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Ethics_manual_3rd_Nov2015_en<\/a><\/p>\n

3rd edition 2015
\n2 1
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nWORLD MEDICAL ASSOCIATION
\nWorld Medical Association
\nMedicalEthicsManual
\nMedical student holding a newborn
\n\u00a9 Roger Ball\/CORBIS
\nMedical Ethics
\nManual
\n3rd edition 2015
\n2 1
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\n\u00a9 2015 by The World Medical Association, Inc.
\nAll rights reserved. Up to 10 copies of this document may be
\nmade for your non-commercial personal use, provided that
\ncredit is given to the original source. You must have prior written
\npermission for any other reproduction, storage in a retrieval
\nsystem or transmission, in any form or by any means. Requests
\nfor permission should be directed to The World Medical
\nAssociation, B.P. 63, 01212 Ferney-Voltaire Cedex, France;
\nemail: wma@wma.net, fax (+33) 450 40 59 37.
\nThis Manual is a publication of the World Medical Association.
\nIt was written by John R. Williams, Director of Ethics,
\nWMA (2003-2006)
\nCover, design and concept by Tuuli Sauren,
\nINSPIRIT International Communications, Belgium.
\nProduction and concept by
\nWorld Health Communication Associates, UK.
\nPictures by Van Parys Media\/CORBIS
\nCataloguing-in-Publication Data
\nWilliams, John R. (John Reynold), 1942-.
\nMedical ethics manual.
\n1. Bioethics 2. Physician-Patient Relations \u2013 ethics.
\n3. Physician\u2019s Role 4. Biomedical Research \u2013 ethics
\n5. Interprofessional Relations 6. Education, Medical \u2013 ethics
\n7. Case reports 8. Manuals I. Title
\nISBN 978-92-990079-0-7
\n(NLM classification: W 50)
\nTABLE OF CONTENTS
\nAcknowledgments…………………………………………………………………………4
\nForeword……………………………………………………………………………………………5
\nIntroduction………………………………………………………………………………………7
\n\u00b7 \t What is medical ethics?
\n\u00b7\t Why study medical ethics?
\n\u00b7\t Medical ethics, medical professionalism, human rights and
\nlaw
\n\u00b7\tConclusion
\nChapter One \u2013 Principal Features of Medical Ethics ….14
\n\u00b7\t Objectives
\n\u00b7\t What\u2019s special about medicine?
\n\u00b7\t What\u2019s special about medical ethics?
\n\u00b7\t Who decides what is ethical?
\n\u00b7\t Does medical ethics change?
\n\u00b7\t Does medical ethics differ from one country to another?
\n\u00b7\t The role of the WMA
\n\u00b7\t How does the WMA decide what is ethical?
\n\u00b7\t How do individuals decide what is ethical?
\n\u00b7\t Conclusion
\nChapter Two \u2013 Physicians and Patients…………………………….34
\n\u00b7\t Objectives
\n\u00b7\t Case study
\n\u00b7\t What\u2019s special about the physician-patient relationship?
\n\u00b7\t Respect and equal treatment
\n\u00b7\t Communication and consent
\n\u00b7\t Decision-making for incompetent patients
\n\u00b7\t Confidentiality
\nMedicalEthicsManual\u2013TableofContents
\n2 3
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\n\u00b7\t Beginning-of-life issues
\n\u00b7\t End-of-life issues
\n\u00b7\t Back to the case study
\nChapter Three \u2013 Physicians and Society…………………………..64
\n\u00b7 \t Objectives
\n\u00b7 \t Case study
\n\u00b7 \t What\u2019s special about the physician-society relationship?
\n\u00b7 \t Dual loyalty
\n\u00b7 \t Resource allocation
\n\u00b7 \t Public health
\n\u00b7 \t Global health
\n\u00b7 \t Physicians and the environment
\n\u00b7 \t Back to the case study
\nChapter Four \u2013 Physicians and Colleagues…………………….84
\n\u00b7 \t Objectives
\n\u00b7 \t Case study
\n\u00b7 \t Challenges to medical authority
\n\u00b7 \tRelationships with physician colleagues, teachers and
\nstudents
\n\u00b7 \t Reporting unsafe or unethical practices
\n\u00b7 \t Relationships with other health professionals
\n\u00b7 \t Cooperation
\n\u00b7 \t Conflict resolution
\n\u00b7 \t Back to the case study
\nChapter Five \u2013 Medical Research…………………………………………98
\n\u00b7 \tObjectives
\n\u00b7 \t Case study
\n\u00b7 \t Importance of medical research
\n\u00b7 \tResearch in medical practice
\n\u00b7 \t Ethical requirements
\nMedicalEthicsManual\u2013TableofContents
\n\u2013 Ethics review committee approval
\n\u2013 Scientific merit
\n\u2013 Social value
\n\u2013 Risks and benefits
\n\u2013 Informed consent
\n\u2013 Confidentiality
\n\u2013 Conflict of roles
\n\u2013 Honest reporting of results
\n\u2013 Whistle blowing
\n\u2013 Unresolved issues
\n\u00b7 \t Back to the case study
\nChapter Six \u2013 Conclusion……………………………………………………….116
\n\u00b7 \tResponsibilities and privileges of physicians
\n\u00b7 \t Responsibilities to oneself
\n\u00b7 \tThe future of medical ethics
\nAppendix A \u2013 Glossary
\n(includes words in italic print in the text)……………………………….124
\nAppendix B \u2013 Medical Ethics Resources on the Internet………..127
\nAppendix C \u2013 World Medical Association:
\n\t Resolution on the Inclusion of Medical Ethics
\nand Human Rights in the Curriculum of
\nMedical Schools World-Wide, and
\n\t World Federation for Medical Education:
\nGlobal Standards for Quality Improvement \u2013
\nBasic Medical Education………………………………………………………….128
\nAppendix D \u2013 Strengthening Ethics Teaching in
\nMedical Schools………………………………………………………………………..130
\nAppendix E \u2013 Additional Case Studies………………………………………132
\n4 5
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nACKNOWLEDGMENTS
\nThe WMA is profoundly grateful to the following individuals
\nfor providing extensive and thoughtful comments on earlier
\ndrafts of this Manual:
\nProf. Solly Benatar, University of Cape Town, South Africa
\nProf. Kenneth Boyd, University of Edinburgh, Scotland
\nDr. Annette J. Braunack-Mayer, University of Adelaide, Australia
\nDr. Robert Carlson, University of Edinburgh, Scotland
\nMr. Sev Fluss, WMA and CIOMS, Geneva, Switzerland
\nProf. Eugenijus Gefenas, University of Vilnius, Lithuania
\nDr. Delon Human, WMA, Ferney-Voltaire, France
\nDr. Girish Bobby Kapur, George Washington University,
\nWashington, DC, USA
\nProf. Nuala Kenny, Dalhousie University, Halifax, Canada
\nProf. Cheryl Cox Macpherson, St. George\u2019s University, Grenada
\nMs. Mareike Moeller, Medizinische Hochschule Hannover,
\nGermany
\nProf. Ferenc Oberfrank, Hungarian Academy of Sciences,
\nBudapest, Hungary
\nMr. Atif Rahman, Khyber Medical College, Peshawar, Pakistan
\nMr. Mohamed Swailem, Banha Faculty of Medicine, Banha,
\nEgypt, and his ten fellow students who identified vocabulary that
\nwas not familiar to individuals whose first language is other than
\nEnglish.
\nThe first edition of this Manual was supported in part by an
\nunrestricted educational grant from Johnson & Johnson.
\nFOREWORD
\nDr. Delon Human
\nSecretary General
\nWorld Medical Association
\nIt is incredible to think that although the founders of medical ethics,
\nsuch as Hippocrates, published their works more than 2000 years
\nago, the medical profession, up until now, has not had a basic,
\nuniversally used, curriculum for the teaching of medical ethics. This
\nfirst WMA Ethics Manual aims to fill that void. What a privilege it is
\nto introduce it to you!
\nThe Manual\u2019s origin dates back to the 51st World Medical Assembly
\nin 1999. Physicians gathered there, representing medical
\nassociationsfromaroundtheworld,decided \u201ctostronglyrecommend
\nto Medical Schools worldwide that the teaching of Medical Ethics
\nand Human Rights be included as an obligatory course in their
\ncurricula.\u201d In line with that decision, a process was started to
\ndevelop a basic teaching aid on medical ethics for all medical
\nstudents and physicians that would be based on WMA policies, but
\nnot be a policy document itself. This Manual, therefore, is the result
\nof a comprehensive global developmental and consultative process,
\nguided and coordinated by the WMA Ethics Unit.
\nModern healthcare has given rise to extremely complex and
\nmultifaceted ethical dilemmas. All too often physicians are
\nunprepared to manage these competently. This publication is
\nspecifically structured to reinforce and strengthen the ethical
\nmindset and practice of physicians and provide tools to find ethical
\nsolutions to these dilemmas. It is not a list of \u201crights and wrongs\u201d
\nbut an attempt to sensitise the conscience of the physician, which
\nis the basis for all sound and ethical decision-making. To this end,
\nyou will find several case studies in the book, which are intended to
\nMedicalEthicsManual\u2013Foreword
\n6 7
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nfoster individual ethical reflection as well as discussion within team
\nsettings.
\nAs physicians, we know what a privilege it is to be involved in the
\npatient-physician relationship, a unique relationship which facilitates
\nan exchange of scientific knowledge and care within a framework of
\nethics and trust. The Manual is structured to address issues related
\nto the different relationships in which physicians are involved, but at
\nthe core will always be the patient-physician relationship. In recent
\ntimes, this relationship has come under pressure due to resource
\nconstraints and other factors, and this Manual shows the necessity
\nof strengthening this bond through ethical practice.
\nFinally, a word on the centrality of the patient in any discussion on
\nmedical ethics. Most medical associations acknowledge in their
\nfoundational policies that ethically, the best interests of the individual
\npatient should be the first consideration in any decision on care. This
\nWMAEthics Manual will only serve its purpose well if it helps prepare
\nmedical students and physicians to better navigate through the many
\nethicalchallengeswefaceinourdailypracticeandfindeffectiveways
\nTO PUT THE PATIENT FIRST.
\nINTRODUCTION
\nWHAT IS MEDICAL ETHICS?
\nConsider the following medical cases, which could have taken place
\nin almost any country:
\n1. \t Dr. P, an experienced and skilled surgeon, is about to finish
\nnight duty at a medium-sized community hospital. A young
\nwoman is brought to the hospital by her mother, who leaves
\nimmediately after telling the intake nurse that she has to look
\nafter her other children. The patient is bleeding vaginally and
\nis in a great deal of pain. Dr. P examines her and decides that
\nshe has had either a miscarriage or a self-induced abortion. He
\ndoes a quick dilatation and curettage and tells the nurse to ask
\nthe patient whether she can afford to stay in the hospital until it
\nis safe for her to be discharged. Dr. Q comes in to replace Dr. P,
\nwho goes home without having spoken to the patient.
\n2. \tDr. S is becoming increasingly frustrated with patients who
\ncome to her either before or after consulting another health
\npractitioner for the same ailment. She considers this to be a
\nwaste of health resources as well as counter-productive for
\nthe health of the patients. She decides to tell these patients
\nthat she will no longer treat them if they continue to see other
\npractitioners for the same ailment. She intends to approach her
\nnational medical association to lobby the government to prevent
\nthis form of misallocation of healthcare resources.
\n3. \tDr. C, a newly appointed anaesthetist* in a city hospital, is
\nalarmed by the behaviour of the senior surgeon in the operating
\nroom. The surgeon uses out-of-date techniques that prolong
\noperations and result in greater post-operative pain and longer
\nrecovery times. Moreover, he makes frequent crude jokes
\nMedicalEthicsManual\u2013Introduction
\n*
\n\t Words written in italics are defined in the glossary (Appendix A).
\n8 9
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nabout the patients that obviously bother the assisting nurses.
\nAs a more junior staff member, Dr. C is reluctant to criticize
\nthe surgeon personally or to report him to higher authorities.
\nHowever, he feels that he must do something to improve the
\nsituation.
\n4. \t Dr. R, a general practitioner in a small rural town, is approached
\nby a contract research organization (C.R.O.) to participate in
\na clinical trial of a new non-steroidal anti-inflammatory drug
\n(NSAID) for osteoarthritis. She is offered a sum of money for
\neachpatientthatsheenrolsinthetrial.TheC.R.O.representative
\nassures her that the trial has received all the necessary
\napprovals, including one from an ethics review committee.
\nDr. R has never participated in a trial before and is pleased
\nto have this opportunity, especially with the extra money. She
\naccepts without inquiring further about the scientific or ethical
\naspects of the trial.
\nEach of these case studies invites ethical reflection. They raise
\nquestions about physician behaviour and decision-making \u2013 not
\nscientific or technical questions such as how to treat diabetes or
\nhow to perform a double bypass, but questions about values, rights
\nand responsibilities. Physicians face these kinds of questions just as
\noften as scientific and technical ones.
\nIn medical practice, no matter what the specialty or the setting, some
\nquestions are much easier to answer than others. Setting a simple
\nfracture and suturing a simple laceration pose few challenges to
\nphysicians who are accustomed to performing these procedures.
\nAt the other end of the spectrum, there can be great uncertainty
\nor disagreement about how to treat some diseases, even common
\nones such as tuberculosis and hypertension. Likewise, ethical
\nquestions in medicine are not all equally challenging. Some are
\nrelatively easy to answer, mainly because there is a well-developed
\nconsensus on the right way to act in the situation (for example, the
\nphysician should always ask for a patient\u2019s consent to serve as a
\nresearch subject). Others are much more difficult, especially those
\nfor which no consensus has developed or where all the alternatives
\nhave drawbacks (for example, rationing of scarce healthcare
\nresources).
\nSo, what exactly is ethics and how does it help physicians deal with
\nsuch questions? Put simply, ethics is the study of morality \u2013 careful
\nand systematic reflection on and analysis of moral decisions and
\nbehaviour, whether past, present or future. Morality is the value
\ndimension of human decision-making
\nand behaviour. The language of
\nmorality includes nouns such as
\n\u2018rights\u2019, \u2018responsibilities\u2019 and \u2018virtues\u2019
\nand adjectives such as \u2018good\u2019 and
\n\u2018bad\u2019 (or \u2018evil\u2019), \u2018right\u2019 and \u2018wrong\u2019,
\n\u2018just\u2019 and \u2018unjust\u2019. According to these
\ndefinitions, ethics is primarily a matter
\nof knowing whereas morality is a
\nmatter of doing. Their close relationship consists in the concern of
\nethics to provide rational criteria for people to decide or behave in
\nsome ways rather than others.
\nSince ethics deals with all aspects of human behaviour and
\ndecision-making, it is a very large and complex field of study
\nwith many branches or subdivisions. The focus of this Manual
\nis medical ethics, the branch of ethics that deals with moral
\nissues in medical practice. Medical ethics is closely related, but
\nnot identical to, bioethics (biomedical ethics). Whereas medical
\nethics focuses primarily on issues arising out of the practice of
\nmedicine, bioethics is a very broad subject that is concerned with
\nthe moral issues raised by developments in the biological sciences
\nMedicalEthicsManual\u2013Introduction
\n\u201c…ethics is the study
\nof morality \u2013 careful
\nand systematic
\nreflection on and
\nanalysis of moral
\ndecisions and
\nbehaviour\u201d
\n10 11
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nmore generally. Bioethics also differs from medical ethics insofar
\nas it does not require the acceptance of certain traditional values
\nthat, as we will see in Chapter Two, are fundamental to medical
\nethics.
\nAs an academic discipline, medical ethics has developed its own
\nspecialized vocabulary, including many terms that have been
\nborrowed from philosophy. This Manual does not presuppose any
\nfamiliarity with philosophy in its readers, and therefore definitions of
\nkey terms are provided either where they occur in the text or in the
\nglossary at the end of the Manual.
\nWHY STUDY MEDICAL ETHICS?
\n\u201cAs long as the physician is a knowledgeable and skilful clinician,
\nethics doesn\u2019t matter.\u201d
\n\u201cEthics is learned in the family, not in medical school.\u201d
\n\u201cMedical ethics is learned by observing how senior physicians act,
\nnot from books or lectures.\u201d
\n\u201cEthics is important, but our curriculum is already too crowded and
\nthere is no room for ethics teaching.\u201d
\nThese are some of the common reasons given for not assigning
\nethics a major role in the medical school curriculum. Each of them
\nis partially, but only partially, valid. Increasingly throughout the
\nworld medical schools are realising that they need to provide their
\nstudents with adequate time and resources for learning ethics. They
\nhave received strong encouragement to move in this direction from
\norganizations such as the World Medical Association and the World
\nFederation for Medical Education (cf. Appendix C).
\nThe importance of ethics in medical education will become apparent
\nthroughout this Manual. To summarize, ethics is and always has
\nbeen an essential component of medical practice. Ethical principles
\nsuch as respect for persons, informed
\nconsent and confidentiality are basic
\nto the physician-patient relationship.
\nHowever, the application of these
\nprinciples in specific situations is
\noften problematic, since physicians,
\npatients, their family members and
\nother healthcare personnel may
\ndisagree about what is the right way
\nto act in a situation. The study of ethics prepares medical students
\nto recognize difficult situations and to deal with them in a rational
\nand principled manner. Ethics is also important in physicians\u2019
\ninteractions with society and their colleagues and for the conduct
\nof medical research.
\nMEDICAL ETHICS, MEDICAL
\nPROFESSIONALISM, HUMAN RIGHTS AND LAW
\nAs will be seen in Chapter One, ethics has been an integral part
\nof medicine at least since the time of Hippocrates, the fifth century
\nB.C.E. (before the Christian era) Greek physician who is regarded
\nas a founder of medical ethics. From Hippocrates came the concept
\nof medicine as a profession, whereby physicians make a public
\npromise that they will place the interests of their patients above their
\nown interests (cf. Chapter Three for further explanation). The close
\nrelationship of ethics and professionalism will be evident throughout
\nthis Manual.
\nIn recent times medical ethics has been greatly influenced by
\ndevelopments in human rights. In a pluralistic and multicultural
\nworld, with many different moral traditions, the major international
\nhuman rights agreements can provide a foundation for medical
\nethics that is acceptable across national and cultural boundaries.
\nMedicalEthicsManual\u2013Introduction
\n\u201cThe study of ethics
\nprepares medical
\nstudents to recognize
\ndifficult situations and
\nto deal with them in a
\nrational and principled
\nmanner.\u201d
\n12 13
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nCHAPTER ONE \u2013 PRINCIPAL FEATURES OF MEDICAL
\nETHICS
\nObjectives
\nAfter working through this chapter you should be able to:
\n\u2022\t explain why ethics is important to medicine
\n\u2022\t identify the major sources of medical ethics
\n\u2022\t recognize different approaches to ethical decision-making,
\nincluding your own.
\nWhat\u2019s Special about Medicine?
\nThroughout almost all of recorded history and in virtually every
\npart of the world, being a physician has meant something special.
\nPeople come to physicians for help with their most pressing needs
\n\u2013 relief from pain and suffering and restoration of health and well-
\nbeing. They allow physicians to see, touch and manipulate every
\npart of their bodies, even the most intimate. They do this because
\nthey trust their physicians to act in their best interests.
\nMoreover, physicians frequently have to deal with medical problems
\nresulting from violations of human rights, such as forced migration
\nand torture.And they are greatly affected by the debate over whether
\nhealthcare is a human right, since the answer to this question in any
\nparticular country determines to a large extent who has access to
\nmedical care. This Manual will give careful consideration to human
\nrights issues as they affect medical practice.
\nMedical ethics is also closely related to law. In most countries there
\nare laws that specify how physicians are required to deal with ethical
\nissues in patient care and research. In
\naddition, the medical licensing and
\nregulatory officials in each country can
\nand do punish physicians for ethical
\nviolations. But ethics and law are not
\nidentical. Quite often ethics prescribes
\nhigher standards of behaviour than
\ndoes the law, and occasionally ethics
\nrequires that physicians disobey laws
\nthat demand unethical behaviour.
