(Lexie, 2020)

BMGT 496 – Week 4 Citations

(Evans, 2017)

(Hadzima Jr., 2006)

(Lexie, 2020)

(National Research Council (US) Committee to Study the Human Health Effects of
Subtherapeutic Antibiotic Use in Animal Feeds, 1980)

(Pearl, 2017)

(Phillips & Cohen, 2021)

(Seres, 2017)

(Silverman, 2016)

(Stratton, Palombi, Blue, & Schneiderhan, 2018)

(Thielking, 2015)

(Weigmann, 2015)

Bibliography
Evans, J. (2017, December). The War on Opioids: An Ethical Perspective. Caring for the Ages,

18(12), 14. doi:https://doi.org/10.1016/j.carage.2017.11.012

Hadzima Jr., J. G. (2006, December). The Importance of Patents: It Pays to Know Patent Rules.
Boston Journal, 1-2. Retrieved April 6, 2021, from http://web.mit.edu/e-
club/hadzima/pdf/the-importance-of-patents.pdf

Lexie. (2020, November 3). 5 famous whistleblowers who risked everything. Retrieved April 6,
2021, from ExpressVPN: https://www.expressvpn.com/blog/5-american-famous-
whistleblowers/

National Research Council (US) Committee to Study the Human Health Effects of Subtherapeutic
Antibiotic Use in Animal Feeds. (1980). Appendix K. In The Effects on Human Health of
Subtherapeutic Use (pp. 317-376). Washington, DC: National Academies Press. Retrieved
April 6, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK216502/#ddd00236

Pearl, R. (2017, January 19). Why Patent Protection In The Drug Industry Is Out Of Control.
Retrieved April 6, 2021, from Forbes:
https://www.forbes.com/sites/robertpearl/2017/01/19/why-patent-protection-in-the-
drug-industry-is-out-of-control/?sh=2741ef9f78ca

Phillips & Cohen. (2021, March 19). Our Successful Whistleblower Cases. Retrieved April 6, 2021,
from Phillips & Cohen: https://www.phillipsandcohen.com/successful-cases/

Seres, D. (2017, March 30). The Danger Of Loosely Regulated Supplements. Retrieved April 6,
2021, from American Council on Science and Health:
https://www.acsh.org/news/2017/03/30/danger-loosely-regulated-supplements-11070

Silverman, E. (2016, November 6). Supreme Court lets pay-to-delay ruling against pharma stand.
Retrieved April 6, 2021, from STAT News:

Supreme Court lets pay-to-delay ruling against pharma stand

Stratton, T. P., Palombi, L., Blue, H., & Schneiderhan, M. E. (2018, August 1). Ethical dimensions of
the prescription opioid abuse crisis. American Journal of Health-System Pharmacy, 75(15),
1145-1150. doi:https://doi.org/10.2146/ajhp170704

Thielking, M. (2015, October 14). Unregulated supplements send thousands to hospital each year.
Retrieved April 6, 2021, from STAT News:
https://www.statnews.com/2015/10/14/unregulated-supplements-send-thousands-to-
hospital-each-year/

Weigmann, K. (2015, May). The ethics of global clinical trials: In developing countries,
participation in clinical trials is sometimes the only way to access medical treatment.
What should be done to avoid exploitation of disadvantaged populations? EMBO Reports,
16(5), 566-570. doi:https://doi.org/10.15252/embr.201540398

14 CARING FOR THE AGES D E C E M B E R 2 0 1 7

scribe them.
There is a war on opioids in this coun-try — and on the people who pre-

We are in the midst of a
public health crisis of addiction that has
already taken the lives of many people
and is straining our limited resources
for fi rst responders and emergency care.

B ecause many deaths occur from the
misuse of prescription-only drugs — and
there have been many highly publicized
instances of unscrupulous prescribers
running “pill mills” — many people nat-
urally assume that the medical profession
is the source of the problem. The power
and privilege of prescribing medications
are limited to a relative few, and with
this great power comes great responsi-
bility; popular resentment is only to be
expected whenever power is perceived to
be abused. As a result, fear and distrust
of the medical profession have increased,
along with the intense effort, now well
underway, to discourage physicians from
prescribing opioids.

