. This increasingly institutionalised process of development, exhibits significant problems with both transparency, democratic access, moral authority and, arguably, depth of analysis.
In many jurisdictions medical associations represent less than half the eligible, practising doctors. In others, legislation against restrictive trade practices, or international trade in services obligations preventing non-tariff barriers to corporate globalisation, increasingly inhibit the capacity of organisations traditionally responsible for drafting codes of medical ethics, to speak on behalf of doctors.
Additionally, the output of such bodies may be adversely affected by restrictive terms of reference and the agendas, for example, of grant-controlling institutions. The sophistication of reasoning and the force of conscience exhibited in their published conclusions is frequently impaired by drafting-by-committee style of process involved, a seeming reluctance to collaborate and share tasks, or to jeopardise careers reliant upon government or professional support despite what this mean for patient safety.
PROBLEMS WITH INSTRUCTION
In its contemporary quest for continued regulatory relevance, medical ethics often appears to be cast as the apparently doctrinally rigorous four principles of Beauchamp and Childress. The authors claimed these were not derived from any ideal or Utopian doctor-patient relation, but arose instead from "considered judgments in the common morality and medical tradition." 12
The cluster of medical ethics principle known as "autonomy" was linked philosophically to the deliberated self-rule of Kant's categorical imperative (beings capable of reason should not be treated instrumentally, but as ends complete in themselves). From it were deduced specific medical ethical rules related to keeping promises, maintaining confidentiality, truth telling, and providing adequate information about the nature of a procedure or treatment and its material risks to permit informed decision-making by patients 13. Beauchamp pronounced that "principles gave an anchor to a youthful bioethics in the 1970s and early l980s and contributed a sense that the field rests on something firmer than disciplinary bias or subjective judgment."
One of the alleged advantages for medical ethics education of the "four principles" approach was the ease with which its components could act as simple mental triggers for professional duties to patients. Asking students to recall the basic ethical principles in this mantric way was also said to emphasise their equivalence, that none was primary.
The importance of what came to be called "principlism" in medical ethics instruction has been profound. Principlism was designed to be communicated through lectures or group discussions about relevant ethical theories (for instance deontology or utilitarianism) and related principles and rules, as well as development of cognitive skills necessary to apply them top complex clinical dilemmas. Its use of deductive logic appealed to the legalistic paranoia of many doctors concerned by rising indemnity costs and greatly influenced the construction of codes and guidelines of medical ethics.
Beauchamp and Childress accepted that ethical principles could be derived from philosophic theories such as deontology or utilitarianism and that they had an important association with virtue. Yet, those authors did not explicitly answer Pellegrino's call to derive the four principles from a single, coherent, virtue-based theory of the doctor-patient relationship.14 Beauchamp and Childress, for instance, asserted their four principles could be "balanced" through a process of "coherence" in reasoning which they explicitly modeled upon Rawls' process of "reflective equilibrium." They failed to emphasise that the latter notion is explicitly based upon intuitive convictions about a foundational social virtue: justice. 15
Principlism, despite the authors' considerable discussion of virtue in later editions, has no manifest theoretical derivation from any foundational professional or social virtue. Principlism's lack of a virtue base has been major conceptual flaw lying dormant at the conceptual heart of medical ethics. 16
Attempts have been made to renovate the theoretical framework of medical ethics with custom-built virtue theory. 17 Pellegrino argued forcefully that virtue must have a normative role in the medical profession. 18 Yet, if one considers where influential doctors with an active social and professional conscience (notably those in NGOs such as Medecins Sans Frontiers, Medact or International Physicians for the Prevention of Nuclear War) now look for their inspiration, it appears to be not medical ethics, but the radical idealism of decency and dignity expressed in the Universal Declaration of Human Rights.