\nMoreover, laws differ significantly from
\none country to another while ethics is applicable across national
\nboundaries. For these reasons, the focus of this Manual is on ethics
\nrather than law.
\nMedicalEthicsManual\u2013Introduction
\nCONCLUSION
\nMedicine is both a science and an art.
\nScience deals with what can be observed
\nand measured, and a competent physician
\nrecognizes the signs of illness and disease
\nand knows how to restore good health.
\nBut scientific medicine has its limits,
\nparticularly in regard to human individuality,
\nculture, religion, freedom, rights and
\nresponsibilities. The art of medicine involves
\nthe application of medical science and
\ntechnology to individual patients, families and
\ncommunities, no two of which are identical.
\nBy far the major part of the differences
\namong individuals, families and communities
\nis non-physiological, and it is in recognizing
\nand dealing with these differences that the
\narts, humanities and social sciences, along
\nwith ethics, play a major role. Indeed, ethics
\nitself is enriched by the insights and data
\nof these other disciplines; for example, a
\ntheatrical presentation of a clinical dilemma
\ncan be a more powerful stimulus for ethical
\nreflection and analysis than a simple case
\ndescription.
\nThis Manual can provide only a basic
\nintroduction to medical ethics and some of
\nits central issues. It is intended to give you
\nan appreciation of the need for continual
\nreflection on the ethical dimension of
\nmedicine, and especially on how to deal with
\nthe ethical issues that you will encounter
\nin your own practice. A list of resources is
\nprovided in Appendix B to help you deepen
\nyour knowledge of this field.
\n\u201c…often ethics
\nprescribes higher
\nstandards of behaviour
\nthan does
\nthe law, and
\noccasionally ethics
\nrequires that
\nphysicians disobey
\nlaws that demand
\nunethical behaviour\u201d
\n14 15
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nCHAPTER ONE \u2013
\nPRINCIPAL FEATURES OF MEDICAL ETHICS
\nOBJECTIVES
\nAfter working through this chapter you should be able to:
\n\u00b7 \texplain why ethics is important to medicine
\n\u00b7 \tidentify the major sources of medical ethics
\n\u00b7 \trecognize different approaches to ethical decision-making,
\nincluding your own.A Day in the Life of a French General Practitioner
\n\u00a9 Gilles Fonlupt\/Corbis
\n16 17
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nWHAT\u2019S SPECIAL ABOUT MEDICINE?
\nThroughout almost all of recorded history and in virtually every part
\nof the world, being a physician has meant something special. People
\ncome to physicians for help with their most pressing needs \u2013 relief
\nfrom pain and suffering and restoration of health and well-being.
\nThey allow physicians to see, touch and manipulate every part of
\ntheir bodies, even the most intimate. They do this because they trust
\ntheir physicians to act in their best interests.
\nThe status of physicians differs from
\none country to another and even
\nwithin countries. In general, though,
\nit seems to be deteriorating. Many
\nphysicians feel that they are no longer
\nas respected as they once were. In
\nsome countries, control of healthcare has moved steadily away
\nfrom physicians to professional managers and bureaucrats, some
\nof whom tend to see physicians as obstacles to rather than partners
\nin healthcare reforms. Patients who used to accept physicians\u2019
\norders unquestioningly sometimes ask physicians to defend their
\nrecommendations if these are different from advice obtained from
\nother health practitioners or the Internet. Some procedures that
\nformerly only physicians were capable of performing are now done
\nby medical technicians, nurses or paramedics.
\nDespite these changes impinging on
\nthe status of physicians, medicine
\ncontinues to be a profession that
\nis highly valued by the sick people
\nwho need its services. It also
\ncontinues to attract large numbers
\nof the most gifted, hard-working and
\ndedicated students. In order to meet
\nthe expectations of both patients and students, it is important
\nthat physicians know and exemplify the core values of medicine,
\nespecially compassion, competence and autonomy. These values,
\nalong with respect for fundamental human rights, serve as the
\nfoundation of medical ethics.
\nWHAT\u2019S SPECIAL ABOUT MEDICAL ETHICS?
\nAlthough compassion, competence and autonomy are not exclusive
\nto medicine, physicians are expected to exemplify them to a very
\nhigh degree.
\nCompassion, defined as understanding and concern for another
\nperson\u2019s distress, is essential for the practice of medicine. In order
\nto deal with the patient\u2019s problems, the physician must identify the
\nsymptoms that the patient is experiencing and their underlying
\ncauses and must want to help the patient achieve relief. Patients
\nrespond better to treatment if they perceive that the physician
\nappreciates their concerns and is treating them rather than just their
\nillness.
\nA very high degree of competence is both expected and required
\nof physicians. A lack of competence can result in death or serious
\nmorbidity for patients. Physicians undergo a long training period to
\nensure competence, but considering the rapid advance of medical
\nknowledge, it is a continual challenge for them to maintain their
\ncompetence. Moreover, it is not just their scientific knowledge
\nand technical skills that they have to maintain but their ethical
\nknowledge, skills and attitudes as well, since new ethical issues
\narise with changes in medical practice and its social and political
\nenvironment.
\nAutonomy, or self-determination, is the core value of medicine that
\nhas changed the most over the years. Individual physicians have
\ntraditionally enjoyed a high degree of clinical autonomy in deciding
\n\u201cMany physicians feel
\nthat they are no longer
\nas respected as they
\nonce were.\u201d
\n\u201c…to meet the
\nexpectations of both
\npatients and students,
\nit is important that
\nphysicians know and
\nexemplify the core
\nvalues of medicine\u201d
\n18 19
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nhow to treat their patients. Physicians collectively (the medical
\nprofession) have been free to determine the standards of medical
\neducation and medical practice. As will be evident throughout this
\nManual, both of these ways of exercising physician autonomy
\nhave been moderated in many countries by governments and
\nother authorities imposing controls on physicians. Despite these
\nchallenges, physicians still value their clinical and professional
\nautonomy and try to preserve it as much as possible. At the same
\ntime, there has been a widespread acceptance by physicians
\nworldwide of patient autonomy, which means that patients should
\nbe the ultimate decision-makers in matters that affect themselves.
\nThis Manual will deal with examples of potential conflicts between
\nphysician autonomy and respect for patient autonomy.
\nBesides its adherence to these three core values, medical ethics
\ndiffers from the general ethics applicable to everyone by being
\npublicly professed in an oath such as the World Medical Association
\nDeclaration of Geneva and\/or a code. Oaths and codes vary
\nfrom one country to another and even within countries, but they
\nhave many common features, including promises that physicians
\nwill consider the interests of their patients above their own, will
\nnot discriminate against patients on the basis of race, religion
\nor other human rights grounds, will protect the confidentiality of
\npatient information and will provide emergency care to anyone in
\nneed.
\nWHO DECIDES WHAT IS ETHICAL?
\nEthics is pluralistic. Individuals disagree among themselves about
\nwhat is right and what is wrong, and even when they agree, it
\ncan be for different reasons. In some societies, this disagreement
\nis regarded as normal and there is a great deal of freedom to
\nact however one wants, as long as it does not violate the rights
\nof others. In more traditional societies, however, there is greater
\nagreement on ethics and greater social pressure, sometimes backed
\nby laws, to act in certain ways rather than others. In such societies
\nculture and religion often play a dominant role in determining ethical
\nbehaviour.
\nTHE WORLD MEDICAL ASSOCIATION
\nDECLARATION OF GENEVA
\nAt the time of being admitted as a member of the medical
\nprofession:
\nI SOLEMNLY PLEDGE to consecrate my life to the service
\nof humanity;
\nI WILL GIVE to my teachers the respect and gratitude that
\nis their due;
\nI WILL PRACTISE my profession with conscience and
\ndignity;
\nTHEHEALTHOFMYPATIENTwillbemyfirstconsideration;
\nI WILL RESPECT the secrets that are confided in me, even
\nafter the patient has died;
\nI WILL MAINTAIN by all the means in my power, the honour
\nand the noble traditions of the medical profession;
\nMY COLLEAGUES will be my sisters and brothers;
\nI WILL NOT PERMIT considerations of age, disease or
\ndisability, creed, ethnic origin, gender, nationality, political
\naffiliation, race, sexual orientation, social standing or any
\nother factor to intervene between my duty and my patient;
\nI WILL MAINTAIN the utmost respect for human life;
\nI WILL NOT USE my medical knowledge to violate human
\nrights and civil liberties, even under threat;
\nI MAKE THESE PROMISES solemnly, freely and upon my
\nhonour.
\n20 21
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nThe answer to the question, \u201cwho decides what is ethical for people
\nin general?\u201d therefore varies from one society to another and even
\nwithin the same society. In liberal societies, individuals have a great
\ndeal of freedom to decide for themselves what is ethical, although
\nthey will likely be influenced by their families, friends, religion, the
\nmedia and other external sources. In more traditional societies,
\nfamily and clan elders, religious authorities and political leaders
\nusually have a greater role than individuals in determining what is
\nethical.
\nDespite these differences, it seems that most human beings
\ncan agree on some fundamental ethical principles, namely, the
\nbasic human rights proclaimed in the United Nations Universal
\nDeclaration of Human Rights and other widely accepted and
\nofficially endorsed documents. The human rights that are especially
\nimportant for medical ethics include the right to life, to freedom from
\ndiscrimination, torture and cruel, inhuman or degrading treatment,
\nto freedom of opinion and expression, to equal access to public
\nservices in one\u2019s country, and to medical care.
\nFor physicians, the question, \u201cwho decides what is ethical?\u201d has
\nuntil recently had a somewhat different answer than for people in
\ngeneral. Over the centuries the medical profession has developed its
\nown standards of behaviour for its members, which are expressed in
\ncodes of ethics and related policy documents.At the global level, the
\nWMA has set forth a broad range of ethical statements that specify
\nthe behaviour required of physicians no matter where they live and
\npractise. In many, if not most, countries medical associations have
\nbeen responsible for developing and enforcing the applicable ethical
\nstandards. Depending on the country\u2019s approach to medical law,
\nthese standards may have legal status.
\nThe medical profession\u2019s privilege of being able to determine
\nits own ethical standards has never been absolute, however. For
\nexample:
\n\u2022\t Physicians have always been subject to the general laws of the
\nland and have sometimes been punished for acting contrary to
\nthese laws.
\n\u2022\t Some medical organizations are strongly influenced by religious
\nteachings, which impose additional obligations on their members
\nbesides those applicable to all physicians.
\n\u2022\t In many countries the organizations that set the standards for
\nphysician behaviour and monitor their compliance now have a
\nsignificant non-physician membership.
\nThe ethical directives of medical associations are general in nature;
\nthey cannot deal with every situation that physicians might face
\nin their medical practice. In most situations, physicians have to
\ndecide for themselves what is the right way to act, but in making
\ndecisions, it is helpful to know what other physicians would do in
\nsimilar situations. Medical codes of ethics and policy statements
\nreflect a general consensus about the
\nway physicians should act and they
\nshould be followed unless there are
\ngood reasons for acting otherwise.
\nDOES MEDICAL ETHICS
\nCHANGE?
\nThere can be little doubt that some aspects of medical ethics have
\nchanged over the years. Until recently physicians had the right and
\nthe duty to decide how patients should be treated and there was
\nno obligation to obtain the patient\u2019s informed consent. In contrast,
\nthe 2005 version of the WMA Declaration on the Rights of the
\nPatient begins with this statement: \u201cThe relationship between
\nphysicians, their patients and broader society has undergone
\n\u201c…in making decisions,
\nit is helpful to know
\nwhat other physicians
\nwould do in similar
\nsituations.\u201d
\n22 23
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nsignificant changes in recent times. While a physician should
\nalways act according to his\/her conscience, and always in the best
\ninterests of the patient, equal effort must be made to guarantee
\npatient autonomy and justice.\u201d Many individuals now consider
\nthat they are their own primary health providers and that the role
\nof physicians is to act as their consultants or instructors. Although
\nthis emphasis on self-care is far from universal, it does seem to
\nbe spreading and is symptomatic of a more general evolution in
\nthe patient-physician relationship that gives rise to different ethical
\nobligations for physicians than previously.
\nUntil recently, physicians generally considered themselves
\naccountable only to themselves, to their colleagues in the medical
\nprofession and, for religious believers, to God. Nowadays, they have
\nadditional accountabilities \u2013 to their patients, to third parties such as
\nhospitalsandmanagedhealthcareorganizations,tomedicallicensing
\nand regulatory authorities, and often
\nto courts of law. These different
\naccountabilities can conflict with one
\nanother, as will be evident in the
\ndiscussion of dual loyalty in Chapter
\nThree.
\nMedical ethics has changed in other
\nways. Participation in abortion was forbidden in medical codes of
\nethics until recently but now is tolerated under certain conditions
\nby the medical profession in many countries. Whereas in traditional
\nmedical ethics the sole responsibility of physicians was to their
\nindividual patients, nowadays it is generally agreed that physicians
\nshould also consider the needs of society, for example, in allocating
\nscarce healthcare resources (cf. Chapter Three).
\nAdvancesinmedicalscienceandtechnologyraisenewethicalissues
\nthat cannot be answered by traditional medical ethics. Assisted
\nreproduction, genetics, health informatics and life-extending and
\nenhancing technologies, all of which require the participation of
\nphysicians, have great potential for benefiting patients but also
\npotential for harm depending on how they are put into practice. To
\nhelp physicians decide whether and under what conditions they
\nshould participate in these activities, medical associations need to
\nuse different analytic methods than simply relying on existing codes
\nof ethics.
\nDespite these obvious changes in medical ethics, there is
\nwidespread agreement among physicians that the fundamental
\nvalues and ethical principles of medicine do not, or at least should
\nnot, change. Since it is inevitable that human beings will always be
\nsubject to illness, they will continue to have need of compassionate,
\ncompetent and autonomous physicians to care for them.
\nDOES MEDICAL ETHICS DIFFER FROM ONE
\nCOUNTRY TO ANOTHER?
\nJust as medical ethics can and does change over time, in response
\nto developments in medical science and technology as well as
\nin societal values, so does it vary from one country to another
\ndepending on these same factors. On euthanasia, for example,
\nthere is a significant difference of opinion among national medical
\nassociations. Some associations condemn it but others are neutral
\nand at least one, the Royal Dutch Medical Association, accepts it
\nunder certain conditions. Likewise, regarding access to healthcare,
\nsome national associations support the equality of all citizens
\nwhereas others are willing to tolerate great inequalities. In some
\ncountries there is considerable interest in the ethical issues posed
\nby advanced medical technology whereas in countries that do not
\nhave access to such technology, these ethical issues do not arise.
\nPhysicians in some countries are confident that they will not be
\n\u201c…different
\naccountabilities can
\nconflict with one
\nanother\u201d
\n24 25
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nforced by their government to do anything unethical while in other
\ncountries it may be difficult for them to meet their ethical obligations,
\nfor example, to maintain the confidentiality of patients in the face of
\npolice or army requirements to report \u2018suspicious\u2019 injuries.
\nAlthough these differences may seem significant, the similarities
\nare far greater. Physicians throughout the world have much in
\ncommon, and when they come together in organizations such as
\nthe WMA, they usually achieve agreement on controversial ethical
\nissues, though this often requires lengthy debate. The fundamental
\nvalues of medical ethics, such as compassion, competence and
\nautonomy, along with physicians\u2019 experience and skills in all aspects
\nof medicine and healthcare, provide a sound basis for analysing
\nethical issues in medicine and arriving at solutions that are in the
\nbest interests of individual patients and citizens and public health
\nin general.
\nTHE ROLE OF THE WMA
\nAs the only international organization that seeks to represent all
\nphysicians, regardless of nationality or specialty, the WMA has
\nundertaken the role of establishing general standards in medical
\nethics that are applicable worldwide. From its beginning in 1947
\nit has worked to prevent any recurrence of the unethical conduct
\nexhibited by physicians in Nazi Germany and elsewhere. The WMA\u2019s
\nfirst task was to update the Hippocratic Oath for 20th
\ncentury use; the
\nresult was the Declaration of Geneva, adopted at the WMA\u2019s 2nd
\nGeneral Assembly in 1948. It has been revised several times since,
\nmost recently in 2006. The second task was the development of an
\nInternational Code of Medical Ethics, which was adopted at the 3rd
\nGeneral Assembly in 1949 and revised in 1968, 1983 and 2006. The
\nnext task was to develop ethical guidelines for research on human
\nsubjects. This took much longer than the first two documents; it was
\nnot until 1964 that the guidelines were adopted as the Declaration
\nof Helsinki. This document has also undergone periodic revision,
\nmost recently in 2013.
\nIn addition to these foundational
\nethical statements, the WMA has
\nadopted policy statements on more
\nthan 100 specific issues, the majority
\nof which are ethical in nature while
\nothers deal with socio-medical topics,
\nincluding medical education and
\nhealth systems. Each year the WMA
\nGeneral Assembly revises some
\nexisting policies and\/or adopts new ones.
\nHOW DOES THE WMA DECIDE
\nWHAT IS ETHICAL?
\nAchieving international agreement on controversial ethical issues
\nis not an easy task, even within a relatively cohesive group such
\nas physicians. The WMA ensures that its ethical policy statements
\nreflect a consensus by requiring a 75% vote in favour of any new or
\nrevised policy at its annual Assembly. A precondition for achieving
\nthis degree of agreement is widespread consultation on draft
\nstatements, careful consideration of the comments received by the
\nWMA Medical Ethics Committee and
\nsometimes by a specially appointed
\nworkgroup on the issue, redrafting
\nof the statement and often further
\nconsultation. The process can be
\nlengthy, depending on the complexity
\nand\/or the novelty of the issue.
\nFor example, one revision of the
\n\u201c…the WMA has
\nundertaken the role of
\nestablishing general
\nstandards in medical
\nethics that
\nare applicable
\nworldwide.\u201d
\n\u201cAchieving
\ninternational
\nagreement on
\ncontroversial ethical
\nissues is not
\nan easy task\u201d
\n26 27
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nDeclaration of Helsinki was begun early in 1997 and completed
\nonly in October 2000. Even then, outstanding issues remained and
\nthese continued to be studied by the Medical Ethics Committee and
\nsuccessive workgroups.
\nA good process is essential to, but does not guarantee, a good
\noutcome. In deciding what is ethical, the WMA draws upon a
\nlong tradition of medical ethics as reflected in its previous ethical
\nstatements. It also takes note of other positions on the topic under
\nconsideration, both of national and international organizations
\nand of individuals with skill in ethics.
\nOn some issues, such as informed
\nconsent, the WMA finds itself in
\nagreement with the majority view.
\nOn others, such as the confidentiality
\nof personal medical information,
\nthe position of physicians may have
\nto be promoted forcefully against
\nthose of governments, health system
\nadministrators and\/or commercial
\nenterprises. A defining feature of
\nthe WMA\u2019s approach to ethics is the
\npriority that it assigns to the individual patient or research subject.
\nIn reciting the Declaration of Geneva, the physician promises,
\n\u201cThe health of my patient will be my first consideration.\u201d And the
\nDeclaration of Helsinki states, \u201cWhile the primary purpose of
\nmedical research is to generate new knowledge, this goal can never
\ntake precedence over the rights and interests of individual research
\nsubjects.\u201d
\nHOW DO INDIVIDUALS DECIDE
\nWHAT IS ETHICAL?
\nFor individual physicians and medical students, medical ethics does
\nnot consist simply in following the recommendations of the WMA
\nor other medical organizations. These
\nrecommendations are usually general
\nin nature and individuals need to
\ndetermine whether or not they apply
\nto the situation at hand. Moreover,
\nmany ethical issues arise in medical
\npractice for which there is no
\nguidance from medical associations.
\nIndividuals are ultimately responsible for making their own ethical
\ndecisions and for implementing them.
\nThere are different ways of approaching ethical issues such as the
\nones in the cases at the beginning of this Manual. These can be
\ndivided roughly into two categories: non-rational and rational. It
\nis important to note that non-rational does not mean irrational but
\nsimply that it is to be distinguished from the systematic, reflective
\nuse of reason in decision-making.