“W e all have strength
enough to endure the
misfortune of others.”
—François de La
Rochefoucauld

H owever, the opioid crisis involves
many deeper causes. Socioeconomic fac-
tors have contributed to the profound
hopelessness and despair that many peo-
ple live with every day. And prescription
opioids continue to be widely available
from illicit sources, as is heroin, which
often is combined with fentanyl.

I am not making ex cuses on behalf
of the medical profession — quite the
contrary. I want to emphasize even more
broadly the moral and ethical responsi-
bility of health care providers, the chang-
ing ethos of health care, and the grave
risks to all the caring professions and
our professional values as we navigate
this storm.

History of Opioid Use
The histor y of opioid use is the his-
tory of medicine. The fi rst recorded use
of opium for medical purposes dates
back at least 5,000 years. The Ebers
papyrus from 1550 B.C. described
the medicinal preparation and use of
opium in Egypt. Hippocrates discussed
the important medicinal uses of opium
in 460 B.C. Opium has been continu-
ously modifi ed for medical use since
then. The use of opium in the form of
laudanum was described by Paracelsus
in 1527. Morphine was commercially

manufactured by Merck and Company
in 1827, and its use in injectable form
was developed in 1840 in Scotland.

The dev elopment of surgery and all its
related subspecialties would have been
impossible without opioids. Although
many other analgesics have been discov-
ered or developed since aspirin, none are
as potent or effective as opioids for the
treatment of severe pain. But the history
of medicine and the history of opium are
also the history of addiction.

Just Say No
“Just Say No” was the mantra of the
war on (illicit) drugs begun in the early
days of the Reagan administration
some 35 years ago. The same refrain is
being heard again today by prescribers
of opioids, along with a reminder of
Hippocrates’ admonition to “fi rst do
no harm” (primum non nocere). Some
believe that doing no harm supersedes
any obligation to do good (benefi cence).
But the obligation to do good is far
more fundamental: it is the guiding
principle of all caring professions and
has formed the basis of every civil soci-
ety in history.

It is a mistake, however, to assume that
most practitioners even want to prescribe
opioids. Most prescribers are generally
(and increasingly) afraid to. And most
report inadequate training in pain man-
agement, fear of enabling addiction, and
fear of getting in trouble. Prescribing
opioids is more than an inconvenience.
We are required to view our patients
with suspicion — they could be lying to
us or drug seeking. We must check up
on them in a database. But if we aren’t
allowed to trust them, why should any
patient trust us? Our job, our obliga-
tion, and our calling is to love and care
for others, not to judge them. And we
resent it, more than anything, when they
judge us.

I ndeed, many physicians now are heed-
ing the call to just say no. An increas-
ing number of practitioners, including
board-certifi ed pain specialists, are fl atly
refusing to prescribe opioids for any rea-
son. Even within our professions the sug-
gestion is increasingly being made that
we are weak because we can’t stand pain.

B ut think about what it means to our
profession, and to our society, if as pre-
scribers we all just say no.

What if we just say no to cancer
patients, to patients with acute fractures
or major surgery, to dying people, and
to people whose pain is so bad they wish
they could die? It means, at a minimum,
we are indifferent to human suffering.
It means that we keep all the power to
prescribe to ourselves yet avoid any of

the responsibilities that go with it. It
means that ours are no longer the car-
ing professions — because we no longer
care. We become technicians following
algorithms, and we can soon be replaced
by computers that are better at it and no
less caring.

T o refuse to accept responsibility for
another’s comfort and well-being is to
repudiate all our professional values,
which thus requires a renunciation of
all the associated privileges.

Medical care is inherently dangerous.
Our obligation isn’t to avoid practicing
medicine, it’s to make it less danger-
ous. Hippocrates’ admonition to fi rst
do no harm was not an admonition to
never treat, and it did not supersede his
instructions on the use of opioids and
other inherently dangerous medicines.
We are, however, obligated to know the
harm — to weigh the benefi ts and risks,
and to guide decision making through
authentic, informed consent, based on
real knowledge of the risks and benefi ts,
rather than on collective ritual practice.
And we are obligated to monitor and
guide the patient, and to accept personal
responsibility for the welfare of another
whole person, not just our favorite dis-
ease or body part.