Many of the most significant problems confronting medical ethics now occur as a result of global influences that require debates and strategies in international fora such as the World Trade Organisation. The Doha Declaration allowing access to cheap generic drugs, was promoted by physician activists in Medecins Sans Frontiers as a victory for human rights over the greed of pharmaceutical companies aggressively enforcing drug patents to the detriment of HIV/AIDS sufferers. 19
The number of articles explicitly on human rights in biomedical journals is increasing. 20 So is the teaching of international human rights in medical schools in areas of the curriculum previously regarded as the domain of medical ethics. 21 Relevant techniques have included student visits to police cells, prisons, interviews with torture victims and doctors who have campaigned against such human rights violations. 22
PROBLEMS WITH INTERPRETATION
Medical ethics, as it appears in modern restatements of the Hippocratic Oath, the Nuremberg and Helsinki Declarations, in professional guidelines and the codes of national medical associations, is often interpreted by courts in order to determine the professional standard of care, or to assist in resolving what Dworkin would term "hard" cases where no settled and definitive legal rule exists. One example of the latter was the decision of the US Supreme Court in Roe v Wade, in which considerable space was devoted to an analysis of the Hippocratic Oath 's alleged prohibition on abortion. 23
Particular controversy has arisen over reinterpreting of the World Medical Association's Declaration of Helsinki concerning the distinction between "therapeutic" and "non-therapeutic" research and the use of "best proven treatment" or placebo in control arms. The value of such revisions is questionable where "governments have demonstrated grossly repressive or corrupt behaviour, or where ethical review systems cannot be regarded as independent." 24
There are now innumerable tribunals both United Nations and regional, interpreting norms of international human rights concerning doctor-patient relations. Cases concerning new reproductive technologies, end of life decisions, privacy and informed consent, are now heavily influenced by international human rights norms, either due to Parliamentary or judicial incorporation into domestic law, or to remedy a common law lacuna, ambiguity or obscurity.
PROBLEMS WITH IMPLEMENTATION
Enhancing enforcement or implementation power has been alleged to be a major reason behind the increasing use of law rather than medical ethics in professional regulation. 25 The exponential growth of health legislation controlling the interstices of doctor-patient relations may provide some proof of this. The Patient Self-Determination Act (US) (1991), as one representative example, covers much traditional territory of medical ethics in requiring hospital staff, at the time of admission, to inform patients of their right to participate in their own health care decisions, to accept or refuse treatment, or make an advance directive.
The obvious disadvantage of medical ethics being subsumed for enforcement purposes by domestic law is that protection of patients would thence be more open to manipulation by the State. This argument cannot with equal force be raised against the regime of international human rights. The development of the capacity for individual patients, with the assistance of doctors, to petition human rights committees and courts concerning violations of patient human rights under Optional Protocols provide an increasingly effective and transparent enforcement mechanism.
PROBLEMS WITH CREDIBILITY.
Shortly after the medieval period, Western medical ethics is said to have resembled a set of guild rules protecting the selfish interests of members from internal and external competition. 26 Its codification arguably was largely an income-protective measure warding off the damage to the profession's esteem from quacks and non-allopaths. 27
The principles of medical ethics, like those of religious systems, cannot be effectively impugned merely by cataloguing the innumerable instances in which they've been breached, ignored or flaunted, unless perhaps such faults arise from manifest textual obscurity, or indicate a catastrophic loss of general faith and respect.
Nevertheless, in the eyes of the public, the inadequacies of medical ethics are partially responsible for physicians continuing worldwide to be involved in torture, the death penalty, institutional abuse of the vulnerable, armaments manufacture and warfare, as well as many other inhumane activities. 28
In 1976, the United Nations invited not the World Medical Association (the body responsible for drafting many core documents of medical ethics), but the WHO to prepare a draft Code of Medical Ethics against physician involvement in torture or cruel or unusual treatment or punishment. 29 In 1982 the United Nations General Assembly passed a resolution on "Principles of Medical Ethics" which endorsed the WHO-instigated recommendations of the International Organisation of Medical Sciences on this issue. 30
The multinational pharmaceutical companies, managed care organizations and other private corporations that increasingly control or influence much of the contemporary medical profession, manifestly are not bound by medical ethics. Globalisation of financial and social services, as well as the rapid international spread of infectious diseases, such as HIV/AIDS and SARS, have bypassed state sovereignty and necessitated international co-operation on doctor-patient matters in a wide range of international institutions. 31 This global and microbial politik has created a need for terminology and norms which extend medical ethics into the realm of international obligations. 32
THE RISE OF MEDICALLY-RELATED HUMAN RIGHTS
The development of medical ethics and human rights has many intriguing parallels.
