Ethical Allocation of Preexposure HIV Prophylaxis

Civil society-led movements transformed global AIDS action from deep skepticism about extending anti-retroviral (ARV) treatment in low and middle-income countries to an historic scaling up of treatment towards universal access. The AIDS movement, however, is at an inflection point due to the interplay of key health and economic determinants—the global financial downturn, tight foreign aid budgets, and intense resource competition. Policy makers will now have to consider implementation of a new intervention—pre-exposure prophylaxis (PrEP), which could mean a diversion of ARVs from treatment to prevention. The principle underlying PrEP is that ARVs could prevent HIV infection among people who are HIV-negative and at high risk. Unlike existing prevention strategies such as voluntary counseling and testing (VCT), condoms, and male circumcision, PrEP is a continuous biomedical intervention. Although it will take several years to fully establish the clinical efficacy of PrEP in varying populations, the encouraging early results from CAPRISA, iPrEx, and CDC 4323 have accelerated global dialogue on its proof of deliverability. The studies encompass diverse populations, including injecting drug users (IDUs), MSM, serodiscordant heterosexual couples, and sex workers. These studies will be completed at different times, raising the question: if a trial demonstrates effectiveness for a given study group, should PrEP be used for others? The ethical issues raised by PrEP are difficult, but not insurmountable. Examining comparative cost-effectiveness, good governance, overcoming access barriers, and ensuring quality improvement would help ensure ethical allocation under circumstances of scarcity

Autopsy

An autopsy is a standardized biomedical procedure during which trained medical pathologists examine the exterior of the body, dissect the corpse, view the vital organs for any obvious abnormality and weigh them, and collect specimens of tissues and fluids for further analysis. The procedure takes 2-4 hours and ends with the body being prepared either for storage until it can be released, or to go to the undertaker for embalming and burial or cremation. After additional laboratory work on the tissues and fluid specimens to detect the presence of drugs and/or coexisting medical conditions, the pathologist forms an opinion on the cause of death. As important as autopsies are in the abstract for law and medicine, they will continue to carry important cultural and emotional meanings as humans face the deaths of relatives and friends

Iowa Physicians: Legitimacy, Institutions, and the Practice of Medicine, Part Three: Dealing with Poverty and Defending Autonomy, 1929-1950

This article, the last of this three-part series, briefly lays out some of the major changes in medical organization and institutions in Iowa between 1929 and 1950. The bulk of the essay then focuses on the effects that the rising costs of medical care had on ordinary Iowa physicians. Anxiety about the expense of medical services for the respectable working and middle classes joined worries about paying for the basic health needs of the indigent and marginally poor. In the 1910s and 1920s, more physicians and more patients expected hospital stays for surgery and childbirth, looked to laboratory-based tests for diagnostic information, and required office visits for vaccinations, health checkups, and ongoing monitoring of treatments, and all of these cost money. These changing standards of medical care had already started to reshape the meaning of access to adequate medical practice, especially in rural areas and among lower income groups, by the late 1920s. The disjunction between what scientifically trained physicians could provide and what people perceived they could afford, along with the widening gap between professional knowledge and common lay understanding of health and disease, led to a widespread crisis of confidence in the traditional fee-for-service, individualistic system of private medical practice. The worsening of the Iowa economy in the late 1920s and the national depression throughout the 1930s turned the problem of medical care for the poor and for those on the margins of solvency into a major issue for Iowa doctors

Iowa Physicians: Legitimacy, Institutions, and the Practice of Medicine, Part Two: Putting Science into Practice, 1887–1928

The second in a three-part series offering an overview of the history of medicine in Iowa from Euro-American settlement through World War II, this survey like part one, concentrates on physicians, medical institutions, public health, and state laws. Developments in these areas shaped the ways Iowans both received health care and, through legislation, tried to translate medical knowledge and values into public benefits. Such a perspective entails omissions. Physicians were by no means the only people who served the ill and injured between 1887 and 1928. Midwives, nurses, dentists, pharmacists, neighbors, relatives, itinerant healers, and nostrum purveyors all provided a range of help and hope to the sick, and much more needs to be discovered about their relationships to physicians and to ordinary people. Individual patients\u27 firsthand experiences with health care are also largely absent from this survey as are details about how local city and county governments implemented (or ignored) directives from Des Moines about public health. Understanding the ways that both patients and local authorities perceived changes in medical knowledge and practice provides an important corrective to physician-centered medical history; I hope that this essay stimulates such contributions. Similarly more work on the political negotiations behind the scenes of legislative and policy decisions will reveal important insights into how lay people interpreted and evaluated proposals to improve the health of Iowans by following the advice of medical experts