S trategies to try to limit our responsi-
bility only limit our worth as profession-
als and as human beings.

Accepting Responsibility
The history of medicine is the history
of medicines. Indeed, the word physi-
cian literally means “drug giver.” Despite
our collective history of more than
5,000 years of medicines, however, we
do a lousy job of prescribing them. It
is estimated that more than 250,000
Americans die every year as a result of
taking (mostly nonopioid) medicines
exactly as prescribed. That number has
likely increased since the introduction
of Medicare Part D drug coverage to
seniors, the age group that is at highest
risk for adverse drug effects. The one-
size-fi ts-all approach to drug prescribing
for adults in the United States further
increases the risk to older patients.

The benefi ts of medicines are exag-
gerated and the risks minimized in the
minds of almost every prescriber (and
most patients). There is widespread,
willful ignorance among prescribers
about the risks, benefi ts, mechanisms
of action, and elimination of almost
every medicine prescribed. This is a deep
cultural fl aw in American health care. A
student of surgery would be expected to
know all the steps of a surgical proce-
dure backward and forward along with
the potential complications before ever

being allowed to proceed under close
supervision. But that same individual
need only know what symptom or prob-
lem a medicine is ‘for’ in order to pre-
scribe it. Nor is that student’s teacher
expected to know more.

We also do a terrible job of under-
standing age-related changes in anatomy
and physiology, as well as drug–drug
and drug–disease interactions to prevent
serious problems caused by medicines.
Medical specialties do not even take
responsibility for disseminating infor-
mation about new drugs to their prac-
titioners — instead, they leave it to the
pharmaceutical sales force. So whatever
condemnation we receive for prescribing
medications is well deserved, even if at
times somewhat misguided.

We should be experts on all the drugs
we prescribe. It should be a source
of professional pride. If these are the
tools of our trade, then we must master
them. Prescribers should be leading the
national dialogue on safe and appropriate
prescribing of opioids, not hanging our
heads or running the other way. It is our
moral obligation, and maintaining the
integrity of our professions requires that
we lead the call for monitoring and safe-
guarding the prescription drug supply in
this country, ensuring timely, appropri-
ate access to opioids for the patients who
need them, those for whom adequate
substitute treatments do not exist. We
should be leading the charge for univer-
sal access to addiction prevention and
recovery, along with access to expertise
in effective pain management and con-
trol. And we should actively police our
own profession for those who abuse the
privilege of prescribing by doing so inap-
propriately, and those who abuse the
privilege of practicing medicine by turn-
ing a blind eye to human suffering.

The challenges to safe and effectiv e
pain management, including appropri-
ate opioid prescribing, are many and are
made worse by increasingly fragmented
care and communication across settings
and across practitioners even for a single
episode of illness. But none of these chal-
lenges are as great — or as great a threat
to our professions and our professional
values — as the prospect of becoming
indifferent to human suffering and to
our awesome responsibility and privilege
to relieve that suffering.

Dr. Evans is a full-time long-term care
physician in Charlottesville, VA, and
medical director of two skilled nurs-
ing facilities. A past Society president,
he serves on the Caring for the Ages
Editorial Advisory Board.

MEDICAL ETHICS
Jonathan Evans, MD, MPH, CMD

The War on Opioids: An Ethical Perspective

4/6/2021 5 Famous American Whistleblowers Who Stood up for What Is Right

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5 famous whistleblowers
who risked everything

L E X I E
Last updated: November 3, 2020

D I G I TA L F R E E D O M
4 mins

“See something, say something” is a safety and
awareness campaign running across multiple

https://www.expressvpn.com/blog/author/lexie/

https://www.expressvpn.com/blog/author/lexie/

https://www.expressvpn.com/blog/category/digital-freedom/

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cities in the United States.

If you see misconduct, criminal activity or just
something suspicious, you are expected to alert
the authorities.

But what if it’s the authorities that are doing
something wrong, by abusing their power or
acting suspiciously? Ideally, an institution should
have internal complaints mechanisms, an
Ombudsperson or an external anti-corruption
agency.