\nNon-rational approaches:
\n\u2022\tObedience is a common way of making ethical decisions,
\nespecially by children and those who work within authoritarian
\nstructures(e.g.,themilitary,police,somereligiousorganizations,
\nmany businesses). Morality consists in following the rules or
\ninstructions of those in authority, whether or not you agree with
\nthem.
\n\u2022\tImitation is similar to obedience in that it subordinates one\u2019s
\njudgement about right and wrong to that of another person,
\nin this case, a role model. Morality consists in following the
\nexample of the role model. This has been perhaps the most
\ncommon way of learning medical ethics by aspiring physicians,
\nwith the role models being the senior consultants and the mode
\nof moral learning being observation and assimilation of the
\n\u201cOn some issues,
\n… the position of
\nphysicians may have
\nto be promoted
\nforcefully against
\nthose of governments,
\nhealth system
\nadministrators
\nand\/or commercial
\nenterprises.\u201d
\n\u201cIndividuals are
\nultimately responsible
\nfor making their own
\nethical decisions and
\nfor implementing
\nthem.\u201d
\n28 29
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nvalues portrayed.
\n\u2022\tFeeling or desire is a subjective approach to moral decision-
\nmaking and behaviour. What is right is what feels right or satisfies
\none\u2019s desire; what is wrong is what feels wrong or frustrates
\none\u2019s desire. The measure of morality is to be found within each
\nindividual and, of course, can vary greatly from one individual
\nto another, and even within the same individual over
\ntime.
\n\u2022\tIntuition is an immediate perception of the right way to act in
\na situation. It is similar to desire in that it is entirely subjective;
\nhowever, it differs because of its location in the mind rather than
\nthe will. To that extent it comes closer to the rational forms of
\nethical decision-making than do obedience, imitation, feeling
\nand desire. However, it is neither systematic nor reflexive but
\ndirects moral decisions through a simple flash of insight. Like
\nfeeling and desire, it can vary greatly from one individual to
\nanother, and even within the same individual over time.
\n\u2022\t Habit is a very efficient method of moral decision-making
\nsince there is no need to repeat a systematic decision-making
\nprocess each time a moral issue arises similar to one that
\nhas been dealt with previously. However, there are bad habits
\n(e.g., lying) as well as good ones (e.g., truth-telling); moreover,
\nsituations that appear similar may require significantly different
\ndecisions. As useful as habit is, therefore, one cannot place all
\none\u2019s confidence in it.
\nRational approaches:
\nAs the study of morality, ethics recognises the prevalence of
\nthese non-rational approaches to decision-making and behaviour.
\nHowever, it is primarily concerned with rational approaches. Four
\nsuch approaches are deontology, consequentialism, principlism and
\nvirtue ethics:
\n\u2022\t Deontology involves a search for well-founded rules that can
\nserve as the basis for making moral decisions. An example of
\nsuch a rule is, \u201cTreat all people as equals.\u201d Its foundation may be
\nreligious (for example, the belief that all God\u2019s human creatures
\nare equal) or non-religious (for example, human beings share
\nalmost all of the same genes). Once the rules are established,
\nthey have to be applied in specific situations, and here there is
\noften room for disagreement about what the rules require (for
\nexample, whether the rule against killing another human being
\nwould prohibit abortion or capital punishment).
\n\u2022\t Consequentialism bases ethical decision-making on an
\nanalysis of the likely consequences or outcomes of different
\nchoices and actions. The right action is the one that produces
\nthe best outcomes. Of course there can be disagreement
\nabout what counts as a good outcome. One of the best-known
\nforms of consequentialism, namely utilitarianism, uses \u2018utility\u2019
\nas its measure and defines this as \u2018the greatest good for the
\ngreatest number\u2019. Other outcome measures used in healthcare
\ndecision-making include cost-effectiveness and quality of life
\nas measured in QALYs (quality-adjusted life-years) or DALYs
\n(disability-adjusted life-years). Supporters of consequentialism
\ngenerally do not have much use for principles; they are too
\ndifficult to identify, prioritise and apply, and in any case they do
\nnot take into account what in their view really matters in moral
\ndecision-making, i.e., the outcomes. However, this setting aside
\nof principles leaves consequentialism open to the charge that
\nit accepts that \u2018the end justifies the means\u2019, for example, that
\nindividual human rights can be sacrificed to attain a social goal.
\n\u2022 \t Principlism, as its name implies, uses ethical principles as the
\nbasis for making moral decisions. It applies these principles
\n30 31
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nto particular cases or situations in order to determine what
\nis the right thing to do, taking into account both rules and
\nconsequences. Principlism has been extremely influential in
\nrecent ethical debates, especially in the USA. Four principles in
\nparticular, respect for autonomy, beneficence, non-maleficence
\nand justice, have been identified as the most important for ethical
\ndecision-making in medical practice. Principles do indeed play
\nan important role in rational decision-making. However, the
\nchoice of these four principles, and especially the prioritisation of
\nrespect for autonomy over the others, is a reflection of Western
\nliberal culture and is not necessarily universal. Moreover, these
\nfour principles often clash in particular situations and there is
\nneed for some criteria or process for resolving such conflicts.
\n\u2022\t Virtue ethics focuses less on decision-making and more on the
\ncharacter of decision-makers as reflected in their behaviour. A
\nvirtue is a type of moral excellence. As noted above, one virtue
\nthat is especially important for physicians is compassion. Others
\ninclude honesty, prudence and dedication. Physicians who
\npossess these virtues are more likely to make good decisions
\nand to implement them in a good way. However, even virtuous
\nindividuals often are unsure how to act in particular situations
\nand are not immune from making wrong decisions.
\nNone of these four approaches, or others that have been proposed,
\nhas been able to win universal assent. Individuals differ among
\nthemselves in their preference for a rational approach to ethical
\ndecision-making just as they do in their preference for a non-
\nrational approach. This can be explained partly by the fact that
\neach approach has both strengths and weaknesses. Perhaps a
\ncombination of all four approaches that includes the best features
\nof each is the best way to make ethical decisions rationally. It
\nwould take serious account of rules (deontology) and principles
\n(principlism) by identifying the ones most relevant to the situation or
\ncase at hand and by attempting to implement them to the greatest
\nextent possible. It would also examine the likely consequences
\n(consequentialism) of alternative decisions and determine which
\nconsequences would be preferable. Finally, it would attempt to
\nensure that the behaviour of the decision-maker both in coming to a
\ndecision and in implementing it is admirable (virtue ethics).\u201d Such a
\nprocess could comprise the following steps:
\n1.\t Determine whether the issue at hand is an ethical one.
\n2.\t Consult authoritative sources such as medical association
\ncodes of ethics and policies and respected colleagues to
\nsee how physicians generally deal with such issues.
\n3.\t Consider alternative solutions in light of the principles and
\nvalues they uphold and their likely consequences.
\n4.\t Discuss your proposed solution with those whom it will
\naffect.
\n5.\t Make your decision and act on it, with sensitivity to others
\naffected.
\n6.\t Evaluate your decision and be prepared to act differently in
\nfuture.
\nCONCLUSION
\nThis chapter sets the stage for what follows.
\nWhen dealing with specific issues in medical
\nethics, it is good to keep in mind that
\nphysicians have faced many of the same
\n32 33
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nissues throughout history and that their
\naccumulated experience and wisdom can be
\nvery valuable today. The WMA and other m
\nCONCLUSION
\nThis chapter sets the stage for what follows.
\nWhen dealing with specific issues in medical
\nethics, it is good to keep in mind that
\nphysicians have faced many of the same
\nissues throughout history and that their
\naccumulated experience and wisdom can be
\nvery valuable today. The WMA and other
\nmedical organizations carry on this tradition
\nand provide much helpful ethical guidance to
\nphysicians. However, despite a large measure
\nof consensus among physicians on ethical
\nissues, individuals can and do disagree on
\nhow to deal with specific cases. Moreover,
\nthe views of physicians can be quite different
\nfrom those of patients and of other healthcare
\nproviders. As a first step in resolving ethical
\nconflicts, it is important for physicians to
\nunderstand different approaches to ethical
\ndecision-making, including their own and
\nthose of the people with whom they are
\ninteracting. This will help them determine for
\nthemselves the best way to act and to explain
\ntheir decisions to others.
\n34 35
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013PhysiciansandPatients
\nCHAPTER TWO \u2013
\nPHYSICIANS AND PATIENTS
\nOBJECTIVES
\nAfter working through this chapter you should be able to:
\n\u00b7 \texplain why all patients are deserving of respect and equal
\ntreatment;
\n\u00b7 \tidentify the essential elements of informed consent;
\n\u00b7 \texplain how medical decisions should be made for patients
\nwho are incapable of making their own decisions;
\n\u00b7 \texplain the justification for patient confidentiality and
\nrecognise legitimate exceptions to confidentiality;
\n\u00b7 \trecognize the principal ethical issues that occur at the
\nbeginning and end of life;
\n\u00b7 \tsummarize the arguments for and against the practice of
\neuthanasia\/assisted suicide and the difference between
\nthese actions and palliative care or forgoing treatment.
\nCompassionate doctor
\n\u00a9 Jose Luis Pelaez, Inc.\/CORBIS
\n36 37
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013PhysiciansandPatients
\nis often very problematic. Equally problematic are other aspects
\nof the relationship, such as the physician\u2019s obligation to maintain
\npatient confidentiality in an era of computerized medical records and
\nmanaged care, and the duty to preserve life in the face of requests
\nto hasten death.
\nThis section will deal with six topics that pose particularly vexing
\nproblems to physicians in their daily
\npractice: respect and equal treatment;
\ncommunication and consent;
\ndecision-making for incompetent
\npatients; confidentiality; beginning-of-
\nlife issues; and end-of-life issues.
\nRESPECT AND EQUAL TREATMENT
\nThe belief that all human beings deserve respect and equal
\ntreatment is relatively recent. In most societies disrespectful and
\nunequal treatment of individuals and groups was regarded as
\nnormal and natural. Slavery was one such practice that was not
\neradicated in the European colonies and the USA until the 19th
\ncentury and still exists in some parts of the world. The end of
\ninstitutional discrimination against non-whites in countries such as
\nSouth Africa is much more recent. Women still experience lack of
\nrespect and unequal treatment in most countries. Discrimination
\non the basis of age, disability or sexual orientation is widespread.
\nClearly, there remains considerable resistance to the claim that all
\npeople should be treated as equals.
\nThe gradual and still ongoing conversion of humanity to a belief
\nin human equality began in the 17th and 18th centuries in Europe
\nand North America. It was led by two opposed ideologies: a new
\ninterpretation of Christian faith and an anti-Christian rationalism.
\nThe former inspired the American Revolution and Bill of Rights;
\nWHAT\u2019S SPECIAL ABOUT THE PHYSICIAN-
\nPATIENT RELATIONSHIP?
\nThe physician-patient relationship is the cornerstone of medical
\npractice and therefore of medical ethics. As noted above, the
\nDeclaration of Geneva requires of the physician that \u201cThe health
\nof my patient will be my first consideration,\u201d and the International
\nCode of Medical Ethics states, \u201cA physician shall owe his\/her
\npatients complete loyalty and all the scientific resources available to
\nhim\/her.\u201d As discussed in Chapter One, the traditional interpretation
\nof the physician-patient relationship as a paternalistic one, in which
\nthe physician made the decisions and the patient submitted to
\nthem, has been widely rejected in recent years, both in ethics and
\nin law. Since many patients are either unable or unwilling to make
\ndecisions about their medical care, however, patient autonomy
\nCASE STUDY #1
\nDr. P, an experienced and skilled surgeon,
\nis about to finish night duty at a medium-
\nsized community hospital. A young woman is
\nbrought to the hospital by her mother, who
\nleaves immediately after telling the intake
\nnurse that she has to look after her other
\nchildren. The patient is bleeding vaginally
\nand is in a great deal of pain. Dr. P examines
\nher and decides that she has had either a
\nmiscarriage or a self-induced abortion. He
\ndoes a quick dilatation and curettage and tells
\nthe nurse to ask the patient whether she can
\nafford to stay in the hospital until it is safe
\nfor her to be discharged. Dr. Q comes in to
\nreplace Dr. P, who goes home without having
\nspoken to the patient.
\n\u201cThe health of my
\npatient will be my first
\nconsideration\u201d
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\nthe latter, the French Revolution and related political developments.
\nUnder these two influences, democracy very gradually took hold
\nand began to spread throughout the world. It was based on a belief
\nin the political equality of all men (and, much later, women) and the
\nconsequent right to have a say in who should govern them.
\nIn the 20th century there was considerable elaboration of the concept
\nof human equality in terms of human rights. One of the first acts of
\nthe newly established United Nations was to develop the Universal
\nDeclaration of Human Rights (1948), which states in article 1, \u201cAll
\nhuman beings are born free and equal in dignity and rights.\u201d Many
\nother international and national bodies have produced statements of
\nrights, either for all human beings, for all citizens in a specific country,
\nor for certain groups of individuals (\u2018children\u2019s rights\u2019, \u2018patients\u2019
\nrights\u2019, \u2018consumers\u2019 rights\u2019, etc.). Numerous organizations have
\nbeen formed to promote action on these statements. Unfortunately,
\nthough, human rights are still not respected in many countries.
\nThemedicalprofessionhashadsomewhatconflictingviewsonpatient
\nequality and rights over the years. On the one hand, physicians have
\nbeen told not to \u201cpermit considerations of age, disease or disability,
\ncreed, ethnic origin, gender, nationality, political affiliation, race,
\nsexual orientation, social standing or any other factor to intervene
\nbetween my duty and my patient\u201d (Declaration of Geneva). At the
\nsame time physicians have claimed the right to refuse to accept a
\npatient, except in an emergency.Although the legitimate grounds for
\nsuch refusal include a full practice, (lack of) educational qualifications
\nand specialization, if physicians do not have to give any reason for
\nrefusing a patient, they can easily practise discrimination without
\nbeing held accountable. A physician\u2019s conscience, rather than the
\nlaw or disciplinary authorities, may be the only means of preventing
\nabuses of human rights in this regard.
\nEven if physicians do not offend against respect and human equality
\nin their choice of patients, they can still do so in their attitudes
\ntowards and treatment of patients. The case study described at
\nthe beginning of this chapter illustrates this problem. As noted in
\nChapter One, compassion is one of the core values of medicine
\nand is an essential element of a good therapeutic relationship.
\nCompassion is based on respect for the patient\u2019s dignity and values
\nbut goes further in acknowledging and responding to the patient\u2019s
\nvulnerability in the face of illness and\/or disability. If patients sense
\nthe physician\u2019s compassion, they will be more likely to trust the
\nphysician to act in their best interests, and this trust can contribute
\nto the healing process.
\nRespect for patients requires that physicians do not put them at
\nany avoidable risk of harm during treatment. In recent years patient
\nsafety has become a major concern for healthcare professionals
\nand institutions. Studies have shown that many patients suffer
\nharm and even death because of inadequate procedures for
\ninfection control (including hand hygiene), accurate record keeping,
\nunderstandable medicine labels, and safe medicines, injections and
\nsurgical procedures. The WMA Declaration on Patient Safety calls
\non physicians to \u201cgo beyond the professional boundaries of health
\ncare and cooperate with all relevant parties, including patients, to
\nadopt a proactive systems approach to patient safety.\u201d
\nThe trust that is essential to the physician-patient relationship has
\ngenerally been interpreted to mean that physicians should not
\ndesert patients whose care they have undertaken. The WMA\u2019s
\nInternational Code of Medical Ethics specifies only one reason
\nfor ending a physician-patient relationship \u2013 if the patient requires
\nanother physician with different skills: \u201cA physician shall owe his\/her
\npatients complete loyalty and all the scientific resources available
\nto him\/her. Whenever an examination or treatment is beyond the
\nphysician\u2019s capacity, he\/she should consult with or refer to another
\nphysician who has the necessary ability.\u201d However, there are many
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\n\u201cA person who
\nis afflicted with AIDS
\nneeds competent,
\ncompassionate
\ntreatment.\u201d
\n\u201c\u2026in ending a
\nphysician-patient
\nrelationship\u2026
\nphysicians\u2026
\nshould be prepared to
\njustify their decision,
\nto themselves, to the
\npatient and to a third
\nparty if appropriate.\u201d
\nother reasons for a physician wanting
\nto terminate a relationship with a
\npatient, for example, the physician\u2019s
\nmoving or stopping practice, the
\npatient\u2019s refusal or inability to pay
\nfor the physician\u2019s services, dislike
\nof the patient and the physician for
\neach other, the patient\u2019s refusal
\nto comply with the physician\u2019s
\nrecommendations, etc. The reasons
\nmay be entirely legitimate, or they may
\nbe unethical. When considering such an action, physicians should
\nconsult their Code of Ethics and other relevant guidance documents
\nand carefully examine their motives. They should be prepared to
\njustify their decision, to themselves, to the patient and to a third party
\nif appropriate. If the motive is legitimate, the physician should help
\nthe patient find another suitable physician or, if this is not possible,
\nshould give the patient adequate notice of withdrawal of services so
\nthat the patient can find alternative medical care. If the motive is not
\nlegitimate, for example, racial prejudice, the physician should take
\nsteps to deal with this defect.
\nMany physicians, especially those in the public sector, often have no
\nchoice of the patients they treat. Some patients are violent and pose
\na threat to the physician\u2019s safety. Others can only be described as
\nobnoxious because of their antisocial attitudes and behaviour. Have
\nsuch patients forsaken their right to respect and equal treatment, or
\nare physicians expected to make extra, perhaps even heroic, efforts
\nto establish and maintain therapeutic relationships with them? With
\nsuch patients, physicians must balance their responsibility for their
\nown safety and well-being and that of their staff with their duty to
\npromote the well-being of the patients. They should attempt to find
\nways to honour both of these obligations. If this is not possible,
\nthey should try to make alternative arrangements for the care of the
\npatients.
\nAnother challenge to the principle of respect and equal treatment for
\nall patients arises in the care of infectious patients. The focus here is
\noften on HIV\/AIDS, not only because it is a life-threatening disease
\nbut also because it is often associated with social prejudices.
\nHowever, there are many other serious infections including some
\nthat are more easily transmissible to healthcare workers than HIV\/
\nAIDS. Some physicians hesitate to perform invasive procedures on
\npatients with such conditions because of the possibility that they,
\nthe physicians, might become infected. However, medical codes of
\nethics make no exception for infectious patients with regard to the
\nphysician\u2019s duty to treat all patients equally. The WMA\u2019s Statement
\non HIV\/AIDS and the Medical Profession puts it this way:
\nUnfair discrimination against HIV\/
\nAIDS patients by physicians must
\nbe eliminated completely from the
\npractice of medicine.
\nAll persons infected or affected by
\nHIV\/AIDS are entitled to adequate
\nprevention, support, treatment and
\ncare with compassion and respect for
\nhuman dignity.
\nA physician may not ethically refuse to treat a patient whose
\ncondition is within his or her current realm of competence, solely
\nbecause the patient is seropositive.
\nA physician who is not able to provide the care and services
\nrequired by patients with HIV\/AIDS should make an appropriate
\nreferral to those physicians or facilities that are equipped
\nto provide such services. Unless or until the referral can be
\naccomplished, the physician must care for the patient to the best
\nof his or her ability.
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\nThe intimate nature of the physician-patient relationship can
\ngive rise to sexual attraction. A fundamental rule of traditional
\nmedical ethics is that such attraction must be resisted. The Oath
\nof Hippocrates includes the following promise: \u201cWhatever houses
\nI may visit, I will come for the benefit of the sick, remaining free
\nof all intentional injustice, of all mischief and in particular of sexual
\nrelations with both female and male persons\u2026.\u201d In recent years
\nmany medical association have restated this prohibition of sexual
\nrelations between physicians and their patients. The reasons for
\nthis are as valid today as they were in Hippocrates\u2019 time, 2500 years
\nago. Patients are vulnerable and put their trust in physicians to
\ntreat them well. They may feel unable to resist sexual advances of
\nphysicians for fear that their treatment will be jeopardized. Moreover,
\nthe clinical judgment of a physician can be adversely affected by
\nemotional involvement with a patient.
