A System of Ethics for Food?

1. A System of Ethics for Food? The Precautionary Principle Cedric Garland, Dr.P.H., F.A.C.E. Adjunct Professor, Family and Preventive Medicine, UCSD October 15, 2003 4:30 PM

2. Objectives: • To be able to explain the Precautionary Principle. • Describe its application to food. • Describe data showing a link between maternal consumption of “cured” meat with brain tumors in their children • Describe the “Random misclassification favors the null” axiom

3. Objectives: • To define a system of ethics • To explain the rationale for a system of ethics • To specify the advantages and limitations of a particular system of ethics • To set criteria for a new system of ethics • Propose a system of ethics for a field which has none or only a vague sense of propriety.

4. The Precautionary Principle • “Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation.”– U.N. Conference on Environment and Development, Principle 15 (www.cid.harvard.edu/)

5. Gastric Cancer Enigma • 185 mg/kg of nitrite was found in Frankfurters in 1923 (some as high as 1400 ppm) • In 1923 USDA limited nitrite to 200 mg/kg, and maximum concentration dropped by 2/3, to about 60 mg/kg in 1937 • Nitrosamines are formed by nitrite in cured meats, and are extremely potent gastric carcinogens

6. Gastric Cancer Enigma • Gastric cancer death rates were increasing in the 1920’ in the U.S. It was then the most common cause of cancer death. • After 1930 they started to decline precipitously , and are still declining • In many countries when nitrite intake is high, such as Japan and Germany, gastric cancer rates remain extremely high. • (Paik et al. Int J Epidemiol 2001)

7. Cured meat and brain tumors • 540 cases of brain tumors, aged 0-19 yr • 801 frequency-matched controls (age, area, birth year) • Odds ratio was 2.3 for average intake of 0.5-1.0 mg/day (95% CI 1.3-4.4). • Random misclassification biases to null principle (True O.R. probably much higher than 2.3)

8. Cured meat and brain tumors • There is 1 mg of nitrite in a hot dog • The high-risk mothers were consuming the equivalent to one-half to one hot dog per day, a smal amount • (Pogoda JM and Preston-Martin S. Public Health Nutrition 2001)

9. Example of an Ethical System • The Hippocratic Oath (Geneva Version, 1948 rev. 1968)

10. Oath • I solemnly pledge myself to consecrate my life to the service of humanity; • I will give to my teachers the respect and gratitude which is their due; • I will practice my profession with conscience and dignity • The health of my patient will be my first consideration

11. Oath - II • I will respect the secrets which are confided in me . . . • I will maintain, by all the means in my power, the honor and the noble traditions of the medical profession • My colleagues will be my brothers;

12. Oath - III • I will not permit considerations of religion, nationality, race, politics or social standing to intervene between my duty and my patient

13. Oath - IV • I will maintain the utmost respect for human life from the time of conception; even under threat, I will not use my medical knowledge contrary to the laws of humanity.

14. Advantages of ethical system • Universal guidelines are provided, despite national and cultural differences in laws and mores. • Adherence will enhance reputation. • Adherence enhances solidarity and peer support (colleagues are brothers)

15. Advantages - II • Adherence: • Confers prestige (consecration of life to the service of humanity is a respected aim) • Avoids loss of community trust by limiting release of confidential information. • May reduce the threat of litigation.

16. Advantages - III • Provides that worthy teachers of medicine will be compensated for their efforts, or at least appreciated. (After all, teachers are the principal disseminators of the system.)

17. New provisions? • There is no provision regarding reasonableness of fees, or exhortation against charging patients or government for services not performed. Proposed addition: • I will not accept a fee for a service not performed, or substantially overcharge, whatever the source of payment.

18. New - II • There is no provision regarding advertising in mass media, which may induce patients to choose physicians based on criteria other than experience, diminishes prestige, and is costly. • Proposed addition: • I will not advertise my practice in mass media.

19. New - III • There is no provision regarding acceptance of valuable inducements by representatives of pharmaceutical manufacturers seeking prescriptions. • Proposed addition: • I will not accept inducements from the pharmaceutical industry intended to influence my choice of medicines

20. New - IV • There is no explicit guidance regarding acceptance of profits from sales of prescriptions or referrals. • Proposed addition: • I will not engage for profit in the sale of medicines, or accept payment for prescribing medicines or referring patients.

21. New - V • Oath does not explicitly include the most enshrined and, arguably, the single most valued guideline in medicine and public health, “First, Do No Harm.” • Proposed addition: • I will remember to “First, do no harm.”

22. Questions • Would a “Hippocratic Oath” for food be worthwhile? • What are the criteria for developing such an oath? • What would be the elements be? • What benefits would it provide? • What harm might it engender?