Members of the United States Intelligence
Community, however, find it difficult to raise
concerns internally and those that do are often
ignored.

Additionally, whistleblower protection often does
not apply (e.g., to contractors), and must only be
reported to Congress.

https://www.theguardian.com/commentisfree/2013/jun/12/snowden-surveillance-subverting-constitution

https://news.vice.com/en_us/article/mb9mza/exclusive-snowden-tried-to-tell-nsa-about-his-concerns

https://en.wikipedia.org/wiki/Whistleblower

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What happens to those who do manage to blow
the whistle? Of the famous examples below, one is
in jail, one has done jail time, one is awaiting trial,
one is in exile, and the other is on the run.

1. Edward Snowden
In 2013, ‘Ed’ left his job with a U.S. defense
contractor for Hong Kong, taking with him 10,000
documents detailing the U.S. surveillance
apparatus.

Snowden handed this trove to journalists who for
years continued to release the information in
various dossiers covering surveillance, espionage,
hacking, and civil rights violations.

Edward Snowden was given asylum in Ecuador
but, due to the U.S. canceling his passport en
route, became stranded at Sheremetyevo airport

https://www.theguardian.com/us-news/the-nsa-files

https://www.expressvpn.com/internet-privacy/infographics/#surveillance

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https://www.expressvpn.com/blog/5-american-famous-whistleblowers/ 4/10

in Moscow. He was granted temporary asylum in
Russia, where he continues to live until today.

2. Daniel Ellsberg
Daniel Ellsberg released the Pentagon Papers in
1971 and detailed the continuous lies of the
Lyndon B. Johnson administration regarding the
war in Vietnam.

The documents were photocopies Ellsberg was
able to make during his work at the RAND
Corporation and, at first, he tried to convince
Senator Fulbright to release the papers to the
Senate (because a Senator could not be
prosecuted for something they say on the floor).

When that failed, Ellsberg sent the documents to
the New York Times, which quickly received a

https://www.archives.gov/research/pentagon-papers

4/6/2021 5 Famous American Whistleblowers Who Stood up for What Is Right

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court order forbidding them to publish or report
on its contents.

Ellsberg, still on the run from the FBI, mailed the
documents to other newspapers, including the
Washington Post, which finally published the
stories.

Ellsberg’s trial in 1973 revealed that the
government had illegally wiretapped Ellsberg and
even broke into his psychiatrist’s office to find
discrediting information. The case was thrown out
by the court.

The Pentagon Papers were only fully released and
made available to the public in 2011.

3. Chelsea Manning

4/6/2021 5 Famous American Whistleblowers Who Stood up for What Is Right

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Chelsea Manning was an Intelligence Analyst with
the U.S. Army stationed in Iraq. She had access to
classified databases containing videos, diplomatic
cables, and war logs from Afghanistan and Iraq—
which she released to Wikileaks.

Some of the content detailed American war
crimes in Iraq, including the murder of Reuters
journalists and those who aided the wounded.

Chelsea Manning told an online acquaintance
about her actions, which resulted in her capture.
Chelsea faced charges that could have resulted in
the death penalty but received a sentence of 35
years in maximum security prison.

In 2017, the sentence was reduced to seven years
by President Obama, and she was released the
same year.

https://www.expressvpn.com/blog/quick-biography-chelsea-manning/

https://wardiaries.wikileaks.org/

https://collateralmurder.wikileaks.org/

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4. Reality Winner
A U.S. military contractor employed Reality
Winner, where she was able to obtain a document
about Russia’s interference in the 2016 election,
which she made available to the publication The
Intercept.

Authorities caught Winner because of
metadata found on the documentswhich revealed
the printer she used. She was sentenced to five
years and three months in jail, the longest such
sentence by a federal court for releasing
information to the media.

There is hope Winner might be pardoned by
President Trump, who voiced his support
for Winner in a Tweet.

Top-Secret NSA Report Details Russian Hacking Effort Days Before 2016 Election

https://www.theatlantic.com/technology/archive/2017/06/the-mysterious-printer-code-that-could-have-led-the-fbi-to-reality-winner/529350/

https://www.expressvpn.com/blog/how-your-printer-tells-on-you/

Ex-NSA contractor to spend 63 months in jail over “classified” information. Gee, this is “small potatoes” compared to what Hillary Clinton did! So unfair Jeff, Double Standard.