\nThis latter reason applies as well to physicians treating their family
\nmembers, which is strongly discouraged in many medical codes of
\nethics. However, as with some other statements in codes of ethics,
\nits application can vary according to circumstances. For example,
\nsolo practitioners working in remote areas may have to provide
\nmedical care for their family members, especially in emergency
\nsituations.
\nCOMMUNICATION AND CONSENT
\nInformed consent is one of the central concepts of present-day
\nmedical ethics. The right of patients to make decisions about their
\nhealthcare has been enshrined in legal and ethical statements
\nthroughout the world. The WMA Declaration on the Rights of the
\nPatient states:
\nThe patient has the right to self-determination, to make free
\ndecisions regarding himself\/herself. The physician will inform
\nthe patient of the consequences of his\/her decisions.Amentally
\ncompetent adult patient has the right to give or withhold consent
\nto any diagnostic procedure or therapy. The patient has the
\nright to the information necessary to make his\/her decisions.
\nThe patient should understand clearly what is the purpose of
\nany test or treatment, what the results would imply, and what
\nwould be the implications of withholding consent.
\nA necessary condition for informed consent is good communication
\nbetween physician and patient. When medical paternalism was
\nnormal, communication was relatively simple; it consisted of the
\nphysician\u2019s orders to the patient to comply with such and such
\na treatment. Nowadays communication requires much more of
\nphysicians. They must provide patients with all the information the
\npatients need to make their decisions. This involves explaining
\ncomplex medical diagnoses, prognoses and treatment regimes in
\nsimple language, ensuring that patients understand the treatment
\noptions, including the advantages and disadvantages of each,
\nanswering any questions they may have, and understanding
\nwhatever decision the patient has reached and, if possible, the
\nreasons for it. Good communication skills do not come naturally
\nto most people; they must be developed and maintained with
\nconscious effort and periodic review.
\nTwo major obstacles to good physician-patient communication are
\ndifferences of language and culture. If the physician and the patient
\ndo not speak the same language, an interpreter will be required.
\nUnfortunately, in many settings there are no qualified interpreters
\nand the physician must seek out the best available person for the
\ntask. Culture, which includes but is much broader than language,
\nraises additional communication issues. Because of different
\ncultural understandings of the nature and causes of illness, patients
\nmay not understand the diagnosis and treatment options provided
\nby their physician. In such circumstances physicians should make
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\n\u201cCompetent patients
\nhave the right to refuse
\ntreatment, even when
\nthe refusal will result in
\ndisability or death.\u201d
\nevery reasonable effort to probe their patients\u2019 understanding of
\nhealth and healing and communicate their recommendations to the
\npatients as best they can.
\nIf the physician has successfully communicated to the patient all the
\ninformation the patient needs and wants to know about his or her
\ndiagnosis, prognosis and treatment options, the patient will then be
\nin a position to make an informed decision about how to proceed.
\nAlthough the term \u2018consent\u2019 implies acceptance of treatment, the
\nconcept of informed consent applies equally to refusal of treatment
\nor to choice among alternative treatments. Competent patients have
\nthe right to refuse treatment, even
\nwhen the refusal will result in disability
\nor death.
\nEvidence of consent can be explicit
\nor implicit (implied). Explicit consent
\nis given orally or in writing. Consent
\nis implied when the patient indicates
\na willingness to undergo a certain procedure or treatment by his or
\nher behaviour. For example, consent for venipuncture is implied by
\nthe action of presenting one\u2019s arm. For treatments that entail risk or
\ninvolve more than mild discomfort, it is preferable to obtain explicit
\nrather than implied consent.
\nThere are two exceptions to the requirement for informed consent
\nby competent patients:
\n\u2022\t Situations where patients voluntarily give over their decision-
\nmaking authority to the physician or to a third party. Because
\nof the complexity of the matter or because the patient has
\ncomplete confidence in the physician\u2019s judgement, the patient
\nmay tell the physician, \u201cDo what you think is best.\u201d Physicians
\nshould not be eager to act on such requests but should provide
\npatients with basic information about the treatment options
\nand encourage them to make their own decisions. However, if
\nafter such encouragement the patient still wants the physician
\nto decide, the physician should do so according to the best
\ninterests of the patient.
\n\u2022\t Instances where the disclosure of information would cause harm
\nto the patient. The traditional concept of \u2018therapeutic privilege\u2019 is
\ninvoked in such cases; it allows physicians to withhold medical
\ninformation if disclosure would be likely to result in serious
\nphysical, psychological or emotional harm to the patient, for
\nexample, if the patient would be likely to commit suicide if the
\ndiagnosis indicates a terminal illness. This privilege is open
\nto great abuse, and physicians should make use of it only in
\nextreme circumstances. They should start with the expectation
\nthat all patients are able to cope with the facts and reserve
\nnondisclosure for cases in which they are convinced that more
\nharm will result from telling the truth than from not telling it.
\nIn some cultures, it is widely held that the physician\u2019s obligation to
\nprovide information to the patient does not apply when the diagnosis
\nis a terminal illness. It is felt that such information would cause the
\npatient to despair and would make the remaining days of life much
\nmore miserable than if there were hope of recovery. Throughout
\nthe world it is not uncommon for family members of patients to
\nplead with physicians not to tell the patients that they are dying.
\nPhysicians do have to be sensitive to cultural as well as personal
\nfactors when communicating bad news, especially of impending
\ndeath. Nevertheless, the patient\u2019s right to informed consent is
\nbecoming more and more widely accepted, and the physician has a
\nprimary duty to help patients exercise this right.
\nIn keeping with the growing trend towards considering healthcare
\nas a consumer product and patients as consumers, patients and
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\nDo patients have a
\nright to services not
\nrecommended by
\nphysicians?
\n\u201cThe physician has
\nno obligation to offer
\na patient futile or
\nnonbeneficial
\ntreatment.\u201d
\ntheir families not infrequently demand access to medical services
\nthat, in the considered opinion of physicians, are not appropriate.
\nExamples of such services range from antibiotics for viral conditions
\nto intensive care for brain-dead patients to promising but unproven
\ndrugs or surgical procedures. Some patients claim a \u2018right\u2019 to
\nany medical service that they feel can benefit them, and often
\nphysicians are only too willing to oblige, even when they are
\nconvinced that the service can offer no medical benefit for
\nthe patient\u2019s condition. This problem is especially serious in
\nsituations where resources are limited and providing \u2018futile\u2019 or
\n\u2018nonbeneficial\u2019 treatments to some patients means that other
\npatients are left untreated.
\nFutile and nonbeneficial can be understood as follows. In some
\nsituations a physician can determine that a treatment is \u2018medically\u2019
\nfutile or nonbeneficial because it offers no reasonable hope of
\nrecovery or improvement or because the patient is permanently
\nunable to experience any benefit. In other cases the utility and
\nbenefit of a treatment can only be determined with reference to the
\npatient\u2019s subjective judgement about his or her overall well-being.
\nAs a general rule a patient should be
\ninvolved in determining futility in his or
\nher case. In exceptional circumstances
\nsuch discussions may not be in the
\npatient\u2019s best interests. The physician
\nhas no obligation to offer a patient futile
\nor nonbeneficial treatment.
\nThe principle of informed consent incorporates the patient\u2019s right
\nto choose from among the options presented by the physician.
\nTo what extent patients and their families have a right to services
\nnot recommended by physicians is becoming a major topic of
\ncontroversy in ethics, law and public policy. Until this matter is
\ndecided by governments, medical
\ninsurance providers and\/or
\nprofessional organisations, individual
\nphysicians will have to decide for
\nthemselves whether they should
\naccede to requests for inappropriate
\ntreatments. They should refuse such
\nrequests if they are convinced that the treatment would produce
\nmore harm than benefit. They should also feel free to refuse if the
\ntreatment is unlikely to be beneficial, even if it is not harmful, although
\nthe possibility of a placebo effect should not be discounted. If limited
\nresources are an issue, they should bring this to the attention of
\nwhoever is responsible for allocating resources.
\nDECISION-MAKING FOR
\nINCOMPETENT PATIENTS
\nMany patients are not competent to make decisions for themselves.
\nExamples include young children, individuals affected by certain
\npsychiatric or neurological conditions, and those who are temporarily
\nunconscious or comatose. These patients require substitute
\ndecision-makers, either the physician or another person. Ethical
\nissues arise in the determination of the appropriate substitute
\ndecision-maker and in the choice of criteria for decisions on behalf
\nof incompetent patients.
\nWhen medical paternalism prevailed, the physician was considered
\nto be the appropriate decision-maker for incompetent patients.
\nPhysicians might consult with family members about treatment
\noptions, but the final decisions were theirs to make. Physicians have
\nbeen gradually losing this authority in many countries as patients
\nare given the opportunity to name their own substitute decision-
\nmakers to act for them when they become incompetent. In addition,
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\nsome states specify the appropriate substitute decision-makers in
\ndescending order (e.g., husband or wife, adult children, brothers
\nand sisters, etc.). In such cases physicians make decisions for
\npatients only when the designated substitute cannot be found, as
\noften happens in emergency situations. The WMA Declaration on
\nthe Rights of the Patient states the physician\u2019s duty in this matter
\nas follows:
\nIf the patient is unconscious or otherwise unable to
\nexpress his\/her will, informed consent must be obtained,
\nwhenever possible, from a legally entitled representative.
\nIf a legally entitled representative is not available, but a
\nmedical intervention is urgently needed, consent of the
\npatient may be presumed, unless it is obvious and beyond
\nany doubt on the basis of the patient\u2019s previous firm
\nexpression or conviction that he\/she would refuse consent to
\nthe intervention in that situation.
\nProblems arise when those claiming to be the appropriate substitute
\ndecision-makers, for example different family members, do not
\nagree among themselves or when they do agree, their decision
\nis, in the physician\u2019s opinion, not in the patient\u2019s best interests. In
\nthe first instance the physician can serve a mediating function, but
\nif the disagreement persists, it can be resolved in other ways, for
\nexample, by letting the senior member of the family decide or by
\nvoting. In cases of serious disagreement between the substitute
\ndecision-maker and the physician, the Declaration on the Rights
\nof the Patient offers the following advice: \u201cIf the patient\u2019s legally
\nentitled representative, or a person authorized by the patient,
\nforbids treatment which is, in the opinion of the physician, in the
\npatient\u2019s best interest, the physician should challenge this decision
\nin the relevant legal or other institution.\u201d
\nThe principles and procedures for informed consent that were
\ndiscussed in the previous section are just as applicable to substitute
\ndecision-making as to patients making their own decisions.
\nPhysicians have the same duty to provide all the information the
\nsubstitute decision-makers need to make their decisions. This
\ninvolves explaining complex medical diagnoses, prognoses and
\ntreatment regimes in simple language, ensuring that the decision-
\nmakers understand the treatment options, including the advantages
\nand disadvantages of each, answering any questions they may
\nhave, and understanding whatever decision they reach and, if
\npossible, the reasons for it.
\nThe principal criteria to be used for treatment decisions for an
\nincompetent patient are his or her preferences, if these are known.
\nThe preferences may be found in an advance directive or may have
\nbeen communicated to the designated substitute decision-maker,
\nthe physician or other members of the healthcare team. When
\nan incompetent patient\u2019s preferences are not known, treatment
\ndecisions should be based on the patient\u2019s best interests, taking into
\naccount: (a) the patient\u2019s diagnosis and prognosis; (b) the patient\u2019s
\nknownvalues;(c)informationreceivedfromthosewhoaresignificant
\nin the patient\u2019s life and who could help in determining his or her best
\ninterests; and (d) aspects of the patient\u2019s culture and religion that
\nwould influence a treatment decision. This approach is less certain
\nthan if the patient has left specific instructions about treatment,
\nbut it does enable the substitute decision-maker to infer, in
\nlight of other choices the patient has made and his or her approach to
\nlife in general, what he or she would decide in the present situation.
\nCompetence to make medical decisions can be difficult to assess,
\nespecially in young people and those whose capacity for reasoning
\nhas been impaired by acute or chronic illness. A person may be
\ncompetent to make decisions regarding some aspects of life but
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\n\u201cIn certain limited
\ncircumstances it is not
\nunethical to disclose
\nconfidential
\ninformation.\u201d
\n\u201c…the patient must
\nbe involved in the
\ndecision-making to
\nthe fullest extent
\nallowed by his\/her
\ncapacity\u201d
\nnot others; as well, competence can be intermittent — a person
\nmay be lucid and oriented at certain times of the day and not at
\nothers. Although such patients may not be legally competent,
\ntheir preferences should be taken into account when decisions
\nare being made for them. The Declaration on the Rights of the
\nPatient states the matter thus: \u201cIf a
\npatient is a minor or otherwise legally
\nincompetent,the consent of a legally
\nentitled representative is required
\nin some jurisdictions. Nevertheless
\nthe patient must be involved in the
\ndecision-making to the fullest extent
\nallowed by his\/her capacity.\u201d
\nNot infrequently, patients are unable to make a reasoned, well
\nthought-out decision regarding different treatment options due to the
\ndiscomfort and distraction caused by their disease. However, they
\nmay still be able to indicate their rejection of a specific intervention,
\nan intravenous feeding tube, for example. In such cases, these
\nexpressions of dissent should be taken very seriously, although they
\nneed to be considered in light of the overall goals of their treatment
\nplan.
\nPatients suffering from psychiatric or neurological disorders who
\nare judged to pose a danger to themselves or to others raise
\nparticularly difficult ethical issues. It is important to honour their
\nhuman rights, especially the right to freedom, to the greatest extent
\npossible. Nevertheless, they may have to be confined and\/or
\ntreated against their will in order to prevent harm to themselves or
\nothers. A distinction can be made between involuntary confinement
\nand involuntary treatment. Some patient advocates defend the
\nright of these individuals to refuse treatment even if they have to
\nbe confined as a result. A legitimate reason for refusing treatment
\ncould be painful experience with treatments in the past, for example,
\nthe severe side effects of psychotropic medications. When serving
\nas substitute decision-makers for such patients, physicians should
\nensure that the patients really do pose a danger, and not just an
\nannoyance, to others or to themselves. They should try to ascertain
\nthe patients\u2019 preferences regarding treatment, and the reasons for
\nthese preferences, even if in the end the preferences cannot be
\nfulfilled.
\nCONFIDENTIALITY
\nThe physician\u2019s duty to keep patient information confidential has
\nbeen a cornerstone of medical ethics since the time of Hippocrates.
\nThe Hippocratic Oath states: \u201cWhat
\nI may see or hear in the course of
\nthe treatment or even outside of
\nthe treatment in regard to the life
\nof men, which on no account one
\nmust spread abroad, I will keep to
\nmyself holding such things shameful
\nto be spoken about.\u201d The Oath, and
\nsome more recent versions, allow no exception to this duty of
\nconfidentiality. However, other codes reject this absolutist approach
\nto confidentiality. For example, the WMA\u2019s International Code
\nof Medical Ethics states, \u201cIt is ethical to disclose confidential
\ninformation when the patient consents to it or when there is a real
\nand imminent threat of harm to the patient or to others and this threat
\ncan be only removed by a breach of confidentiality.\u201d That breaches
\nof confidentiality are sometimes justified calls for clarification of the
\nvery idea of confidentiality.
\nThe high value that is placed on confidentiality has three sources:
\nautonomy, respect for others and trust. Autonomy relates to
\nconfidentiality in that personal information about an individual
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\nbelongs to him or her and should not be made known to others
\nwithout his or her consent. When an individual reveals personal
\ninformation to another, a physician or nurse for example, or when
\ninformation comes to light through a medical test, those in the know
\nare bound to keep it confidential unless authorized to divulge it by
\nthe individual concerned.
\nConfidentiality is also important because human beings deserve
\nrespect. One important way of showing them respect is by
\npreserving their privacy. In the medical setting, privacy is often
\ngreatly compromised, but this is all the more reason to prevent
\nfurther unnecessary intrusions into a person\u2019s private life. Since
\nindividuals differ regarding their desire for privacy, we cannot
\nassume that everyone wants to be treated as we would want to
\nbe. Care must be taken to determine which personal information a
\npatient wants to keep secret and which he or she is willing to have
\nrevealed to others.
\nTrust is an essential part of the physician-patient relationship. In
\norder to receive medical care, patients have to reveal personal
\ninformation to physicians and others who may be total strangers
\nto them—information that they would not want anyone else to
\nknow. They must have good reason to trust their caregivers not to
\ndivulge this information. The basis of this trust is the ethical and
\nlegal standards of confidentiality that healthcare professionals are
\nexpected to uphold. Without an understanding that their disclosures
\nwill be kept secret, patients may withhold personal information. This
\ncan hinder physicians in their efforts to provide effective interventions
\nor to attain certain public health goals.
\nThe WMA Declaration on the Rights of the Patient summarises
\nthe patient\u2019s right to confidentiality as follows:
\n\u2022\t All identifiable information about a patient’s health status,
\nmedical condition, diagnosis, prognosis and treatment
\nand all other information of a personal kind, must be
\nkept confidential, even after death. Exceptionally, the
\ndescendants may have a right of access to information that
\nwould inform them of their health risks.
\n\u2022\t Confidential information can only be disclosed if the patient
\ngives explicit consent or if expressly provided for in the law.
\nInformation can be disclosed to other healthcare providers
\nonly on a strictly \u00abneed to know\u00bb basis unless the patient
\nhas given explicit consent.
\n\u2022\t All identifiable patient data must be protected. The
\nprotection of the data must be appropriate to the manner of
\nits storage. Human substances from which identifiable data
\ncan be derived must be likewise protected.
\nAs this WMA Declaration states, there are exceptions to the
\nrequirement to maintain confidentiality. Some of these are relatively
\nnon-problematic; others raise very difficult ethical issues for
\nphysicians.
\nRoutine breaches of confidentiality occur frequently in most
\nhealthcare institutions. Many individuals \u2013 physicians, nurses,
\nlaboratory technicians, students, etc. \u2013 require access to a patient\u2019s
\nhealth records in order to provide adequate care to that person and,
\nfor students, to learn how to practise medicine. Where patients
\nspeak a different language than their caregivers, there is a need
\nfor interpreters to facilitate communication. In cases of patients
\nwho are not competent to make their own medical decisions, other
\nindividuals have to be given information about them in order to make
\ndecisions on their behalf and to care for them. Physicians routinely
\ninform the family members of a deceased person about the cause
\nof death. These breaches of confidentiality are usually justified,
\nbut they should be kept to a minimum and those who gain access
\nto confidential information should be made aware of the need
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\nnot to spread it any further than is necessary for the patient\u2019s or
\ndescendants\u2019 benefit. Where possible, patients should be informed
\nthat such breaches occur.
\nAnother generally accepted reason for breaching confidentiality is
\nto comply with legal requirements. For example, many jurisdictions
\nhave laws for the mandatory reporting of patients who suffer from
\ndesignated diseases, those deemed not fit to drive and those
\nsuspected of child abuse. Physicians should be aware of the legal
\nrequirements for the disclosure of
\npatient information where they work.
\nHowever, legal requirements can
\nconflict with the respect for human
\nrights that underlies medical ethics.
\nTherefore, physicians should view with
\na critical eye any legal requirement
\nto breach confidentiality and assure
\nthemselves that it is justified before
\nadhering to it.
\nIf physicians are persuaded to comply with legal requirements to
\ndisclose their patients\u2019 medical information, it is desirable that they
\ndiscuss with the patients the necessity of any disclosure before it
\noccurs and enlist their co-operation. For example, it is preferable
\nthat a patient suspected of child abuse call the child protection
\nauthorities in the physician\u2019s presence to self-report, or that the
\nphysician obtain his or her consent before the authorities are notified.