John Locke, one of the fathers of human rights jurisprudence, was a physician who studied alongside Sydenham, a great clinical empiricist inheritor of the Hippocratic tradition of medical ethics. 33 It is interesting to speculate that a major factor promoting each corpus of norms was direct proximity to the relief of individual human suffering. 34 International humanitarian law is an aggregation of customary and treaty-based norms concerned with the treatment of wounded, civilians and prisoners in war, and overlapping with many areas of medical ethics. Its origins, likewise, may be traced to the unrelieved suffering witnessed by Henry Durant on the battlefield after the battle of Solferino in 1859. 35
Widespread horror at the global suffering occasioned by the Second World War promoted the Universal Declaration of Human Rights (UDHR) 36 and the drafting process that eventually lead to the International Covenant on Civil and Political Rights (ICCPR) 37 and the International Covenant on Economic, Cultural and Social Rights (ICESCR) 38. These instruments contained many principles and obligations that resembled norms of medical ethics. They were unambiguously directed at relationships between individuals (albeit within the sphere of governmental responsibility) and not merely relations between States. 39
Particularly relevant to medical ethics in the UDHR were provisions requiring State respect for human dignity and equality (articles I and 2), the human right to life (article 3), prohibiting torture or cruel, inhuman or degrading treatment or punishment (article 5), requiring non-discrimination (article 7), freedom from arbitrary interference with privacy (article 12), requiring progressive realization of the human right to a standard of living adequate for health and medical care (article 25) and the human right to share in scientific advancement and its benefits (article 27).
As a Declaration, however, rather than a Convention, the UDHR did not directly create human rights norms with binding obligations under international law. Neither does UNESCO's Universal Declaration on the Human Genome and Human Rights, which claims that the human genome represents part of the common heritage of humanity and also forbids practices contrary to human dignity such as human reproductive cloning. 40
Article 38 of the Statute of the International Court of Justice, provides the following definitions of international law:
1. international conventions, whether general or particular, establishing rules expressly recognized by the contesting states;
2. international custom, as evidence of a general practice accepted as law;
3. the general principles of law recognized by civilized nations;
4. judicial decisions and the teachings of the most highly qualified publicists of the various nations, as subsidiary means for the determination of rules of law
The final wording of Article 38(l)(c) on "general principles of law" was a compromise between those who viewed them as derived from natural law (which would have lead to a virtue-based coherence approach to law making) and those who focused descriptively on domestic legal systems. Arguably, the UDHR and its medically-related human rights, as a result of continued State practice and opinio juris, now represents customary international law under article 38 (c) above.
Medical ethics clearly overlaps with international human rights norms in the regional European Convention on Human Rights and Biomedicine, whose impact has been restricted by limited ratification. 41 This Convention covers matters such as equitable access to health care (Article3), consent (Chapter 11), private life and right to information (Chapter 111), the human genome (Chapter IV), scientific research (Chapter V) and organ and tissue removal from living donors for transplantation (Chapter VI).
Many other international Conventions contain protections of the "right to life," prohibitions on "torture or cruel and unusual treatment or punishment," or obligations upon States to progressively realise the "human right to health" and so also have an obvious overlap with norms of medical ethics.42 Numerous jurisdictions have Constitutional provisions on similar subjects and interpretation of them contributes to the global development of international human rights.
Article 7 of the International Covenant on Civil and Political Rights (1CC'PR,) as well as prohibiting torture or cruel, unusual or degrading treatment or punishment, also provides that "no one shall be subjected without his free consent to medical or scientific experimentation." Under General Comment 20 (44) the UN Human Rights Committee has interpreted this to require "special protections" (for example no institutionally-nominated surrogate decision making) for persons "under any form of detention or imprisonment," or those hospitalized on grounds of necessity or involuntarily due to mental illness. Obligations to protect individuals from third party violations could create State responsibility to protect patients from doctors who failed to provide such "free consent," even where doctors are not considered State agents.