— Donald J. Trump (@realDonaldTrump) August 24, 2018

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5. Shadow Brokers
The Shadow Brokers are a hacking group (and
whistleblowers) active since 2010. They alert the
public about security vulnerabilities created and
exploited by the NSA.

The leader of the Shadow Brokers is Harold T.
Martin III, a contractor with the same company
Snowden worked with before he blew the whistle.

Some speculate that Shadow Brokers is the work
of Russian counter-intelligence, acting with the
aim of undermining the NSA in its global
operations.

Harold T. Martin III is currently under arrest and
awaiting trial.

https://en.wikipedia.org/wiki/Harold_T._Martin_III

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Bonus: Paul Revere a
whistleblower?
Paul Revere was an American Revolutionary who
literally blew a whistle in 1775, alerting American
revolutionaries about the arrival of British colonial
militia.

While not commonly referred to as a
whistleblower, the British forces did at the time
rule over the colonies. Their acts of power were
lawful, while the revolution was illegal.

Doing what’s right is not always doing what’s
legal, and the many women and men who do
what’s right in the face of jail time or even the
death are heroes.

Anonymity is an essential tool for staying safe as a
whistleblower. Be careful, but do get help, from
reputable journalists and lawyers and

https://www.expressvpn.com/blog/anonymous-whistleblowing-guide/

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technologists when alerting the world about the
crimes conducted by authority.

4/6/2021 Antibiotics In Animal Feeds – The Effects on Human Health of Subtherapeutic Use of Antimicrobials in Animal Feeds – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK216502/?report=printable 1/32

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Research Council (US) Committee to Study the Human Health Effects of Subtherapeutic Antibiotic Use in Animal Feeds. The
Effects on Human Health of Subtherapeutic Use of Antimicrobials in Animal Feeds. Washington (DC): National Academies Press (US);
1980.

Appendix K Antibiotics In Animal Feeds

Committee on Animal Health and the Committee on Animal Nutrition

Board on Agriculture and Renewable Resources National Research Council

Executive Summary
The food-producing animal and poultry industries have undergone a dramatic change that began around 1950. What was an
extensive industry became extremely intensive: units increased in animal concentration, both physically and numerically.
Utilization of the beneficial responses of feed-additive antibiotics in improved growth and feed efficiency developed
concurrently with the intensification of the animal industry. It has been proposed that feed-additive antibiotic usage was an
integral part of this revolution in animal-production technology. It is estimated, at present, that 40 percent of the antibiotics
produced are used for feed additives. Estimates allocate 0.5 million kg to the cattle industry, 1.0 million kg to poultry, 1.4
million kg to swine, and 0.4 million kg to other animals such as companion animals.

The animal producer can obtain antibiotics in the form of balanced supplements and premixes that are processed and sold
by the feed-manufacturing industry. The producer also has access to and can purchase antibiotic products from farm and
veterinary supply centers. Administration of antibiotics in the drinking water is becoming increasingly important in both
poultry and swine production.

Feedlot systems for beef cattle and sheep would not change if low-level antibiotic feedings were not permitted, but it is
likely that disease problems and therapeutic use of antibiotics would increase.

The discontinuance of low-level (5 to 10 g/ton) usage of penicillin and tetracyclines would have little effect on the poultry
industry. However, the elimination of higher levels (100 to 200 g/ton) would make it very difficult to control bacterial
disease in young chickens and turkeys. If all tetracyclines and penicillin were banned as feed additives for poultry, the
effective alternative antibiotics and sulfa drugs would likely maintain present production and efficiency standards.
However, the problem of selective pressure for some multiple antibiotic resistance mediated by plasmids may still persist
with alternative antimicrobials.

If only tetracyclines and penicillin were banned as feed-additive antibiotics for swine, there would be little if any effect on
swine productivity or efficiency. There are other promising antibacterial agents that could serve the industry well.