\nThis approach will prepare the way for subsequent interventions. If
\nsuch co-operation is not forthcoming and the physician has reason
\nto believe any delay in notification may put a child at risk of serious
\nharm, then the physician ought to immediately notify child protection
\nauthorities and subsequently inform the patient that this has been
\ndone.
\nIn addition to those breaches of confidentiality that are required
\nby law, physicians may have an ethical duty to impart confidential
\ninformation to others who could be at risk of harm from the patient.
\nTwo situations in which this can occur are when a patient tells a
\npsychiatrist that he intends to harm another person and when
\na physician is convinced that an HIV-positive patient is going to
\ncontinue to have unprotected sexual intercourse with his spouse or
\nother partners.
\nConditions for breaching confidentiality when not required by law
\nare that the expected harm is believed to be imminent, serious (and
\nirreversible), unavoidable except by unauthorised disclosure, and
\ngreater than the harm likely to result from disclosure. In determining
\nthe proportionality of these respective harms, the physician needs
\nto assess and compare the seriousness of the harms and the
\nlikelihood of their occurrence. In cases of doubt, it would be wise for
\nthe physician to seek expert advice.
\nWhen a physician has determined that the duty to warn justifies an
\nunauthorised disclosure, two further decisions must be made. Whom
\nshould the physician tell? How much should be told? Generally
\nspeaking, the disclosure should contain only that information
\nnecessary to prevent the anticipated harm and should be directed
\nonly to those who need the information in order to prevent the harm.
\nReasonable steps should be taken to minimize the harm and offence
\nto the patient that may arise from the disclosure. It is recommended
\nthat the physician should inform the patient that confidentiality might
\nbe breached for his or her own protection and that of any potential
\nvictim. The patient\u2019s co-operation should be enlisted if possible.
\nIn the case of an HIV-positive patient, disclosure to a spouse or
\ncurrent sexual partner may not be unethical and, indeed, may be
\njustified when the patient is unwilling to inform the person(s) at risk.
\nSuch disclosure requires that all of the following conditions are
\n\u201c…physicians should
\nview with a critical
\neye any legal
\nrequirement to breach
\nconfidentiality and
\nassure themselves
\nthat it is justified
\nbefore adhering to it.\u201d
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\nmet: the partner is at risk of infection with HIV and has no other
\nreasonable means of knowing the risk; the patient has refused to
\ninform his or her sexual partner; the patient has refused an offer of
\nassistance by the physician to do so on the patient\u2019s behalf; and the
\nphysician has informed the patient of his or her intention to disclose
\nthe information to the partner.
\nThe medical care of suspected and convicted criminals poses
\nparticular difficulties with regard to confidentiality. Although
\nphysicians providing care to those in custody have limited
\nindependence, they should do their best to treat these patients as
\nthey would any others. In particular, they should safeguard
\nconfidentiality by not revealing details of the patient\u2019s medical
\ncondition to prison authorities without first obtaining the patient\u2019s
\nconsent.
\nBEGINNING-OF-LIFE ISSUES
\nMany of the most prominent issues in medical ethics relate to the
\nbeginning of human life. The limited scope of this Manual means
\nthat these issues cannot be treated in detail here but it is worth
\nlisting them so that they can be recognized as ethical in nature and
\ndealt with as such. Each of them has been the subject of extensive
\nanalysis by medical associations, ethicists and government advisory
\nbodies, and in many countries there are laws, regulations and
\npolicies dealing with them.
\n\u2022\t CONTRACEPTION \u2013 although there is increasing
\ninternational recognition of a woman\u2019s right to control her
\nfertility, including the prevention of unwanted pregnancies,
\nphysicians still have to deal with difficult issues such as
\nrequests for contraceptives from minors and explaining the
\nrisks of different methods of contraception.
\n\u2022\t ASSISTED REPRODUCTION \u2013 for couples (and
\nindividuals) who cannot conceive naturally there are various
\ntechniques of assisted reproduction, such as artificial
\ninsemination and in-vitro fertilization and embryo transfer,
\nwidely available in major medical centres. Surrogate or
\nsubstitute gestation is another alternative. None of these
\ntechniques is unproblematic, either in individual cases or
\nfor public policies. The 2006 WMA Statement on Assisted
\nReproductive Technologies notes that \u201cwhilst consensus
\ncan be reached on some issues, there remain fundamental
\ndifferences of opinion that cannot be resolved.\u201d The
\nstatement identifies areas of agreement and also highlights
\nthose matters on which agreement cannot be reached.\u201d
\n\u2022\t PRENATAL GENETIC SCREENING \u2013 genetic tests are
\nnow available for determining whether an embryo or foetus
\nis affected by certain genetic abnormalities and whether it
\nis male or female. Depending on the findings, a decision
\ncan be made whether or not to proceed with pregnancy.
\nPhysicians need to determine when to offer such tests and
\nhow to explain the results to patients.
\n\u2022\t ABORTION \u2013 this has long been one of the most divisive
\nissues in medical ethics, both for physicians and for
\npublic authorities. The WMA Statement on Therapeutic
\nAbortion acknowledges this diversity of opinion and belief
\nand concludes that \u201cThis is a matter of individual conviction
\nand conscience that must be respected.\u201d
\n\u2022\t SEVERELY COMPROMISED NEONATES \u2013 because of
\nextreme prematurity or congenital abnormalities, some
\nneonates have a very poor prognosis for survival. Difficult
\ndecisions often have to be made whether to attempt to
\nprolong their lives or allow them to die.
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\n\u2022\t RESEARCH ISSUES \u2013 these include the production of new
\nembryos or the use of \u2018spare\u2019 embryos (those not wanted
\nfor reproductive purposes) to obtain stem cells for potential
\ntherapeutic applications, testing of new techniques for
\nassisted reproduction, and experimentation on foetuses.
\nEND-OF-LIFE ISSUES
\nEnd-of-life issues range from attempts to prolong the lives of dying
\npatients through highly experimental technologies, such as the
\nimplantation of animal organs, to efforts to terminate life prematurely
\nthrough euthanasia and medically assisted suicide. In between these
\nextremes lie numerous issues regarding the initiation or withdrawing
\nof potentially life-extending treatments, the care of terminally ill
\npatients and the advisability and use of advance directives.
\nTwo issues deserve particular attention: euthanasia and assistance
\nin suicide.
\n\u2022\t EUTHANASIA means knowingly and intentionally performing
\nan act that is clearly intended to end another person\u2019s life and
\nthat includes the following elements: the subject is a competent,
\ninformed person with an incurable illness who has voluntarily
\nasked for his or her life to be ended; the agent knows about
\nthe person\u2019s condition and desire to die, and commits the act
\nwith the primary intention of ending the life of that person; and
\nthe act is undertaken with compassion and without personal
\ngain.
\n\u2022\t ASSISTANCE IN SUICIDE means knowingly and intentionally
\nproviding a person with the knowledge or means or both
\nrequired to commit suicide, including counselling about lethal
\ndoses of drugs, prescribing such lethal doses or supplying the
\ndrugs.
\nEuthanasia and assisted suicide are often regarded as morally
\nequivalent, although there is a clear practical distinction, and in
\nsome jurisdictions a legal distinction, between them.
\nEuthanasia and assisted suicide, according to these definitions,
\nare to be distinguished from the withholding or withdrawal of
\ninappropriate, futile or unwanted medical treatment or the provision of
\ncompassionate palliative care, even when these practices shorten life.
\nRequests for euthanasia or assistance in suicide arise as a result of
\npain or suffering that is considered by the patient to be intolerable.
\nThey would rather die than continue to live in such circumstances.
\nFurthermore, many patients consider that they have a right to die if
\nthey so choose, and even a right to assistance in dying. Physicians
\nare regarded as the most appropriate instruments of death since
\nthey have the medical knowledge and access to the appropriate
\ndrugs for ensuring a quick and painless death.
\nPhysicians are understandably reluctant to implement requests for
\neuthanasia or assistance in suicide because these acts are illegal
\nin most countries and are prohibited in most medical codes of
\nethics. This prohibition was part of the Hippocratic Oath and has
\nbeen emphatically restated by the WMA in its 2005 Statement
\non Physician-Assisted Suicide and its 2005 Declaration on
\nEuthanasia The latter document states:
\nEuthanasia, that is the act of deliberately ending the life of a
\npatient, even at the patient\u2019s own request or at the request of
\nclose relatives, is unethical. This does not prevent the physician
\nfrom respecting the desire of a patient to allow the natural
\nprocess of death to follow its course in the terminal phase
\nof sickness.
\nThe rejection of euthanasia and assisted suicide does not mean
\nthat physicians can do nothing for the patient with a life-threatening
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\nillness that is at an advanced stage and for which curative measures
\nare not appropriate. The 2006 WMA Declaration of Venice on
\nTerminal Illness and the 2011 WMA Declaration on End-of-
\nLife Medical Care provide guidance for assisting such patients,
\nespecially by means of palliative care. In recent years there have
\nbeen great advances in palliative care treatments for relieving pain
\nand suffering and improving quality of life. Palliative care can be
\nappropriate for patients of all ages, from a child with cancer to a
\nsenior nearing the end of life. One aspect of palliative care that needs
\ngreater attention for all patients is pain control. All physicians who
\ncare for dying patients should ensure
\nthat they have adequate skills in this
\ndomain, as well as, where available,
\naccess to skilled consultative help
\nfrom palliative care specialists. Above
\nall, physicians should not abandon
\ndying patients but should continue
\nto provide compassionate care even
\nwhen cure is no longer possible.
\nThe approach of death presents many other ethical challenges
\nfor patients, substitute decision-makers and physicians. The
\npossibility of prolonging life through recourse to drugs, resuscitative
\ninterventions, radiological procedures and intensive care requires
\ndecisions about when to initiate these treatments and when to
\nwithdraw them if they are not working.
\nAs discussed above in relation to communication and consent,
\ncompetent patients have the right to refuse any medical treatment,
\neven if the refusal results in their death. Individuals differ greatly
\nwith regard to their attitude towards dying; some will do anything to
\nprolong their lives, no matter how much pain and suffering it involves,
\nwhile others so look forward to dying that they refuse even simple
\nmeasures that are likely to keep them alive, such as antibiotics for
\nbacterial pneumonia. Once physicians have made every effort to
\nprovide patients with information about the available treatments and
\ntheir likelihood of success, they must respect the patients\u2019 decisions
\nabout the initiation or continuation of any treatment.
\nEnd-of-life decision-making for incompetent patients presents
\ngreater difficulties. If patients have clearly expressed their wishes in
\nadvance, for example in an advance directive, the decision will be
\neasier, although such directives are often very vague and need to be
\ninterpreted with respect to the patient\u2019s actual condition. If patients
\nhave not adequately expressed their wishes, the appropriate
\nsubstitute decision-maker must use another criterion for treatment
\ndecisions, namely, the best interests of the patient.\u201c…physicians should
\nnot abandon dying
\npatients but should
\ncontinue to provide
\ncompassionate care
\neven when cure is no
\nlonger possible.\u201d
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\nBACK TO THE CASE STUDY
\nAccording to the analysis of the physician-
\npatient relationship presented in this chapter,
\nDr. P\u2019s conduct was deficient in several
\nrespects: (1) COMMUNICATION \u2013 he
\nmade no attempt to communicate with the
\npatient regarding the cause of her condition,
\ntreatment options or her ability to afford to
\nstay in the hospital while she recovered;
\n(2) CONSENT \u2013 he did not obtain her
\ninformed consent to treatment:
\n(3) COMPASSION \u2013 his dealings with her
\ndisplayed little compassion for her plight.
\nHis surgical treatment may have been highly
\ncompetent and he may have been tired at the
\nend of a long shift, but that does not excuse
\nthe breaches of ethics.
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\nCHAPTER THREE \u2013
\nPHYSICIANS AND SOCIETY
\nOBJECTIVES
\nAfter working through this chapter you should be able to:
\n\u00b7 \trecognize conflicts between the physician\u2019s obligations
\nto patients and to society and identify the reasons for the
\nconflicts
\n\u00b7\tidentify and deal with the ethical issues involved in allocating
\nscarce medical resources
\n\u00b7\trecognize physician responsibilities for public and global
\nhealth.Looking AIDS in the Face
\n\u00a9 Gideon Mendel\/CORBIS
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\nWHAT\u2019S SPECIAL ABOUT THE PHYSICIAN-
\nSOCIETY RELATIONSHIP?
\nMedicine is a profession. The term \u2018profession\u2019 has two distinct,
\nalthough closely related, meanings: (1) an occupation that is
\ncharacterized by dedication to the well-being of others, high moral
\nstandards, a body of knowledge and skills, and a high level of
\nautonomy; and (2) all the individuals who practise that occupation.
\n\u2018The medical profession\u2019 can mean either the practice of medicine
\nor physicians in general.
\nMedical professionalism involves not just the relationship between
\na physician and a patient, as discussed in Chapter Two, and
\nrelationships with colleagues and other health professionals, which
\nwill be treated in Chapter Four. It also involves a relationship with
\nsociety. This relationship can be characterized as a \u2018social contract\u2019
\nwhereby society grants the profession privileges, including exclusive
\nor primary responsibility for the provision of certain services and a
\nhigh degree of self-regulation, and in return, the profession agrees
\nto use these privileges primarily for the benefit of others and only
\nsecondarily for its own benefit.
\nMedicine is today, more than ever
\nbefore, a social rather than a strictly
\nindividual activity. It takes place in a
\ncontext of government and corporate
\norganisation and funding. It relies
\non public and corporate medical
\nresearch and product development for
\nits knowledge base and treatments. It requires complex healthcare
\ninstitutions for many of its procedures. It treats diseases and
\nillnesses that are as much social as biological in origin.
\nThe Hippocratic tradition of medical ethics has little guidance to offer
\nwith regard to relationships with society. To supplement this tradition,
\npresent-day medical ethics addresses the issues that arise beyond
\nthe individual patient-physician relationship and provides criteria
\nand processes for dealing with these issues.
\nTo speak of the \u2018social\u2019 character of medicine immediately raises
\nthe question \u2013 what is society? In this Manual the term refers to
\na community or nation. It is not synonymous with government;
\ngovernments should, but often do not, represent the interests of
\nsociety, but even when they do, they are acting for society, not as
\nsociety.
\nPhysicians have various relationships with society. Because society,
\nand its physical environment, are important factors in the health
\nof patients, both the medical profession in general and individual
\nphysicians have significant roles to play in public health, health
\neducation, environmental protection, laws affecting the health or
\nwell-being of the community, and testimony at judicial proceedings.
\nAs the WMA Declaration on the Rights of the Patient puts it:
\n\u201cWheneverlegislation,governmentactionoranyotheradministration
\nCASE STUDY #2
\nDr. S is becoming increasingly frustrated with
\npatients who come to her either before or
\nafter consulting another health practitioner for
\nthe same ailment. She considers this to be a
\nwaste of health resources as well as counter-
\nproductive for the health of the patients.
\nShe decides to tell these patients that she
\nwill no longer treat them if they continue
\nto see other practitioners for the same
\nailment. She intends to approach her national
\nmedical association to lobby the government
\nto prevent this form of misallocation of
\nhealthcare resources.
\n\u201cMedicine is today,
\nmore than ever before,
\na social rather than
\na strictly individual
\nactivity.\u201d
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\nor institution denies patients [their] rights, physicians should pursue
\nappropriate means to assure or to restore them.\u201d Physicians are
\nalso called upon to play a major role in the allocation of society\u2019s
\nscarce healthcare resources, and sometimes they have a duty to
\nprevent patients from accessing services to which they are not
\nentitled. Implementing these responsibilities can raise ethical
\nconflicts, especially when the interests of society seem to conflict
\nwith those of individual patients.
\nDUAL LOYALTY
\nWhen physicians have responsibilities and are accountable both to
\ntheir patients and to a third party and when these responsibilities and
\naccountabilities are incompatible, they find themselves in a situation
\nof \u2018dual loyalty\u2019. Third parties that demand physician loyalty include
\ngovernments, employers (e.g., hospitals and managed healthcare
\norganizations), insurers, military officers, police, prison officials and
\nfamily members.Although the WMAInternational Code of Medical
\nEthics states that \u201cA physician shall owe his\/her patients complete
\nloyalty,\u201d it is generally accepted
\nthat physicians may in exceptional
\nsituations have to place the interests
\nof others above those of the patient.
\nThe ethical challenge is to decide
\nwhen and how to protect the patient
\nin the face of pressures from third
\nparties.
\nDual loyalty situations comprise a spectrum ranging from those
\nwhere society\u2019s interests should take precedence to those where
\nthe patient\u2019s interests are clearly paramount. In between is a large
\ngrey area where the right course of action requires considerable
\ndiscernment.
\nAt one end of the spectrum are requirements for mandatory reporting
\nof patients who suffer from designated diseases, those deemed not
\nfit to drive or those suspected of child abuse. Physicians should fulfil
\nthese requirements without hesitation, although patients should be
\ninformed that such reporting will take place.
\nAt the other end of the spectrum are requests or orders by the police
\nor military to take part in practices that violate fundamental human
\nrights, such as torture. In its 2007 Resolution on the Responsibility
\nof Physicians in the\u202fDenunciation of Acts of Torture or Cruel
\nor Inhuman or Degrading Treatment of which\u202fThey are Aware,
\nthe WMA provides specific guidance to physicians who are in this
\nsituation. In particular, physicians should guard their professional
\nindependence to determine the best interests of the patient and
\nshould observe, as far as possible, the normal ethical requirements
\nofinformedconsentandconfidentiality.Any
\nbreach of these requirements must be
\njustified and must be disclosed to the
\npatient.Physiciansshouldreporttothe
\nappropriate authorities any unjustified
\ninterference in the care of their
\npatients, especially if fundamental
\nhuman rights are being denied. If the
\nauthorities are unresponsive, help
\nmay be available from a national
\nmedical association, the WMA and
\nhuman rights organizations.
\nCloser to the middle of the spectrum are the practices of some
\nmanaged healthcare programmes that limit the clinical autonomy
\nof physicians to determine how their patients should be treated.
\nAlthough such practices are not necessarily contrary to the best
\ninterests of patients, they can be, and physicians need to consider
\ncarefully whether they should participate in such programmes. If
\n\u201c…physicians may in
\nexceptional situations
\nhave to place the
\ninterests of others
\nabove those of the
\npatient.\u201d
\n\u201cPhysicians should
\nreport to the
\nappropriate authorities
\nany unjustified
\ninterference in
\nthe care of their
\npatients, especially if
\nfundamental human
\nrights are being
\ndenied.\u201d
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\nthey have no choice in the matter, for example, where there are no
\nalternative programmes, they should advocate vigorously for their
\nown patients and, through their medical associations, for the needs
\nof all the patients affected by such restrictive policies.
\nA particular form of a dual loyalty issue faced by physicians is
\nthe potential or actual conflict of interest between a commercial
\norganization on the one hand and patients and\/or society on the
\nother. Pharmaceutical companies, medical device manufacturers
\nand other commercial organizations frequently offer physicians
\ngifts and other benefits that range from free samples to travel and
\naccommodation at educational events to excessive remuneration
\nfor research activities (see Chapter Five). A common underlying
\nmotive for such company largesse is to convince the physician to
\nprescribe or use the company\u2019s products, which may not be the best
\nones for the physician\u2019s patients and\/or may add unnecessarily to a
\nsociety\u2019s health costs. The WMA\u2019s 2009 Statement Concerning the
\nRelationship between Physicians and Commercial Enterprises
\nprovides guidelines for physicians in
\nsuch situations and many national
\nmedical associations have their
\nown guidelines. The primary ethical
\nprinciple underlying these guidelines
\nis that physicians should resolve any
\nconflict between their own interests
\nand those of their patients in their
\npatients\u2019 favour.