Iowa Physicians: Legitimacy, Institutions, and the Practice of Medicine, Part Two: Putting Science into Practice, 1887–1928

The second in a three-part series offering an overview of the history of medicine in Iowa from Euro-American settlement through World War II, this survey like part one, concentrates on physicians, medical institutions, public health, and state laws. Developments in these areas shaped the ways Iowans both received health care and, through legislation, tried to translate medical knowledge and values into public benefits. Such a perspective entails omissions. Physicians were by no means the only people who served the ill and injured between 1887 and 1928. Midwives, nurses, dentists, pharmacists, neighbors, relatives, itinerant healers, and nostrum purveyors all provided a range of help and hope to the sick, and much more needs to be discovered about their relationships to physicians and to ordinary people. Individual patients\u27 firsthand experiences with health care are also largely absent from this survey as are details about how local city and county governments implemented (or ignored) directives from Des Moines about public health. Understanding the ways that both patients and local authorities perceived changes in medical knowledge and practice provides an important corrective to physician-centered medical history; I hope that this essay stimulates such contributions. Similarly more work on the political negotiations behind the scenes of legislative and policy decisions will reveal important insights into how lay people interpreted and evaluated proposals to improve the health of Iowans by following the advice of medical experts

Beyond the Grave –The Use and Meaning of Human Body Parts: A Historical Introduction

In this essay I outline the wide range of ways that human beings have used body parts in the past, primarily within Anglo-American cultural frameworks and experiences. I concentrate on practices much more than on the formation of theories (e.g., development of abstract legal perspectives or philosophical analyses of the body ) or the expression of particular ethical principles (e.g., should body parts be used? should medical researchers be allowed to use tissue samples stored from days before informed consent?). A focus on historical actions, including suggestive comments on how these actions made sense at particular times and places, offers us a way to look at the harmonies and tensions between expressed values and cultural practice. At a time when taking, storing, and using human tissues for a variety of purposes seems to have become a common practice in Western biomedicine with little advance discussion about their status in law or contemporary ethics, a historical perspective can sharply remind us that practices always express cultural values (whether overt or hidden) and that cultural values vary considerably among different populations, even within a single overarching group defined by religious or political boundaries, be they medieval Europeans or twentieth-century Americans. To create useful, fair, and sensitive ethical guidelines for future use of human materials requires that we take the diversity of beliefs and practices of a pluralistic society into account

Iowa Physicians: Legitimacy, Institutions, and the Practice of Medicine, Part Three: Dealing with Poverty and Defending Autonomy, 1929-1950

This article, the last of this three-part series, briefly lays out some of the major changes in medical organization and institutions in Iowa between 1929 and 1950. The bulk of the essay then focuses on the effects that the rising costs of medical care had on ordinary Iowa physicians. Anxiety about the expense of medical services for the respectable working and middle classes joined worries about paying for the basic health needs of the indigent and marginally poor. In the 1910s and 1920s, more physicians and more patients expected hospital stays for surgery and childbirth, looked to laboratory-based tests for diagnostic information, and required office visits for vaccinations, health checkups, and ongoing monitoring of treatments, and all of these cost money. These changing standards of medical care had already started to reshape the meaning of access to adequate medical practice, especially in rural areas and among lower income groups, by the late 1920s. The disjunction between what scientifically trained physicians could provide and what people perceived they could afford, along with the widening gap between professional knowledge and common lay understanding of health and disease, led to a widespread crisis of confidence in the traditional fee-for-service, individualistic system of private medical practice. The worsening of the Iowa economy in the late 1920s and the national depression throughout the 1930s turned the problem of medical care for the poor and for those on the margins of solvency into a major issue for Iowa doctors

“Desirous of Improvements in Medicine : Pupils and Practitioners in the Medical Societies at Guy\u27s and St. Bartholomews Hospitals, 1795–1815

Guy\u27s Hospital Physical Society and St. Bartholomew\u27s Hospital Medical and Philosophical Society served important educational and professional functions in London between 1795 and 1815. They provided the opportunity for discussing everyday problems, sharing new discoveries and encouraging pupils to exploit fully their hospital experiences. They allowed hospital men to pontificate at times, but also to support the efforts of local practitioners and ambitious students. While not improving medicine in the sense of directing research or organizing clinical investigations, they did help medical men at all levels to think about their experiences before their observations were lost in the demands of the next case. Perhaps most important, the societies fostered the medical communities associated with three of the great London hospitals. They did this by providing links between pupils and practitioners from different hospitals, different kinds of practice, and different professional levels