If subtherapeutic use of feed additive antibiotics is banned, future changes in disease control will include preventing
exposure to infectious agents, treatment of disease after an outbreak has occurred, and control of infectious disease by
immunological means. Preventing exposure to infectious agents will be extremely difficult and will result in a slowing
down of animal production. Post-outbreak treatment has had variable effectiveness, but would certainly be less effective
than the present use of subtherapeutic levels of antibiotics. The control of infectious disease by immunological means
would be an ideal way to safeguard against subclinical infection. However, thus far there has been limited success in
protecting animals against bacterial pathogens that affect the intestinal and respiratory tracts.

Antibiotics have been effective in improving the rate and efficiency of gain in swine, cattle, and poultry. The responses in
poultry and swine are generally greater in younger animals than in those reaching the end of the growing-finishing period.
There is some evidence that the improved farrowing rate of swine is associated with the use of antibiotics. Responses in
cattle have not been as great as those in swine and poultry. Improvement in rate of gain and feed efficiency in cattle has
averaged about 5 percent. Evidence indicates that the effectiveness of antibiotics has not decreased over time.

Antibiotics in feed have also been used in animal production in Europe since 1953. The British have monitored microbial
resistance to antibiotics and have conducted some basic and applied research concerning this aspect. Although the use of
antibiotics in the United Kingdom has been restricted as a result of the Report of the Joint Committee on the Use of

4/6/2021 Antibiotics In Animal Feeds – The Effects on Human Health of Subtherapeutic Use of Antimicrobials in Animal Feeds – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK216502/?report=printable 2/32

1.

2.

3.

Antibiotics in Animal Husbandary and Veterinary Medicine (referred to in this report as the Swann Report; Swarm et al.
1969), the total tonnage used in animal production in 1975 was at an all-time high. Although the amount used in animals
was only about 15 percent of the total usage, the ratio of the human population to the livestock population receiving
antibiotics is substantially higher than in the United States.

Ingestion of antibiotics results in the development of resistance in bacteria such as in the E. coli and Salmonella species.
The resistance appears to be related to usage patterns. British research has shown that resistance persists longer following
long-term use, compared to short-term use. There is strong evidence that development of resistant strains of bacteria in
humans is closely related to antibiotics used in humans. No concrete evidence has been reported in the United Kingdom
showing that antibiotic resistance has decreased since the Swann Report, or that antibiotic use has decreased.

The wise use of antibiotics is not a substitute for, but a complement to, good sanitation and husbandry practices. Extensive
use of low-level antibiotics in feeds has brought about concern for potential harmful effects due to development of resistant
strains of organisms in host animals that might compromise animal as well as human health. Drug resistance in bacteria
was observed soon after the introduction of antibiotics. Antibiotics have been used extensively in animal feeds for nearly
30 years. Questions and discussions concerned with the potential human health hazards from subtherapeutic antibiotic
feeding to animals have been aired for nearly 30 years. Yet, it is difficult to cite human health problems that can be
attributed specifically to meat animals fed antibiotics or that can be associated with contact with animals fed low levels of
antibiotics. There have been incidents of salmonellosis in humans involving antibiotic resistant strains of animal origin but
there is no evidence of any relation to low-level antibiotic feeding.

Surveys of the use of drugs for therapeutic purposes indicate that antibacterial agents account for almost 50 percent of
drugs used by practicing veterinarians. In vitro testing has sometimes been questioned in that infections associated with
organisms that seem to be resistant in vitro are quite responsive to antibacterial therapy in vivo in clinical use.

Scattered reports, published and unpublished, attribute failure in drug therapy to low-level antibiotic feeding. Others claim
continued effectiveness of drugs previously fed for long periods at subtherapeutic levels. Carefully controlled studies
exploring possible relationships between antibiotic feeding and subsequent drug effectiveness are needed.

Critical experimental studies on the effect of low-level antibiotic feeding on animal therapy and human health are de
finitely needed. It is proposed that studies be conducted in the following areas:

Does the Feeding of Tetracycline and Penicillin Compromise Animal Therapy?—This research should be done with
swine, poultry, and cattle. In swine and poultry, conditions should be closely controlled. In cattle it would seem
essential that research be conducted in commercial-type feedlots.

The Relationship of Antibiotic Feeding to Human Health— Although these studies are very complex and time-
consuming, it is important that some …