\nRESOURCE ALLOCATION
\nIn every country in the world, including the richest ones, there is an
\nalready wide and steadily increasing gap between the needs and
\ndesires for healthcare services and the availability of resources to
\nprovide these services. This gap requires that the existing resources
\nbe rationed in some manner. Healthcare rationing, or \u2018resource
\nallocation\u2019 as it is more commonly referred to, takes place at three
\nlevels:
\n\u2022\t At the highest (\u2018macro\u2019) level, governments decide how much
\nof the overall budget should be allocated to health; which
\nhealthcare expenses will be provided at no charge and which
\nwill require payment either directly from patients or from their
\nmedical insurance plans; within the health budget, how much
\nwill go to remuneration for physicians, nurses and other heath
\ncare workers, to capital and operating expenses for hospitals
\nand other institutions, to research, to education of health
\nprofessionals, to treatment of specific conditions such as
\ntuberculosis or AIDS, and so on.
\n\u2022\t At the institutional (\u2018meso\u2019) level, which includes hospitals,
\nclinics, healthcare agencies, etc., authorities decide which
\nservices to provide; how much to spend on staff, equipment,
\nsecurity, other operating expenses, renovations, expansion, etc.
\n\u2022\t At the individual patient (\u2018micro\u2019) level, healthcare providers,
\nespecially physicians, decide what tests should be ordered,
\nwhether a referral to another physician is needed, whether the
\npatient should be hospitalised, whether a brand-name drug is
\nrequired rather than a generic one, etc. It has been estimated
\nthat physicians are responsible for initiating 80% of healthcare
\nexpenditures, and despite the growing encroachment of
\nmanaged care, they still have considerable discretion as to
\nwhich resources their patients will have access.
\nThe choices that are made at each level have a major ethical
\ncomponent, since they are based on values and have significant
\nconsequences for the health and well-being of individuals and
\ncommunities. Although individual physicians are affected by
\n\u201c…physicians should
\nresolve any conflict
\nbetween their own
\ninterests and those of
\ntheir patients in their
\npatients\u2019 favour. \u201d
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\ndecisions at all levels, they have the greatest involvement at
\nthe micro-level. Accordingly, this will be the focus of what
\nfollows.
\nAs noted above, physicians were traditionally expected to act solely
\nin the interests of their own patients, without regard to the needs
\nof others. Their primary ethical values of compassion, competence
\nand autonomy were directed towards serving the needs of their own
\npatients. This individualistic approach to medical ethics survived the
\ntransition from physician paternalism to patient autonomy, where the
\nwill of the individual patient became the main criterion for deciding
\nwhat resources he or she should receive. More recently, however,
\nanother value, justice, has become an important factor in medical
\ndecision-making. It entails a more
\nsocial approach to the distribution
\nof resources, one that considers the
\nneeds of other patients. According
\nto this approach, physicians are
\nresponsible not just for their own
\npatients but, to a certain extent, for
\nothers as well.
\nThis new understanding of the physician\u2019s role in allocating
\nresources is expressed in many national medical association codes
\nof ethics and, as well, in the WMA Declaration on the Rights of
\nthe Patient, which states: \u201cIn circumstances where a choice must
\nbe made between potential patients for a particular treatment that
\nis in limited supply, all such patients are entitled to a fair selection
\nprocedure for that treatment. That choice must be based on medical
\ncriteria and made without discrimination.\u201d
\nOne way that physicians can exercise their responsibility for the
\nallocation of resources is by avoiding wasteful and inefficient
\npractices, even when patients request them. The overuse of
\nantibiotics is just one example of
\na practice that is both wasteful
\nand harmful. Many other common
\ntreatments have been shown in
\nrandomized clinical trials to be
\nineffective for the conditions for
\nwhich they are used. Clinical practice
\nguidelines are available for many
\nmedical conditions; they help to
\ndistinguish between effective and
\nineffective treatments. Physicians
\nshould familiarize themselves with these guidelines, both to
\nconserve resources and to provide optimal treatment to their
\npatients.
\nA type of allocation decision that many physicians must make
\nis the choice between two or more patients who are in need of
\na scarce resource such as emergency staff attention, the one
\nremaining intensive care bed, organs for transplantation, high-tech
\nradiological tests, and certain very expensive drugs. Physicians who
\nexercise control over these resources must decide which patients
\nwill have access to them and which will not, knowing full well that
\nthose who are denied may suffer, and even die, as a result.
\nSome physicians face an additional conflict in allocating resources,
\nin that they play a role in formulating general policies that affect
\ntheir own patients, among others. This conflict occurs in hospitals
\nand other institutions where physicians hold administrative
\npositions or serve on committees where policies are recommended
\nor determined. Although many physicians attempt to detach
\nthemselves from their preoccupation with their own patients, others
\nmay try to use their position to advance the cause of their patients
\nover others with greater needs.
\n\u201c…physicians are
\nresponsible not
\njust for their own
\npatients but, to a
\ncertain extent, for
\nothers as well. \u201d
\n\u201cOne way that
\nphysicians can
\nexercise their
\nresponsibility for
\nthe allocation of
\nresources is by
\navoiding wasteful and
\ninefficient practices,
\neven when patients
\nrequest them. \u201d
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\n\u201c…physicians
\n…have a responsibility
\nto advocate for
\nexpansion of these
\nresources where they
\nare insufficient to
\nmeet patient
\nneeds.\u201d
\nIn dealing with these allocation issues, physicians must not
\nonly balance the principles of compassion and justice but, in doing
\nso, must decide which approach to justice is preferable. There are
\nseveral such approaches, including the following:
\n\u2022\t LIBERTARIAN \u2013 resources should be distributed according to
\nmarket principles (individual choice conditioned by ability and
\nwillingness to pay, with limited charity care for the destitute);
\n\u2022\t UTILITARIAN \u2013 resources should be distributed according to
\nthe principle of maximum benefit for all;
\n\u2022\t EGALITARIAN \u2013 resources should be distributed strictly
\naccording to need;
\n\u2022\t RESTORATIVE \u2013 resources should be distributed so as to
\nfavour the historically disadvantaged.
\nAs noted above, physicians have been gradually moving away from
\nthe traditional individualism of medical ethics, which would favour
\nthe libertarian approach, towards a more social conception of their
\nrole. For example, the WMA Statement on Access to Health Care
\nsays that \u201cNo one who needs care should be denied it because of
\ninability to pay. Society has an obligation to provide a reasonable
\nsubsidy for care of the needy, and physicians have an obligation to
\nparticipate to a reasonable degree in such subsidized care.\u201d Even
\nif the libertarian approach is generally rejected, however, medical
\nethicists have reached no consensus on which of the other three
\napproaches is superior. Each one clearly has very different results
\nwhen applied to the issues mentioned above, that is, deciding what
\ntests should be ordered, whether a referral to another physician
\nis needed, whether the patient should be hospitalised, whether
\na brand-name drug is required rather than a generic one, who
\ngets the organ for transplantation, etc. The utilitarian approach
\nis probably the most difficult for individual physicians to practise,
\nsince it requires a great deal of
\ndata on the probable outcomes of
\ndifferent interventions, not just for
\nthe physician\u2019s own patients but for
\nall others. The choice between the
\nother two (or three, if the libertarian
\nis included) will depend on the
\nphysician\u2019s own personal morality as
\nwell as the socio-political environment
\nin which he or she practises. Some countries, such as the
\nU.S.A., favour the libertarian approach; others, e.g., Sweden,
\nare known for their egalitarianism; while still others, such as
\nSouth Africa, are attempting a restorative approach. Many health
\nplanners promote utilitarianism. Despite their differences, two or
\nmore of these concepts of justice often coexist in national health
\nsystems, and in these countries physicians may be able to choose
\na practice setting (e.g., public or private) that accords with their own
\napproach.
\nIn addition to whatever roles physicians may have in allocating
\nexisting healthcare resources, they also have a responsibility
\nto advocate for expansion of these
\nresources where they are insufficient
\nto meet patient needs. This usually
\nrequires that physicians work together,
\nin their professional associations,
\nto convince decision-makers in
\ngovernment and elsewhere of the
\nexistence of these needs and how
\nbest to meet them, both within their
\nown countries and globally.
\n\u201c…choice \u2026will depend
\non the physician\u2019s
\nown personal morality
\nas well as the socio-
\npolitical environment
\nin which he or she
\npractises.\u201d
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\n\u201call physicians need to
\nbe aware of the social
\nand environmental
\ndeterminants that
\ninfluence the health
\nstatus of their
\nindividual patients.\u201d
\nPUBLIC HEALTH
\n20th century medicine witnessed the emergence of an unfortunate
\ndivision between \u2018public health\u2019 and other healthcare (presumably
\n\u2018private\u2019 or \u2018individual\u2019 health). It is unfortunate because, as noted
\nabove, the public is made up of individuals, and measures designed
\nto protect and enhance the health of the public result in health
\nbenefits for individuals.
\nConfusion also arises if \u2018public health\u2019 is taken to mean \u2018publicly-
\nfunded healthcare\u2019 (i.e., healthcare funded through a country\u2019s
\ntaxation system or a compulsory universal insurance system) and
\nseen as the opposite of \u2018privately-funded healthcare\u2019(i.e., healthcare
\npaid for by the individual or through private health insurance and
\nusually not universally available).
\nThe term \u2018public health\u2019, as understood here, refers both to the health
\nof the public and also to the medical specialty that deals with health
\nfrom a population perspective rather than on an individual basis.
\nThere is a great need for specialists
\nin this field in every country to advise
\non and advocate for public policies
\nthat promote good health as well as
\nto engage in activities to protect the
\npublic from communicable diseases
\nand other health hazards. The practice
\nof public health (sometimes called
\n\u2018public health medicine\u2019 or \u2018community
\nmedicine\u2019) relies heavily for its scientific basis on epidemiology,
\nwhich is the study of the distribution and determinants of health and
\ndisease in populations. Indeed, some physicians go on to take extra
\nacademic training and become medical epidemiologists. However,
\nall physicians need to be aware of the social and environmental
\ndeterminants that influence the health status of their individual
\npatients. As the WMA Statement on Health Promotion notes:
\n\u201cMedical practitioners and their professional associations have an
\nethical duty and professional responsibility to act in the best interests
\nof their patients at all times and to integrate this responsibility with a
\nbroader concern for and involvement in promoting and assuring the
\nhealth of the public.\u201d
\nPublic health measures such as vaccination campaigns and
\nemergency responses to outbreaks of contagious diseases are
\nimportant factors in the health of individuals but social factors such
\nas housing, nutrition and employment are equally, if not more,
\nsignificant. Physicians are seldom able to treat the social causes
\nof their individual patients\u2019 illnesses, although they should refer the
\npatients to whatever social services are available. However, they can
\ncontribute, even if indirectly, to long-term solutions to these problems
\nby participating in public health and health education activities,
\nmonitoring and reporting environmental hazards, identifying and
\npublicizing adverse health effects from social problems such as
\nabuse and violence, and advocating for improvements in public
\nhealth services.
\nSometimes, though, the interests of public health may conflict with
\nthose of individual patients, for example, when a vaccination that
\ncarries a risk of an adverse reaction will prevent an individual from
\ntransmitting a disease but not from contracting it, or when notification
\nis required for certain contagious diseases, for cases of child or
\nelder abuse, or for conditions that may render certain activities, such
\nas driving a car or piloting an aircraft, dangerous to the individual
\nand to others. These are examples of dual-loyalty situations as
\ndescribed above. Procedures for dealing with these and related
\nsituations are discussed under \u2018confidentiality\u2019 in Chapter Two of
\nthis Manual. In general, physicians should attempt to find ways to
\nminimise any harm that individual patients might suffer as a result
\nof meeting public health requirements. For example, when reporting
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\nis required, the patient\u2019s confidentiality should be protected to the
\ngreatest extent possible while fulfilling the legal requirements.
\nA different type of conflict between the interests of individual
\npatients and those of society arises when physicians are asked to
\nassist patients to receive benefits to which they are not entitled, for
\nexample, insurance payments or sick-leave. Physicians have been
\nvested with the authority to certify that patients have the appropriate
\nmedical condition that would qualify them for such benefits.Although
\nsome physicians are unwilling to deny requests from patients for
\ncertificates that do not apply in their circumstances, they should
\nrather help their patients find other means of support that do not
\nrequire unethical behaviour.
\nGLOBAL HEALTH
\nThe recognition that physicians have responsibilities to the society
\nin which they live has been expanded in recent years to include a
\nresponsibility for global health. This term has been defined as health
\nproblems, issues and concerns that transcend national boundaries,
\nthat may be influenced by circumstances or experiences in other
\ncountries, and that are best addressed by cooperative actions and
\nsolutions. Global health is part of the much larger movement of
\nglobalization that encompasses information exchange, commerce,
\npolitics, tourism and many other human activities.
\nThe basis of globalization is
\nthe recognition that individuals
\nand societies are increasingly
\ninterdependent. This is clearly evident
\nwith regard to human health, as the
\nrapid spread of diseases such as
\ninfluenza and SARS has shown. Such
\nepidemics require international action
\nfor their control. The failure to recognize and treat highly contagious
\ndiseases by a physician in one country can have devastating effects
\non patients in other countries. For this reason, the ethical obligations
\nof physicians extend far beyond their individual patients and even
\ntheir communities and nations.
\nThe development of a global view of health has resulted in an
\nincreasing awareness of health disparities throughout the world.
\nDespite large-scale campaigns to combat premature mortality and
\ndebilitating morbidity in the poorest countries, which have resulted
\nin certain success stories such as the elimination of smallpox,
\nthe gap in health status between high and low-income countries
\ncontinues to widen. This is partly due to HIV\/AIDS, which has had
\nits worst effects in poor countries, but it is also due to the failure of
\nmany low-income countries to benefit from the increase in wealth
\nthat the world as a whole has experienced during the past decades.
\nAlthough the causes of poverty are largely political and economic
\nand are therefore far beyond the control of physicians and their
\nassociations, physicians do have to deal with the ill-health that is
\nthe result of poverty. In low-income countries physicians have few
\nresources to offer these patients and are constantly faced with the
\nchallenge of allocating these resources in the fairest way. Even in
\nmiddle- and high-income countries, though, physicians encounter
\npatients who are directly affected by globalization, such as refugees,
\nand who sometimes do not have access to the medical coverage
\nthat citizens of those countries enjoy.
\nAnother feature of globalization is the international mobility of health
\nprofessionals, including physicians. The outflow of physicians from
\ndeveloping to highly industrialized countries has been advantageous
\nfor both the physicians and the receiving countries but not so for the
\nexporting countries. The WMA, in its Ethical Guidelines for the
\nInternational Migration of Health Workers, states that physicians
\nshould not be prevented from leaving their home or adopted country
\n\u201cThe failure to
\nrecognize and treat
\nhighly contagious
\ndiseases by a physician
\nin one country can have
\ndevastating effects
\non patients in other
\ncountries.\u201d
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\nto pursue career opportunities in another country. It does, however,
\ncall on every country to do its utmost to educate an adequate
\nnumber of physicians, taking into account its needs and resources,
\nand not to rely on immigration from other countries to meet its need
\nfor physicians.
\nPhysicians in the industrialized countries have a long tradition
\nof providing their experience and skills to developing countries.
\nThis takes many forms: emergency medical aid coordinated by
\norganizations such as the Red Cross and Red Crescent Societies
\nand M\u00e9decins sans Fronti\u00e8res, short-term surgical campaigns
\nto deal with conditions such as cataracts or cleft palates, visiting
\nfaculty appointments in medical schools, short- or long-term medical
\nresearch projects, provision of medicines and medical equipment,
\netc. Such programmes exemplify the positive side of globalization
\nand serve to redress, at least partially, the movement of physicians
\nfrom poorer to wealthier countries.
\nPHYSICIANS AND THE ENVIRONMENT
\nA major threat to both public health and global health is the
\ndeterioration of the environment. The 2006 WMA Statement on
\nthe Role of Physicians in Environmental Issues states that
\n\u201cThe effective practice of medicine increasingly requires that
\nphysicians and their professional associations turn their attention to
\nenvironmental issues that have a bearing on the health of individuals
\nand population.\u201d These issues include air, water and soil pollution,
\nunsustainable deforestation and fishing, and the proliferation of
\nhazardous chemicals in consumer products. But perhaps the most
\nserious environmental challenge to health is climate change. The
\n2009 WMA Declaration of Delhi on Health and Climate Change
\nnotes that \u201cClimate change currently contributes to the global burden
\nof disease and premature deaths\u2026.. At this early stage the effects
\nare small but are projected to progressively increase in all countries
\nand regions.\u201d The document encourages individual physicians and
\nmedical associations to educate patients and communities about
\nthe potential consequences of global warming for health and to
\nlobby governments and industries to significantly reduce carbon
\nemissions and other contributors to climate change.
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\nBACK TO THE CASE STUDY
\nAccording to the analysis of the physician-
\nsociety relationship presented in this chapter,
\nDr. S is right to consider the impact on
\nsociety of her patient\u2019s behaviour.
\nEven if the consultations with the other
\nhealth practitioner occur outside of the health
\nsystem in which Dr. S works and therefore do
\nnot entail any financial cost to society,
\nthe patient is taking up Dr. S\u2019s time that could
\nbe devoted to other patients in need of her
\nservices. However, physicians such as
\nDr. S must be cautious in dealing with
\nsituations such as this. Patients are often
\nunable to make fully rational decisions for a
\nvariety of reasons and may need considerable
\ntime and health education to come to an
\nunderstanding of what is in the best interests
\nof themselves and of others. Dr. S is also
\nright to approach her medical association to
\nseek a societal solution to this problem,
\nsince it affects not just herself and this one
\npatient but other physicians and patients
\nas well.
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\nCHAPTER FOUR \u2013
\nPHYSICIANS AND COLLEAGUES
\nOBJECTIVES
\nAfter working through this chapter you should be able to:
\n\u00b7\tdescribe how physicians should behave towards one
\nanother
\n\u00b7\tjustify reporting unethical behaviour of colleagues
\n\u00b7\tidentify the main ethical principles relating to cooperation
\nwith others in the care of patients
\n\u00b7\texplain how to resolve conflicts with other healthcare
\nprovidersMedical team going over a case
\n\u00a9 Pete Saloutos\/CORBIS
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\nThis chapter will deal with ethical issues that arise in both internal
\nand external hierarchies. Some issues are common to both; others
\nare found only in one or the other. Many of these issues are relatively
\nnew, since they result from recent changes in medicine and health-
\ncare.Abrief description of these changes is in order, since they pose
\nmajor challenges to the traditional exercise of medical authority.
\nWith the rapid growth in scientific knowledge and its clinical
\napplications, medicine has become increasingly complex. Individual
\nphysicians cannot possibly be experts in all their patients\u2019 diseases
\nand potential treatments and they need the assistance of other
\nspecialist physicians and skilled health professionals such as
\nnurses, pharmacists, physiotherapists, laboratory technicians,
\nsocial workers and many others. Physicians need to know how to
\naccess the relevant skills that their patients require and that they
\nthemselves lack.
\nAs discussed in Chapter Two, medical paternalism has been
\ngradually eroded by the increasing recognition of the right of patients
\nto make their own medical decisions. As a result, a cooperative
\nmodel of decision-making has replaced the authoritarian model
\nthat was characteristic of traditional
\nmedical paternalism. The same
\nthing is happening in relationships
\nbetween physicians and other
\nhealth professionals. The latter
\nare increasingly unwilling to follow
\nphysicians\u2019 orders without knowing
\nthe reasons behind the orders. They
\nsee themselves as professionals with
\nspecific ethical responsibilities towards patients; if their perception
\nof these responsibilities conflicts with the physician\u2019s orders, they
\nfeel that they must question or even challenge the orders. Whereas
\nunder the hierarchical model of authority, there was never any doubt
\nCASE STUDY #3
\nDr. C, a newly appointed anaesthetist in a
\ncity hospital, is alarmed by the behaviour of
\nthe senior surgeon in the operating room.
\nThe surgeon uses out-of-date techniques
\nthat prolong operations and result in greater
\npost-operative pain and longer recovery
\ntimes. Moreover, he makes frequent crude
\njokes about the patients that obviously bother
\nthe assisting nurses. As a more junior staff
\nmember, Dr. C is reluctant to criticize the
\nsurgeon personally or to report him to higher
\nauthorities. However, he feels that he must do
\nsomething to improve the situation.