Informed consent before medical or scientific treatment probably meets the requirements of state practice and opinio juris sive necessitatis required for acceptance as a rule of customary international law binding on States regardless of treaty ratification. 43 It could further be granted this status as deriving from "general principles of law" recognised by civilised nations. 44
If a detailed jurisprudence of informed consent as a human right is developed under international law, such norms could easily recirculate to sustain a uniform regime in domestic legal jurisdictions throughout the world.45 This process would particularly be facilitated in jurisdictions such as the United Kingdom, New Zealand and the Australian Capital Territory where courts are required by legislation to attempt to achieve coherence between the domestic law and international human rights.
AN INTERNATIONAL BIOETHICS CONVENTION
On June 13 2003 the International Bioethics Committee of UNESCO issued its report on the possibility of elaborating a universal Convention on bioethics. 46 This was the outcome of work commencing with a resolution of the General Conference of UNESCO at its 31st session, that its Director-General submit "the technical and legal studies undertaken regarding the possibility of elaborating universal norms on bioethics." 47
The content of norms to be included in such a Convention remains a matter for speculation. Criticisms may be made concerning the transparency of UNESCO's procedures in this regard, public access to deliberations is apparently restricted and few meetings take place in developing countries. There also seems to be a reluctance to expeditiously tackle difficult issues such as patenting of the genome. 48
Creation of such an International Bioethics Convention may represent an important stage in the process whereby the moral, political and international law aspects of human rights begin to subsume medical ethics. It could create norms categorised as both medical ethics (to the extent they regulated the medical profession of ratifying States and affected doctor-patient relations therein) and international human rights law.
Those commercial interests with a vested interest in maintaining certain advantageous positions in medical ethics, might find it more convenient to target their lobbying, deals and negotiations at one international body, that responsible for monitoring and implementing the International Bioethics Convention. One example might include pharmaceutical companies promoting the fiction that placebo controlled trials are justifiable, so they don't have to establish the efficacy of new products against existing (often cheaper) ones. Another might involve biotechnology companies striving to prevent a ban on lucrative non-reproductive cloning.
On the other hand, physician-related NGO's, human rights and patient advocacy organisations might discover in such a forum an authoritative and relatively efficient means of ensuring that appropriate standards filtered down to a global uniformity of practise upon issues such as physician involvement in torture and capital punishment, female genital mutilation, treatment of refugees and asylum seekers as well as protest against nuclear and other weapons of mass and indiscriminate destruction.
FUTURE DEVELOPMENTS AND CONCLUSION
I have attempted to show that international human rights is capable now of regulating many areas of medical ethics. Such norms are being developed b transparent processes, appear capable of more uniform interpretation by a wide range of regulatory bodies and have at their disposal a collection of enforcement mechanisms more effective against global pressures on the profession.
Amongst the strong contrary arguments emphasis must be given to the claim that international human rights undoubtedly remains highly suspect in Islamic societies for its lack of connection with the Quaran or Sunna. 49 It is constantly qualified by shari'a-based Islamic criteria and by suspicions that the primary norm-creating bodies in international human rights, are dominated by developed, northern countries. In this context medical ethics may actually gain regulatory strength from its nonnative separation from such international institutions. Human rights treaties are also negotiated and entered by executive fiat, typically without legitimising parliamentary debate.
One alternative, of course, is for medical ethics itself to seek coherence with the language and norms of international human rights. Medical Boards and Clinical and Research ethics committees might even publish their interpretations, building up a
global "common law of medical ethics." Glimmers of this approach appear in the increasing use of concepts such as "human dignity," "inalienable rights," "progressive development" "proportionality" and the "margin of appreciation" in medical codes and education. 50 Medical students could be taught that human rights enforcement mechanisms are actually an important means of implementing medical ethics. 51 States who ratify the International Bioethics Convention may acquire obligations to ensure their domestic legislation on bioethics, public health or the doctor-patient relationships conforms to international norms. The Convention may have its own monitoring committee receiving States reports, issuing General Comments and receiving communications from individuals.
Medical ethics is not at risk of being abolished by human rights. But perhaps there is scope in these developments for it to be standardized and globalised more effectively, for its credibility to be enhanced in an era when patient suffering increasingly arises from the forces of corporate and military globalisation and from violations of human rights by States.
