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?