\nCHALLENGES TO MEDICAL AUTHORITY
\nPhysicians belong to a profession
\nthat has traditionally functioned in
\nan extremely hierarchical fashion,
\nboth internally and externally.
\nInternally, there are three overlapping
\nhierarchies: the first differentiates
\namong specialties, with some being
\nconsidered more prestigious, and
\nbetter remunerated, than others; the second is within specialties,
\nwith academics being more influential than those in private or public
\npractice; the third relates to the care of specific patients, where the
\nprimary caregiver is at the top of the hierarchy and other physicians,
\neven those with greater seniority and\/or skills, serve simply as
\nconsultants unless the patient is transferred to their care. Externally,
\nphysicians have traditionally been at the top of the hierarchy of
\ncaregivers, above nurses and other health professionals.
\n\u201cPhysicians belong
\nto a profession that
\nhas traditionally
\nfunctioned in an
\nextremely hierarchical
\nfashion\u201d
\n\u201c…a cooperative model
\nof decision-making
\nhas replaced the
\nauthoritarian model
\nthat was characteristic
\nof traditional medical
\npaternalism.\u201d
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\nabout who was in charge and who should prevail when conflict
\noccurred, the cooperative model can give rise to disputes about
\nappropriate patient care.
\nDevelopments such as these are changing the \u2018rules of the game\u2019
\nfor the relationships of physicians with their medical colleagues and
\nother health professionals. The remainder of this chapter will identify
\nsome problematic aspects of these relationships and suggest ways
\nof dealing with them.
\nRELATIONSHIPS WITH PHYSICIAN
\nCOLLEAGUES, TEACHERS AND STUDENTS
\nAs members of the medical profession, physicians have traditionally
\nbeen expected to treat each other more as family members than
\nas strangers or even as friends. The WMA Declaration of Geneva
\nincludes the pledge, \u201cMy colleagues will be my sisters and brothers.\u201d
\nThe interpretation of this requirement has varied from country to
\ncountry and over time. For example, where fee-for-service was the
\nprincipal or only form of remuneration for physicians, there was a
\nstrong tradition of \u2018professional courtesy\u2019 whereby physicians did
\nnot charge their colleagues for medical treatment. This practice has
\ndeclined in countries where third-party reimbursement is available.
\nBesides the positive requirements to treat one\u2019s colleagues
\nrespectfully and to work cooperatively to maximize patient care,
\nthe WMA International Code of Medical Ethics contains two
\nrestrictions on physicians\u2019 relationships with one another: (1) paying
\nor receiving any fee or any other consideration solely to procure
\nthe referral of a patient; and (2) stealing patients from colleagues.
\nA third obligation, to report unethical or incompetent behaviour by
\ncolleagues, is discussed below.
\nIn the Hippocratic tradition of medical ethics, physicians owe special
\nrespect to their teachers. The Declaration of Geneva puts it this
\nway: \u201cI will give to my teachers the respect and gratitude that is their
\ndue.\u201d Although present-day medical education involves multiple
\nstudent-teacher interactions rather than the one-on-one relationship
\nof former times, it is still dependent on the good will and dedication
\nof practising physicians, who often receive no remuneration for their
\nteaching activities. Medical students and other medical trainees
\nowe a debt of gratitude to their teachers, without whom medical
\neducation would be reduced to self-instruction.
\nFor their part, teachers have an
\nobligation to treat their students
\nrespectfully and to serve as good
\nrole models in dealing with patients.
\nThe so-called \u2018hidden curriculum\u2019 of
\nmedical education, i.e., the standards
\nof behaviour exhibited by practising
\nphysicians, is much more influential
\nthan the explicit curriculum of medical
\nethics, and if there is a conflict between the requirements of ethics
\nand the attitudes and behaviour of their teachers, medical students
\nare more likely to follow their teachers\u2019 example.
\nTeachers have a particular obligation not to require students to
\nengage in unethical practices. Examples of such practices that
\nhave been reported in medical journals include medical students
\nobtaining patient consent for medical treatment in situations where
\na fully qualified health professional should do this, performing pelvic
\nexaminations on anaesthetized or newly dead patients without
\nconsent, and performing unsupervised procedures that, although
\nminor (e.g., I-V insertion), are considered by some students to
\nbe beyond their competence. Given the unequal power balance
\nbetween students and teachers and the consequent reluctance of
\n\u201c…teachers have an
\nobligation to treat their
\nstudents respectfully
\nand to serve as good
\nrole models in dealing
\nwith patients.\u201d
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\nstudents to question or refuse such
\norders, teachers need to ensure that
\nthey are not requiring students to act
\nunethically. In many medical schools,
\nthere are class representatives or
\nmedical student associations that,
\namong their other roles, may be
\nable to raise concerns about ethical
\nissues in medical education. Students
\nconcerned about ethical aspects of their education should have
\naccess to such mechanisms where they can raise concerns without
\nnecessarily being identified as the whistle-blower, as well as access
\nto appropriate support if it becomes necessary to take the issue to
\na more formal process.
\nFor their part, medical students are expected to exhibit high
\nstandards of ethical behaviour as appropriate for future physicians.
\nThey should treat other students as colleagues and be prepared to
\noffer help when it is needed, including corrective advice in regard
\nto unprofessional behaviour. They should also contribute fully to
\nshared projects and duties such as study assignments and on-call
\nservice.
\nREPORTING UNSAFE OR
\nUNETHICAL PRACTICES
\nMedicine has traditionally taken pride in its status as a self-
\nregulating profession. In return for the privileges accorded to it by
\nsociety and the trust given to its members by their patients, the
\nmedical profession has established high standards of behaviour for
\nits members and disciplinary procedures to investigate accusations
\nof misbehaviour and, if necessary, to punish the wrongdoers. This
\nsystem of self-regulation has often failed, and in recent years
\nsteps have been taken to make the profession more accountable,
\nfor example, by appointing lay members to regulatory authorities.
\nThe main requirement for self-regulation, however, is wholehearted
\nsupport by physicians for its principles and their willingness to
\nrecognise and deal with unsafe and unethical practices.
\nThis obligation to report incompetence, impairment or misconduct
\nof one\u2019s colleagues is emphasised in codes of medical ethics. For
\nexample, the WMA International Code of Medical Ethics states
\nthat \u201cA physician shall\u2026report to the appropriate authorities those
\nphysicians who practice unethically or incompetently or who engage
\nin fraud or deception.\u201d The application of this principle is seldom easy,
\nhowever. On the one hand, a physician may be tempted to attack
\nthe reputation of a colleague for unworthy personal motives, such
\nas jealousy, or in retaliation for a perceived insult by the colleague.A
\nphysician may also be reluctant to report a colleague\u2019s misbehaviour
\nbecause of friendship or sympathy (\u201cthere but for the grace of God
\ngo I\u201d). The consequences of such reporting can be very detrimental
\nto the one who reports, including almost certain hostility on the part
\nof the accused and possibly other colleagues as well.
\nDespite these drawbacks to reporting wrongdoing, it is a professional
\nduty of physicians. Not only are they responsible for maintaining
\nthe good reputation of the profession,
\nbut they are often the only ones who
\nrecognise incompetence, impairment
\nor misconduct. However, reporting
\ncolleagues to the disciplinary authority
\nshould normally be a last resort after
\nother alternatives have been tried and
\nfound wanting. The first step might be
\nto approach the colleague and say
\nthat you consider his or her behaviour
\nunsafe or unethical. If the matter can be resolved at that level,
\nthere may be no need to go farther. If not, the next step might be to
\n\u201cStudents concerned
\nabout ethical aspects
\nof their education
\nshould have access
\nto such mechanisms
\nwhere they can raise
\nconcerns\u201d
\n\u201c…reporting
\ncolleagues to the
\ndisciplinary authority
\nshould normally be a
\nlast resort after other
\nalternatives have
\nbeen tried and found
\nwanting\u201d
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\ndiscuss the matter with your and\/or the offender\u2019s supervisor and
\nleave the decision about further action to that person. If this tactic is
\nnot practical or does not succeed, then it may be necessary to take
\nthe final step of informing the disciplinary authority.
\nRELATIONSHIPS WITH OTHER HEALTH
\nPROFESSIONALS
\nChapter Two on relationships with patients began with a discussion
\nof the great importance of respect and equal treatment in the
\nphysician-patient relationship. The principles set forth in that
\ndiscussion are equally relevant for relationships with co-workers. In
\nparticular, the prohibition against discrimination on grounds such as
\n\u201cage, disease or disability, creed, ethnic origin, gender, nationality,
\npolitical affiliation, race, sexual orientation, social standing or
\nany other factor\u201d (WMA Declaration of Geneva) is applicable in
\ndealings with all those with whom physicians interact in caring for
\npatients and other professional activities.
\nNon-discrimination is a passive characteristic of a relationship.
\nRespect is something more active and positive. With regard to other
\nhealthcare providers, whether physicians, nurses, auxiliary health
\nworkers, etc., it entails an appreciation of their skills and experience
\ninsofar as these can contribute to the care of patients. All healthcare
\nproviders are not equal in terms of their education and training, but
\nthey do share a basic human equality as well as similar concern for
\nthe well-being of patients.
\nAs with patients, though, there are legitimate grounds for refusing
\nto enter or for terminating a relationship with another healthcare
\nprovider. These include lack of confidence in the ability or integrity
\nof the other person and serious personality clashes. Distinguishing
\nthese from less worthy motives can require considerable ethical
\nsensitivity on the physician\u2019s part.
\nCOOPERATION
\nMedicine is at the same time a highly individualistic and a highly
\ncooperative profession. On the one hand, physicians are quite
\npossessive of \u2018their\u2019 patients. It is claimed, with good reason, that
\nthe individual physician-patient relationship is the best means of
\nattaining the knowledge of the patient and continuity of care that
\nare optimal for the prevention and treatment of illness. The retention
\nof patients also benefits the physician, at least financially. At the
\nsame time, as described above, medicine is highly complex and
\nspecialized, thus requiring close cooperation among practitioners
\nwith different but complementary knowledge and skills. This tension
\nbetween individualism and cooperation has been a recurrent theme
\nin medical ethics.
\nThe weakening of medical paternalism
\nhas been accompanied by the
\ndisappearance of the belief that
\nphysicians \u2018own\u2019 their patients. The
\ntraditional right of patients to ask for
\na second opinion has been expanded
\nto include access to other healthcare
\nproviders who may be better able
\nto meet their needs. According to
\nthe WMA Declaration on the Rights
\nof the Patient, \u201cThe physician has an obligation to cooperate in
\nthe coordination of medically indicated care with other healthcare
\nproviders treating the patient.\u201d However, as noted above, physicians
\nare not to profit from this cooperation by fee-splitting.
\nThese restrictions on the physician\u2019s \u2018ownership\u2019 of patients need
\nto be counterbalanced by other measures that are intended to
\nsafeguard the primacy of the patient-physician relationship. For
\nexample, a patient who is being treated by more than one physician,
\n\u201cThe weakening of
\nmedical paternalism
\nhas been accompanied
\nby the disappearance
\nof the belief that
\nphysicians \u2018own\u2019 their
\npatients.\u201d
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\nwhich is usually the case in a hospital, should, wherever possible,
\nhave one physician coordinating the care who can keep the patient
\ninformed about his or her overall progress and help the patient make
\ndecisions.
\nWhereas relationships among physicians are governed by generally
\nwell-formulated and understood rules, relationships between
\nphysicians and other healthcare professionals are in a state of flux
\nand there is considerable disagreement about what their respective
\nroles should be. As noted above, many nurses, pharmacists,
\nphysiotherapists and other professionals consider themselves to be
\nmore competent in their areas of patient care than are physicians
\nand see no reason why they should not be treated as equals to
\nphysicians. They favour a team approach to patient care in which
\nthe views of all caregivers are given equal consideration, and
\nthey consider themselves accountable to the patient, not to the
\nphysician. Many physicians, on the other hand, feel that even if the
\nteam approach is adopted, there has to be one person in charge,
\nand physicians are best suited for that role given their education
\nand experience.
\nAlthough some physicians may resist challenges to their traditional,
\nalmost absolute, authority, it seems certain that their role will
\nchange in response to claims by both patients and other healthcare
\nproviders for greater participation in medical decision-making.
\nPhysicians will have to be able to justify their recommendations to
\nothers and persuade them to accept these recommendations. In
\naddition to these communication skills, physicians will need to be
\nable to resolve conflicts that arise among the different participants in
\nthe care of the patient.
\nA particular challenge to cooperation in the best interests of patients
\nresultsfromtheirrecoursetotraditionaloralternativehealthproviders
\n(\u2018healers\u2019). These individuals are consulted by a large proportion of
\nthe population in Africa and Asia and increasingly so in Europe and
\nthe Americas. Although some would consider the two approaches
\nas complementary, in many situations they may be in conflict.
\nSince at least some of the traditional and alternative interventions
\nhave therapeutic effects and are sought out by patients, physicians
\nshould explore ways of cooperation with their practitioners. How this
\ncan be done will vary from one country to another and from one type
\nof practitioner to another. In all such interactions the well-being of
\npatients should be the primary consideration.
\nCONFLICT RESOLUTION
\nAlthough physicians can experience many different types of conflicts
\nwith other physicians and healthcare providers, for example, over
\noffice procedures or remuneration,
\nthe focus here will be on conflicts
\nabout patient care. Ideally, healthcare
\ndecisions will reflect agreement
\namong the patient, physicians and
\nall others involved in the patient\u2019s
\ncare. However, uncertainty and
\ndiverse viewpoints can give rise to
\ndisagreement about the goals of
\ncare or the means of achieving those
\ngoals. Limited healthcare resources and organisational policies may
\nalso make it difficult to achieve consensus.
\nDisagreements among healthcare providers about the goals of
\ncare and treatment or the means of achieving those goals should
\nbe clarified and resolved by the members of the healthcare team
\nso as not to compromise their relationships with the patient.
\nDisagreements between healthcare providers and administrators
\nwith regard to the allocation of resources should be resolved within
\nthe facility or agency and not be debated in the presence of the
\n\u201c…uncertainty and
\ndiverse viewpoints
\ncan give rise to
\ndisagreement about
\nthe goals of care or
\nthe means of achieving
\nthose goals.\u201d
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\npatient. Since both types of conflicts are ethical in nature, their
\nresolution can benefit from the advice of a clinical ethics committee
\nor an ethics consultant where such resources are available.
\nThe following guidelines can be useful for resolving such conflicts:
\n\u2022\t Conflicts should be resolved as informally as possible, for
\nexample, through direct negotiation between the persons
\nwho disagree, moving to more formal procedures only
\nwhen informal measures have been unsuccessful.
\n\u2022\t The opinions of all those directly involved should be elicited
\nand given respectful consideration.
\n\u2022\t The informed choice of the patient, or authorized substitute
\ndecision-maker, regarding treatment should be the primary
\nconsideration in resolving disputes.
\n\u2022\t If the dispute is about which options the patient should be
\noffered, a broader rather than a narrower range of options is
\nusually preferable. If a preferred treatment is not available
\nbecause of resource limitations, the patient should normally
\nbe informed of this.
\n\u2022\t If, after reasonable effort, agreement or compromise cannot
\nbe reached through dialogue, the decision of the person
\nwith the right or responsibility for making the decision
\nshould be accepted. If it is unclear or disputed who has
\nthe right or responsibility to make the decision, mediation,
\narbitration or adjudication should be sought.
\nIf healthcare providers cannot support the decision that prevails
\nas a matter of professional judgement or personal morality, they
\nshould be allowed to withdraw from participation in carrying out the
\ndecision, after ensuring that the person receiving care is not at risk
\nof harm or abandonment.
\nDr. C is right to be alarmed by the behaviour
\nof the senior surgeon in the operating room.
\nNot only is he endangering the health of the
\npatient but he is being disrespectful to both
\nthe patient and his colleagues. Dr. C has
\nan ethical duty not to ignore this behaviour
\nbut to do something about it. As a first
\nstep, he should not indicate any support
\nfor the offensive behaviour, for example,
\nby laughing at the jokes. If he thinks that
\ndiscussing the matter with the surgeon might
\nbe effective, he should go ahead and do
\nthis. Otherwise, he may have to go directly
\nto higher authorities in the hospital. If they
\nare unwilling to deal with the situation, then
\nhe can approach the appropriate physician
\nlicensing body and ask it to investigate.
\nBACK TO THE CASE STUDY
\nDr. C is right to be alarmed by the behaviour
\nof the senior surgeon in the operating room.
\nNot only is he endangering the health of the
\npatient but he is being disrespectful to both
\nthe patient and his colleagues. Dr. C has
\nan ethical duty not to ignore this behaviour
\nbut to do something about it. As a first
\nstep, he should not indicate any support
\nfor the offensive behaviour, for example,
\nby laughing at the jokes. If he thinks that
\ndiscussing the matter with the surgeon might
\nbe effective, he should go ahead and do
\nthis. Otherwise, he may have to go directly
\nto higher authorities in the hospital. If they
\nare unwilling to deal with the situation, then
\nhe can approach the appropriate physician
\nlicensing body and ask it to investigate.
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\nOBJECTIVES
\nAfter working through this chapter you should be able to:
\n\u00b7\tidentify the main principles of research ethics
\n\u00b7\tknow how to balance research and clinical care
\n\u00b7\tsatisfy the requirements of ethics review committees
\nSleeping sickness is back
\n\u00a9 Robert Patric\/CORBIS SYGMA
\nCHAPTER FIVE \u2013
\nETHICS AND MEDICAL RESEARCH
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\ntechniques. Great progress has been made in this area over the
\npast 50 years and today there is more medical research underway
\nthan ever before. Nevertheless, there are still many unanswered
\nquestions about the functioning of the human body, the causes of
\ndiseases (both familiar and novel ones) and the best ways to prevent
\nor cure them. Medical research is the only means of answering
\nthese questions.
\nIn addition to seeking a better understanding of human physiology,
\nmedical research investigates a wide variety of other factors in
\nhuman health, including patterns of disease (epidemiology), the
\norganization, funding and delivery of healthcare (health systems
\nresearch), social and cultural aspects of health (medical sociology
\nand anthropology), law (legal medicine) and ethics (medical ethics).
\nThe importance of these types of research is being increasingly
\nrecognized by funding agencies, many of which have specific
\nprograms for non-physiological medical research.
\nRESEARCH IN MEDICAL PRACTICE
\nAll physicians make use of the results of medical research in their
\nclinical practice. To maintain their competence, physicians must
\nkeep up with the current research in their area of practice through
\nContinuing Medical Education\/
\nContinuing Professional Development
\nprograms, medical journals and
\ninteraction with knowledgeable
\ncolleagues. Even if they do not engage
\nin research themselves, physicians
\nmust know how to interpret the results
\nof research and apply them to their
\npatients. Thus, a basic familiarity with
\nresearch methods is essential for
\ncompetent medical practice. The best way to gain this familiarity
\nCASE STUDY #4
\nDr. R, a general practitioner in a small rural
\ntown, is approached by a contract research
\norganization (C.R.O.) to participate in a
\nclinical trial of a new non-steroidal anti-
\ninflammatory drug (NSAID) for osteoarthritis.
\nShe is offered a sum of money for each
\npatient that she enrols in the trial. The C.R.O.
\nrepresentative assures her that the trial
\nhas received all the necessary approvals,
\nincluding one from an ethics review
\ncommittee. Dr. R has never participated in
\na trial before and is pleased to have this
\nopportunity, especially with the extra money.
\nShe accepts without inquiring further about
\nthe scientific or ethical aspects of the trial.
\nIMPORTANCE OF MEDICAL RESEARCH
\nMedicine is not an exact science in the way that mathematics and
\nphysics are. It does have many general principles that are valid most
\nof the time, but every patient is different and what is an effective
\ntreatment for 90% of the population
\nmay not work for the other 10%. Thus,
\nmedicine is inherently experimental.
