Aquino’s defense crumbles under ‘first, do no harm’ and ‘do not plunder’ ethical principles



First word
THE disquiet of many with President Aquino’s defense of the Dengvaxia deal inheres in his remorseless claim of “good faith” for a policy decision and program that has cost our people and the nation dearly. How, we ask, can something costly, harmful and possibly unlawful be good and faithful?

I think the proper standard against which the Dengvaxia program, should be judged is the fundamental principle of medical ethics: “Do no harm.” It should eventually face also the law on plunder.

If the student and practitioner of medicine, upon entering the citadel, is made to swear by the Hippocratic dictum “do no harm,” so must the maker of health policy and administrator of health care take an oath of harm avoidance.

Do no harm explained
I think the reader will understand my argument better if I begin by explaining first the principle of “Do no harm.”

In a column on medical ethics, Dr. Jonathan M. Evans, has provided in my view a most enlightening and informative explanation of “Do no harm.” He wrote:

“The phrase “first do no harm” (in Latin, primum non nocere) is fundamental to the ethics of medical treatment in the Western world and has endured for approximately 2,500 years. It is attributed to Hippocrates, who wrote that “The physician must … have two special objects in view with regard to disease, namely, to do good or to do no harm.” These are the principles of beneficence (“to do good”) and nonmaleficence (“to do no harm”)…

The primary ethical principle that forms the foundation for medical care (and the foundation of every society throughout history) is the concept of beneficence — the obligation to do good for others.

The desire to do good often compels health care practitioners to perform some action in virtually any clinical situation, regardless of its effectiveness or even lack thereof…

There is a biased belief in the good that will be done. This belief is based on hope, fear, an exaggerated sense of the power of medicine, surgery, and the expectation that doctors will do good, as well as a cultural and historical awareness of “miraculous” advances in medicine and surgery over the past 150 years.”

Harm avoidance not for all situations
“Do no harm” as an ethical principle is not applicable to all health situations. There are times when risk-taking is sound, because it could lead to good results.

If physicians took “first, do no harm” literally, no one would have surgery, even if it was lifesaving. We might stop ordering mammograms, because they could lead to a biopsy for a non-cancerous lump.

But doctors do recommend these things within the bounds of ethical practice because the modern interpretation of “first, do no harm” is closer to this: doctors should help their patients as much as they can by recommending tests or treatments for which the potential benefits outweigh the risks of harm.

From harm to plunder
I cannot rest this comment on Dengvaxia on just the transgression of an ethical principle. There is something bigger and more malodorous in this scandal—perhaps a crime.

An editorial in the Daily Tribune (“Midnight deal, clear as daylight,” December 13, 2017) awakened me to the bigger issue. It listed the suspicious and scandalous aspects of the Dengvaxia deal, as follows:

1.The Senate inquiry into the P3.5-billion Dengvaxia vaccine scandal was not the first time that a congressional inquiry was held on the issue. An earlier inquiry was prompted when two public school students who had been vaccinated died. But it was aborted.

2.Sanofi-Pasteur, the French pharmaceutical firm, triggered new concerns about the medicine when it issued an advisory saying a severe disease may occur when the vaccine is administered to those who have no history of dengue.

The warning was issued after more than 830,000 public school students had already been inoculated via a nationwide immunization drive.

3. The funding for the immunization drive was not part of the national budget, or the GAA (General Appropriations Act). The funding was inserted in the budget despite the absence of any compelling reason for the immunization program.

4. Dengvaxia was not listed in the Philippine National Drug Formulary, or the essential drugs list, which is the record of drugs that are allowed to be widely distributed.

5. The Aquino administration scrounged for funds for Dengvaxia. It found these in the MPBF (miscellaneous personnel benefits fund) which was the usual victim of underspending in the Aquino administration.

7. Negotiations with Sanofi on Dengvaxia were constant and continuing. There were meetings among Noynoy Aquino, Janette Garin and Sanofi officials in Paris and Beijing.

The timeline in the adoption of Dengvaxia looks like a smoking gun:

The first meeting took place in November,2014, between Aquino and a Sanofi senior vice president for the Asian region in Beijing during the annual Asia Pacific Economic Cooperation Summit (APEC).

Another meeting was held in mid-2015 in Paris.

On August 29, 2015 Sanofi applied for Dengvaxia to be included in the Philippine National Drug Formulary.

Aquino then met again with Sanofi officials together with Garin in Paris on December 1, 2015.

Garin then filed for a health facility enhancement program funding and procurement of three million doses of dengue vaccine. Nine days immediately after, Garin’s proposal was approved by the Department of Budget and Management (DBM) under Secretary Butch Abad.

On December 22, 2015, Dengvaxia got Food and Drug Administration (FDA) approval that allows its marketing in the Philippines. The FDA was then under Garin, who was concurrent FDA officer-in-charge and health secretary.

The special allotment release order (SARO) was made on December 28, and the following day it was issued by the DBM to the DoH, which was made valid until December 31, 2015.

On January 21,2016, the Philippine Children’s Medical Center (PCMC) made out a purchase order for the dengue vaccine to Zuellig Pharma without approval from the Philippine National Drug Formulary (PNDF). On March 2, 2016, the notice for cash allocation was issued for P4.3 billion for the DoH, and P3.5 billion of the amount was transferred to the PCMC. Three days after, the purchase order was made to Zuellig Pharma, the local distributor of Sanofi.

8. The rush of the Dengvaxia deal and its timing when Aquino was about to step down and when the Liberal Party needed massive funds for the 2016 polls point to plunder, the Tribune concluded.

The Tribune’s timeline clinched the issue for me. It’s not just “Do no harm”, it’s “do not plunder.”

Aquino’s defense
In his Senate testimony, and subsequently in a surreal press conference, President Aquino explained that he made the decision on the Dengvaxia purchase because no one in his government objected to the policy.

Aquino also claimed that the choice and purchase of the dengue vaccine was a matter of great urgency for the nation. Public health was under serious threat. He believed that if he did not act, and the situation deteriorated, he would then be blamed for inaction.

In answer to the charge that Dengvaxia was not certified by the proper authorities, including the World Health Organizaion (WHO) before the purchase, Aquino claimed that he had ordered Secretary Garin to subject Dengvaxia to the requisite processes.

It was typical Noynoy rationalization of a grievous mistake committed under his watch. He did not know. He sought to escape responsibility by washing his hands and pointing to others. Remember how he tried to elude responsibility for the Mamasapano massacre by claiming that he told Gen. Netulio Napeñas to coordinate with the military?

No one believed Aquino then. Will anyone believe him now?


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