Earlier I compared the Hippocratic Oath to the sacred scrolls being sought by the virtue-seeking pilgrim Tripitaka. When Tripitaka and his fellow pilgrims, finally reach their journey's end, they are met by a bureaucrat no doubt appropriately titled "The Golden Crested Great Immortal of the Jade Truth Temple at the Foot of the Holy Mountain."
After the customary prevarications, this official is ordered by the Buddha himself to deliver the holy texts. The pilgrims, however, discover that the documents are blank. 52 The point, it seems, is that wisdom resides in the heart or soul of man and not in words or laws. This practical message of virtue ethics must again be that of medical ethics, if it is not to be subsumed by international human rights.
NOTES
* Senior Lecturer in Health Law, Ethics and Human Rights Faculty of Medicine and Lecturer Faculty of Law, Australian National University
1 Harris J. Bioethics. Oxford: Oxford University Press 2001. 1-4
2 Parker C and Braithwaite I. Regulation. In: Cane P and Tushnet M, eds The Oxford Handbook of Legal Studies. Oxford: Oxford University Press 2003
3 Smith DC. The Hippocratic Oath and modern medicine. J Hist Med Allied Sci 1996; 51: 484-500
4 Davey LM. The oath of Hippocrates: an historical review. Neurosurgery 2001; 49(3): 554
5 Porter R. The greatest benefit to mankind. A medical history of humanity from antiquity to the present. Harper Collins. London. 1997. 369
6 R v Bourne [1939] 1 KB 697. [1938] 3 All ER 615
7 The Nuremberg Code repr in Trials of war criminals before the Nuremberg Military Tribunals under Control Council Law No l0, Nuremberg, October, 1946-April 1949
8 Pellegrino ED. Medical commencement oaths: shards of a fractured myth, or seeds of hope against a dispiriting future? Med J Aust 2002; 176: 99
9 Bolsin SN. More on the Wisehart affair. BMJ 1999; 318: 1010-11
10 Nanji AA. Medical ethics and the Islamic tradition. J Med and Philos 1983; 13: 257-260
11 Jonsen AR. A short history of medical ethics. Oxford University Press, New York 2000 13-26
12 Beauchamp TL and Childress JF. Principles of biomedical ethics, [4th ed] Oxford: Oxford University Press, 1994 15, 37, 462, 101
13 Beauchamp TL. Principlism and its alleged competitors; Kennedy Inst of Ethics 1995; 5(3): 181
14 Pellegrino ED. Toward a reconstruction of medical morality: the primacy of the act of profession and the fact of illness J Med and Philos 1979; 4 (1): 33
15 John Rawls, A Theory of Justice (1976) 20 and 41
16 Beauchamp TL. What's so special about the virtues? in Shelp EE, ed. Virtue and medicine D
Reidel: Dodretch, Holland 1985 323
17 Crisp R and Slote M (eds). Virtue ethics. Oxford: Oxford University Press 1997
18 Pellegrino ED, Toward a virtue-based normative ethics for the health professions Kennedy Inst Eth J 1995; 5 (3): 253
19 Gathii JT. The legal status of the Doha Declaration on TRIPS and public health under the Vienna Convention on the Law of Treaties Harvard J Law and Tech 2002; 15(2): 292
20 Flanagin A. Human rights in biomedical literature. The social responsibility of medical journals JAMA 2000; 284 (5): 52
21 Sonis J, Gorenflo DW, Jha P, Williams C. Teaching of human rights in US medical schools JAMA 1996; 276 (20): 1676
22 L London and G McCarthy, Teaching medical students on the ethical dimensions of human rights: meeting the challenge in South Africa" J Med Ethics I998; 24: 257
23 Roe v Wade 410 US 116 (1973)
24 Loff B and Black J. The Declaration of Helsinki and research in vulnerable populations; Med J Aust 2000; 172: 292-295
25 Annas GJ. Standard of care. The law of American bioethics Oxford: Oxford University Press, 1993
26 Jonsen. A short history of medical ethics. New York: Oxford University Press, 2000; 24-25
