From the editor's desk: ethics and current medical controversies.

Physicians have many responsibilities to their patients first and foremost but also to other patients using the same resources; to their colleagues; to the healthcare system, towards society at large; to their students; and not to be forgotten, to themselves, to maintain one’s integrity by respecting one’s moral values. While those duties are often prioritized in ethical and professional codes such as the Code of Ethics of the Canadian Medical Association (CMA) (1), many situations arise in which the physician has to make a decision on uncertain ethical grounds. Should an unconscious patient be enrolled in a trial of a new, potentially life-saving therapy without prior consent? Should patients be exposed to the risks of having procedures performed by students, under the justification of learning opportunities to better serve the future? Should physicians refuse to perform a procedure (e.g. abortion) while knowing that the patient will likely undergo the procedure illegally under unsafe conditions? In the Crossroads section of this issue of the McGill Journal of Medicine, we present two articles that foray into controversial topics, where duties and responsibilities of the physician seem to conflict. In “Blood substitutes: the Polyheme Trials”, the author explores the controversy over the clinical trials of Polyheme, an artificial blood substitute that has the potential to revolutionize emergency pre-hospital care, and to be a solution to the world-wide problem of blood donations shortage. It is necessary to allow waiving of patient consent for participation in a trial of emergency treatment, but is it ethical? Should physicians follow a utilitarian approach and make decisions for incapacitated patients in the name of research and potential benefits to the general population? The second Crossroads article, “Paying Kidney Donors: Time to Follow Iran?”, describes the converse situation: if a patient wishes to undergo an operation to sell his or her kidney, does the physician have a role in opposing such a decision? If we bear the knowledge that those patients will be facing great risks by selling their kidneys and undergoing the transplant operation in the black market, what is the physician’s duty in protecting these patients? The Iranian model of kidney transplants offers financial compensation and life-long healthcare coverage to kidney donors, and is being credited for a significant shortening of transplant waiting lists. The objectification and commercialization of the human body that it entails is however not considered ethically acceptable by most medical associations in Western Europe and North America (2, 3). In Canada, for instance, the only living non-related donations that are currently legally permitted are anonymous, voluntary, and given to the public healthcare associations. In July 2006, the British Columbia Transplant Society in association with the British Columbia branch of the Kidney Society, was the first in North America to start a pilot project of financial compensation of all living kidney donors for the expenses associated with their donations (4). Small steps are being taken in Canada towards forming legislation allowing a government-centered commercial donation system designed to protect both donor and receiver, but it remains to be seen if those projects will garner enough public support and override the current ethical concerns. Similarly to the issues we present in the Crossroads section, the debate over the privatization of healthcare in Canada is often centered on the duty of physicians to patients: is it more important to serve everyone equally or to improve global delivery of healthcare by reducing the load on the present system, even if it entails positive discrimination? In our Focus section we seek to provide a balanced perspective of the ethical, social, economical, and political implications of a possible reform of the Canadian healthcare system. We have thus invited two experts in the field, Dr. Edwin Coffey, former President of the Quebec Medical Association and Senior Fellow at the Montreal Economic Institute, and Dr. Harvey Barkun, Officer of the Order of Canada, member of the Rochon Commission and President of the Society of Medical Administrators (USA), to respectively discuss the arguments for and against privatization. In addition, we have interviewed two Quebec physicians, Dr. Paul Saba, family physician practicing at the Lachine Hospital and the Medi-Centre de Montreal-Ouest and Co-President of the Coalition of Physicians for Social Justice, and Dr. Lawrence Stein, Chief of the Division of Diagnostic Radiology at the Royal Victoria Hospital (McGill University, Montreal, Qc), to describe their respective experiences with public or private realms of medicine. Lastly, two physicians practicing abroad, Dr. Andrew Vallance-Owen, Medical Director of the British United Provident Association, and Dr. Hisayuki Hamada, Chief of Medical Education at the National Nagasaki Medical Center (Japan), described their respective countries’ health care systems. The current issue of the MJM intentionally raises more questions than provides answers. We hope to encourage students not only to conduct scientific research, but also to participate in ethical debates. Since one will often be confronted with difficult predicaments in clinical practice with no clear right or wrong answers, it is helpful for medical students to discuss abstract ethical and moral issues from the beginning of their training in order to develop critical thinking skills. As physicians of tomorrow, decisions will someday be ours to make. It therefore becomes our duty, towards ourselves and society at large, to reflect and to shape the ethical cores that define our profession. Regards, AS, AYZ, YG

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