27 Baker R. The history of medical ethics. In Bynum WF and Porter R, eds. Companion encyclopaedia of the history of medicine. London: Routledge, 1993: Vol 2 , 861
28 Taipale I, ed. War or health. A reader. London: Zed Books, 2002
29 United Nations General Assembly, Resolution 31/85 13 December 1976
30 United Nations General Assembly, Resolution 37/194 18 December 1982
31 Fidler DP. Return of the fourth horseman: emerging infectious diseases and international law
Minn L Rev 1997; 81: 771-775
32 Fidler DP "Microbialpolitik Infectious diseases and international relations" Am Univ Int'l LR 1998; 14: 1-11
33 Borden EC, "John Locke, physician and author of the first Carolina constitution" South. Med. J 1967; 60: 1283
34 Dewhurst K, Sydenham 's letters to John Locke. Practitioner 1995; 175: 314
35 United Nations Convention for the amelioration of the condition of the wounded and sick in armed forces in the field UNTS 1949; 75: 31. Convention for the amelioration of the condition of the wounded, sick and shipwrecked members of armed forces at sea UNTS 1949; 75: 85. Convention relative to the treatment of prisoners of war UNTS 1949; 75: 135. Convention relative to the protection of civilian persons in time of war UNTS 1949; 75: 287. Additional protocol 1 1977
36 United Nations. Universal declaration of human rights. Adopted 10 Dec 1948. GA Res 217A (Ill). UN Doc A1810 (1948) 71
37 United Nations. International covenant on civil and political rights. Adopted 16 Dec 1966, entry into force 23 March 1976. GA Res 2200A (XXI). UN GAOR Supp (No 16) 52. UN Doc A/6316 (1966). 999 UNTS 17 repr Int Legal Mats 1967; 6: 368
38 United Nations. International covenant on economic, cultural and social rights. Adopted 16 Dec 1966, entry into force 3 Jan 1976. GA Res 2200A (XXI). UN Doc A/6316 (1966). 993 IJNTS 3 repr Int Legal Mats 1966; 6: 360
39 Velasquez Rodriguez v Honduras, Inter-American Court of Human Rights (ser C) No 4 (1988) repr Int'l. L. Mats 1989; 28: 294
40 UNESCO, Universal Declaration on the Human Genome and Human Rights. Art 1
41 Council of Europe. Convention for the Protection of Human Rights and the Dignity of Human Beings With regard to the Application of Biology and Medicine (1996). In force since 1997
42 Toebes B. Towards an improved understanding of the international human right to health.
Human Rights Quarterly 1999; 21(3): 661 at 670-671
43 United Nations Statute of the ICJ 1945 (1945) 1 UNTS xvi World Medical Association, Helsinki Declaration (1966) and since revised, Tokyo 1975, Venice 1983, Hong Kong 1989
44 Bassiouni M A functional approach to general principles of International Law Michigan J Int Law1990; 11: 768
45 Simma B and Alston P, The sources of human rights law: custom, "Jus Cogens and general principles" Australian Yearbook lnt Law 1992; 12: 82 at 102
46 United Nations Educational, Scientific and Cultural Organisation. Report of the IBC on the possibility of elaborating a universal instrument on bioethics. SHS/EST/02/CIB-9/5 (rev.3) 13 June 2003
47 UNESCO General Conf. 31st session 31C/Resolution Bioethics Programme:Priorities andPerspectives. 2002
48 Taylor AL, Globalisation and biotechnology: UNESCO and an international strategy to advance human rights and public health Am J Law and Med 1999; 25: 479
49 Abdullah Ahmed An-Na'im Human rights in the Muslim world. Harvard Human Rights J 1990; 3: 13
50 Sonis J et al. Teaching of human rights in US medical schools" JAMA 1996; 276(20): 1676
51 Claude RP and Issel BW. "Health, medicine and science in the Universal Declaration of Human Rights" Health and Human Rights 1998; 3 (2): 127
52 Coleman S and Eisner J. Pilgrimage past and present. Sacred travel and sacred space in the world's religions. London: British Museum Press, 1995 180
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