\nEven the most widely accepted
\ntreatments need to be monitored
\nand evaluated to determine whether
\nthey are effective for specific patients and, for that matter, for
\npatients in general. This is one of the functions of medical
\nresearch.
\nAnother, perhaps better known, function is the development of
\nnew treatments, especially drugs, medical devices and surgical
\n\u201c…medicine is
\ninherently
\nexperimental\u201d
\n\u201cEven if they do
\nnot engage in
\nresearch themselves,
\nphysicians must know
\nhow to interpret the
\nresults of research
\nand apply them to
\ntheir patients.\u201d
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\nis to take part in a research project, either as a medical student or
\nfollowing qualification.
\nThe most common method of research for practising physicians is
\nthe clinical trial. Before a new drug can be approved by government-
\nmandated regulatory authorities, it must undergo extensive testing
\nfor safety and efficacy. The process begins with laboratory studies
\nfollowed by testing on animals. If this proves promising, the four
\nsteps, or phases, of clinical research, are next:
\n\u2022\t Phase one research, usually conducted on a relatively small
\nnumber of healthy volunteers, who are often paid for their
\nparticipation, is intended to determine what dosage of the drug
\nis required to produce a response in the human body, how the
\nbody processes the drug, and whether the drug produces toxic
\nor harmful effects.
\n\u2022\t Phase two research is conducted on a group of patients who
\nhave the disease that the drug is intended to treat. Its goals are
\nto determine whether the drug has any beneficial effect on the
\ndisease and has any harmful side effects.
\n\u2022\t Phase three research is the clinical trial, in which the drug is
\nadministered to a large number of patients and compared to
\nanother drug, if there is one for the condition in question, and\/or
\nto a placebo. Where possible, such trials are \u2018double-blinded\u2019,
\ni.e., neither research subjects nor their physicians know who is
\nreceiving which drug or placebo.
\n\u2022\t Phase four research takes place after the drug is licensed and
\nmarketed. For the first few years, a new drug is monitored for side
\neffects that did not show up in the earlier phases. Additionally,
\nthe pharmaceutical company is usually interested in how well
\nthe drug is being received by physicians who prescribe it and
\npatients who take it.
\nThe rapid increase in recent years in the number of ongoing trials
\nhas required finding and enrolling ever-larger numbers of patients
\nto meet the statistical requirements of the trials. Those in charge
\nof the trials, whether independent physicians or pharmaceutical
\ncompanies, now rely on many other physicians, often in different
\ncountries, to enrol patients as research subjects.
\nAlthough such participation in research is valuable experience for
\nphysicians, there are potential problems that must be recognized
\nand avoided. In the first place, the physician\u2019s role in the physician-
\npatientrelationshipisdifferentfromthe
\nresearcher\u2019s role in the researcher-
\nresearch subject relationship, even
\nif the physician and the researcher
\nare the same person. The physician\u2019s
\nprimary responsibility is the health and
\nwell-being of the patient, whereas the
\nresearcher\u2019s primary responsibility is
\nthe generation of knowledge, which
\nmay or may not contribute to the research subject\u2019s health and well-
\nbeing. Thus, there is a potential for conflict between the two roles.
\nWhen this occurs, the physician role must take precedence over the
\nresearcher. What this means in practice will be evident below.
\nAnother potential problem in combining these two roles is conflict
\nof interest. Medical research is a well-funded enterprise, and
\nphysicians are sometimes offered considerable rewards for
\nparticipating. These can include cash payments for enrolling
\nresearch subjects, equipment such as computers to transmit the
\nresearch data, invitations to conferences to discuss the research
\nfindings, and co-authorship of publications on the results of the
\nresearch. The physician\u2019s interest in obtaining these benefits can
\nsometimes conflict with the duty to provide the patient with the best
\navailable treatment. It can also conflict with the right of the patient
\n\u201c…the physician\u2019s
\nrole in the physician-
\npatient relationship
\nis different from the
\nresearcher\u2019s role in the
\nresearcher-research
\nsubject relationship\u201d
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\nto receive all the necessary information to make a fully informed
\ndecision whether or not to participate in a research study.
\nThese potential problems can be overcome. The ethical values of
\nthe physician \u2013 compassion, competence, autonomy \u2013 apply to the
\nmedical researcher as well. So there is no inherent conflict between
\nthe two roles. As long as physicians understand and follow the basic
\nrules of research ethics, they should have no difficulty participating
\nin research as an integral component of their clinical practice.
\nETHICAL REQUIREMENTS
\nThe basic principles of research ethics are well established. It was
\nnot always so, however. Many prominent medical researchers
\nin the 19th
\nand 20th
\ncenturies conducted experiments on patients
\nwithout their consent and with little if any concern for the patients\u2019
\nwell-being. Although there were some statements of research ethics
\ndating from the early 20th
\ncentury, they did not prevent physicians in
\nNazi Germany and elsewhere from performing research on subjects
\nthat clearly violated fundamental human rights. Following World
\nWar Two, some of these physicians were tried and convicted by a
\nspecial tribunal at Nuremberg, Germany. The basis of the judgment
\nis known as the Nuremberg Code, which has served as one of the
\nfoundational documents of modern research ethics. Among the ten
\nprinciples of this Code is the requirement of voluntary consent if a
\npatient is to serve as a research subject.
\nThe World Medical Association was established in 1947, the
\nsame year that the Nuremberg Code was set forth. Conscious
\nof the violations of medical ethics before and during World War
\nTwo, the founders of the WMA immediately took steps to ensure
\nthat physicians would at least be aware of their ethical obligations.
\nIn 1954, after several years of study, the WMA adopted a
\nset of Principles for Those in Research and Experimentation.
\nThis document was revised over the next ten years and eventually
\nwas adopted as the Declaration of Helsinki (DoH) in 1964. It
\nwas further revised in 1975, 1983, 1989, 1996, 2000, 2008 and
\n2013. The DoH is a concise summary of research ethics. Other,
\nmuch more detailed, documents have been produced in recent
\nyears on research ethics in general (e.g., Council for International
\nOrganizations of Medical Sciences, International Ethical
\nGuidelines for Biomedical Research Involving Human Subjects,
\n1993, revised in 2002) and on specific topics in research ethics
\n(e.g., Nuffield Council on Bioethics [UK], The Ethics of Research
\nRelated to Healthcare in Developing Countries, 2002).
\nDespite the different scope, length and authorship of these
\ndocuments, they agree to a very large extent on the basic principles
\nof research ethics. These principles have been incorporated in
\nthe laws and\/or regulations of many countries and international
\norganizations, including those that deal with the approval of drugs
\nand medical devices. Here is a brief description of the principles,
\ntaken primarily from the DoH:
\nEthics Review Committee
\nApproval
\nParagraph 23 of the DoH stipulates
\nthat every proposal for medical
\nresearch on human subjects must
\nbe reviewed and approved by an
\nindependent ethics committee before
\nit can proceed. In order to obtain
\napproval, researchers must explain
\nthe purpose and methodology of the project; demonstrate how
\nresearch subjects will be recruited, how their consent will be obtained
\nand how their privacy will be protected; specify how the project is
\nbeing funded; and disclose any potential conflicts of interest on the
\n\u201c…every proposal
\nfor medical research
\non human subjects
\nmust be reviewed
\nand approved by an
\nindependent ethics
\ncommittee before
\nit can proceed.\u201d
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\npart of the researchers. The ethics committee may approve the
\nproject as presented, require changes before it can start, or refuse
\napproval altogether. The committee has a further role of monitoring
\nprojects that are underway to ensure that the researchers fulfil their
\nobligations and it can if necessary stop a project because of serious
\nunexpected adverse events.
\nThe reason why ethics committee approval of a project is required
\nis that neither researchers nor research subjects are always
\nknowledgeable and objective enough to determine whether a
\nproject is scientifically and ethically appropriate. Researchers need
\nto demonstrate to an impartial expert committee that the project is
\nworthwhile, that they are competent to conduct it, and that potential
\nresearch subjects will be protected against harm to the greatest
\nextent possible.
\nOne unresolved issue regarding ethics committee review is whether
\na multi-centre project requires committee approval at each centre or
\nwhether approval by one committee is sufficient. If the centres are
\nin different countries, review and approval is generally required in
\neach country.
\nScientific Merit
\nParagraph 21 of the DoH requires
\nthat medical research involving
\nhuman subjects must be justifiable on
\nscientific grounds. This requirement
\nis meant to eliminate projects that
\nare unlikely to succeed, for example,
\nbecause they are methodologically
\ninadequate, or that, even if successful,
\nwill likely produce trivial results. If patients are being asked to
\nparticipate in a research project, even where risk of harm is minimal,
\nthere should be an expectation that important scientific knowledge
\nwill be the result.
\nTo ensure scientific merit, paragraph 21 requires that the project be
\nbased on a thorough knowledge of the literature on the topic and on
\nprevious laboratory and, where appropriate, animal research that
\ngives good reason to expect that the proposed intervention will be
\nefficacious in human beings. All research on animals must conform
\nto ethical guidelines that minimize the number of animals used and
\nprevent unnecessary pain. Paragraph 12 adds a further requirement
\n\u2013 that only scientifically qualified persons should conduct research
\non human subjects. The ethics review committee needs to be
\nconvinced that these conditions are fulfilled before it approves the
\nproject.
\nSocial Value
\nOne of the more controversial
\nrequirements of a medical research
\nproject is that it contribute to the well-
\nbeing of society in general. It used to
\nbe widely agreed that advances in
\nscientific knowledge were valuable
\nin themselves and needed no further justification. However,
\nas resources available for medical research are increasingly
\ninadequate, social value has emerged as an important criterion for
\njudging whether a project should be approved.
\nParagraphs 16 and 20 of the DoH clearly favour the consideration of
\nsocial value in the evaluation of research projects. The importance
\nof the project\u2019s objective, understood as both scientific and social
\nimportance, should outweigh the risks and burdens to research
\nsubjects. Furthermore, the populations in which the research is
\ncarried out should benefit from the results of the research. This is
\n\u201c…medical research
\ninvolving human
\nsubjects must be
\njustifiable on
\nscientific grounds\u201d
\n\u201c…social value has
\nemerged as an
\nimportant criterion
\nfor judging whether
\na project should be
\nfunded.\u201d
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\n\u201cThe voluntary
\nconsent of the human
\nsubject is absolutely
\nessential.\u201d
\n\u201cIf the risk is entirely
\nunknown, then the
\nresearcher should
\nnot proceed with the
\nproject until some
\nreliable data are
\navailable\u201d
\nespecially important in countries where there is potential for unfair
\ntreatment of research subjects who undergo the risks and discomfort
\nof research while the drugs developed as a result of the research
\nonly benefit patients elsewhere.
\nThe social worth of a research project is more difficult to determine
\nthan its scientific merit but that is not a good reason for ignoring
\nit. Researchers, and ethics review committees, must ensure that
\npatients are not subjected to tests that are unlikely to serve any
\nuseful social purpose. To do otherwise would waste valuable health
\nresources and weaken the reputation of medical research as a
\nmajor contributing factor to human health and well-being.
\nRisks and Benefits
\nOnce the scientific merit and social
\nworth of the project have been
\nestablished, it is necessary for the
\nresearcher to demonstrate that the
\nrisks to the research subjects are not
\nunreasonable or disproportionate to
\nthe expected benefits of the research,
\nwhich may not even go to the research
\nsubjects. A risk is the potential for an adverse outcome (harm) to
\noccur. It has two components: (1) the likelihood of the occurrence
\nof harm (from highly unlikely to very likely), and (2) the severity of
\nthe harm (from trivial to permanent severe disability or death). A
\nhighly unlikely risk of a trivial harm would not be problematic for
\na good research project. At the other end of the spectrum, a likely
\nrisk of a serious harm would be unacceptable unless the project
\nprovided the only hope of treatment for terminally ill research
\nsubjects. In between these two extremes, Paragraphs 17 and 18
\nof the DoH require researchers to adequately assess the risks and
\nbe sure that they can be managed. If the risk is entirely unknown,
\nthen the researcher should not proceed with the project until some
\nreliable data are available, for example, from laboratory studies or
\nexperiments on animals.
\nInformed Consent
\nThe first principle of the Nuremberg
\nCode reads as follows: \u201cThe voluntary
\nconsent of the human subject is
\nabsolutely essential.\u201d The explanatory
\nparagraph attached to this principle
\nrequires, among other things, that the research subject \u201cshould have
\nsufficient knowledge and comprehension of the elements of the
\nsubject matter involved as to enable him to make an understanding
\nand enlightened decision.\u201d
\nThe DoH goes into some detail about informed consent. Paragraph
\n26 specifies what the research subject needs to know in order to
\nmake an informed decision about participation. Paragraph 27 warns
\nagainst pressuring individuals to participate in research, since
\nin such circumstances the consent may not be entirely voluntary.
\nParagraphs 28 to 30 deal with research subjects who are unable
\nto give consent (minor children, severely mentally handicapped
\nindividuals, unconscious patients). They can still serve as research
\nsubjects but only under restricted conditions.
\nThe DoH, like other research ethics documents, recommends that
\ninformed consent be demonstrated by having the research subject
\nsign a \u2018consent form\u2019(paragraph 26). Many ethics review committees
\nrequire the researcher to provide them with the consent form they
\nintend to use for their project. In some countries these forms have
\nbecome so long and detailed that they no longer serve the purpose
\nof informing the research subject about the project. In any case, the
\nprocess of obtaining informed consent does not begin and end with
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\n\u201c…research subjects
\nhave a right to privacy
\nwith regard to their
\npersonal health
\ninformation\u201d
\nthe form being signed but must involve a careful oral explanation of
\nthe project and all that participation in it will mean to the research
\nsubject. Moreover, research subjects should be informed that they
\nare free to withdraw their consent to participate at any time, even
\nafter the project has begun, without any sort of reprisal from the
\nresearchers or other physicians and without any compromise of
\ntheir healthcare (paragraph 31).
\nConfidentiality
\nAs with patients in clinical care,
\nresearch subjects have a right to
\nprivacy with regard to their personal
\nhealth information. Unlike clinical
\ncare, however, research requires the
\ndisclosure of personal health information
\nto others, including the wider scientific community and sometimes
\nthe general public. In order to protect privacy, researchers must
\nensure that they obtain the informed consent of research subjects
\nto use their personal health information for research purposes,
\nwhich requires that the subjects are told in advance about the
\nuses to which their information is going to be put. As a general
\nrule, the information should be de-identified and should be stored
\nand transmitted securely. The WMA Declaration on Ethical
\nConsiderations Regarding Health Databases provides further
\nguidance on this topic.
\nConflict of Roles
\nIt was noted earlier in this chapter that the physician\u2019s role in the
\nphysician-patient relationship is different from the researcher\u2019s
\nrole in the researcher-research subject relationship, even if the
\nphysician and the researcher are the same person. Paragraph 14 of
\nthe DoH specifies that in such cases, the physician role must take
\nprecedence. This means, among other things, that the physician
\nmust be prepared to recommend that the patient not take part in a
\nresearch project if the patient seems to be doing well with the current
\ntreatment and the project requires that patients be randomized
\nto different treatments and\/or to a placebo. Only if the physician,
\non solid scientific grounds, is truly uncertain whether the patient\u2019s
\ncurrent treatment is as suitable as a proposed new treatment, or
\neven a placebo, should the physician ask the patient to take part in
\nthe research project.
\nHonest Reporting of Results
\nIt should not be necessary to require that research results be
\nreported accurately, but unfortunately there have been numerous
\nrecent accounts of dishonest practices in the publication of
\nresearch results. Problems include plagiarism, data fabrication,
\nduplicate publication and \u2018gift\u2019 authorship. Such practices may
\nbenefit the researcher, at least until they
\nare discovered, but they can cause
\ngreat harm to patients, who may be
\ngiven incorrect treatments based on
\ninaccurate or false research reports,
\nand to other researchers, who may
\nwaste much time and resources trying
\nto follow up the studies.
\nWhistle-blowing
\nIn order to prevent unethical research from occurring, or to expose it
\nafter the fact, anyone who has knowledge of such behaviour has an
\nobligation to disclose this information to the appropriate authorities.
\nUnfortunately, such whistle-blowing is not always appreciated or
\neven acted on, and whistle-blowers are sometimes punished or
\navoided for trying to expose wrong-doing. This attitude seems to
\n\u201c…there have been
\nnumerous recent
\naccounts of dishonest
\npractices in the
\npublication of
\nresearch results\u201d
\n112 113
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013EthicsandMedicalResearch
\nbe changing, however, as both medical scientists and government
\nregulators are seeing the need to detect and punish unethical
\nresearch and are beginning to appreciate the role of whistle-blowers
\nin achieving this goal.
\nJunior members of a research team, such as medical students, may
\nfind it especially difficult to act on suspicions of unethical research,
\nsince they may feel unqualified to judge the actions of senior
\nresearchers and will likely be subject to punishment if they speak
\nout. At the very least, however, they should refuse to participate
\nin practices that they consider clearly unethical, for example, lying
\nto research subjects or fabricating data. If they observe others
\nengaging in such practices, they should take whatever steps they
\ncan to alert relevant authorities, either directly or anonymously.
\nUnresolved Issues
\nNot all aspects of research ethics
\nenjoy general agreement. As medical
\nscience continues to advance,
\nin areas such as genetics, the
\nneurosciences and organ and tissue
\ntransplantation, new questions arise
\nregarding the ethical acceptability of
\ntechniques, procedures and treatments
\nfor which there are no ready-made answers. Moreover, some
\nolder issues are still subjects of continuing ethical controversy, for
\nexample, under what conditions should a placebo arm be included
\nin a clinical trial and what continuing care should be provided to
\nparticipants in medical research. At a global level, the 10\/90 gap in
\nmedical research (only 10% of global research funding is spent on
\nhealth problems that affect 90% of the world\u2019s population) is clearly
\nan unresolved ethical issue. And when researchers do address
\nproblems in resource-poor areas of the world, they often encounter
\nproblems due to conflicts between their ethical outlook and that of
\nthe communities where they are working.All these issues will require
\nmuch further analysis and discussion before general agreement is
\nachieved.
\nDespite all these potential problems, medical research is a valuable
\nand rewarding activity for physicians and medical students as well
\nas for the research subjects themselves. Indeed, physicians and
\nmedical students should consider serving as research subjects so
\nthat they can appreciate the other side of the researcher-research
\nsubject relationship.
\n\u201c…only 10% of global
\nresearch funding
\nis spent on health
\nproblems that affect
\n90% of the world\u2019s
\npopulation\u201d
\n114 115
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013EthicsandMedicalResearch
\nBACK TO THE CASE STUDY
\nDr. R should not have accepted so quickly.
\nShe should first find out more about the
\nproject and ensure that it meets all the
\nrequirements for ethical research.
\nIn particular, she should ask to see the
\nprotocol that was submitted to the ethics
\nreview committee and any comments or
\nconditions that the committee put on the
\nproject. She should only participate in
\nprojects in her area of practice, and she
\nshould satisfy herself about the scientific
\nmerit and social value of the project. If she
\nis not confident in her ability to evaluate
\nthe project, she should seek the advice of
\ncolleagues in larger centres. She should
\nensure that she acts in the best interests of
\nher patients and only enrols those who will
\nnot be harmed by changing their current
\ntreatment to the experimental one or to a
\nplacebo. She must be able to explain the
\nalternatives to her patients so they can give
\nfully informed consent to participate or not
\nto participate. She should not agree to enrol
\na fixed number of patients as subjects since
\nthis could lead her to pressure patients to
\nagree, perhaps against their best interests.
\nShe should carefully monitor the patients in
\nthe study for unexpected adverse events and
\nbe prepared to adopt rapid corrective action.
\nFinally, she should communicate to her
\npatients the results of the research as they
\nbecome available.
\nMedicalEthicsManual\u2013EthicsandMedicalResearch
\n112 113
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013Conclusion
\nCHAPTER SIX \u2013
\nCONCLUSION
\nMan Hiking on Steep Incline
\n\u00a9 Don Mason\/CORBIS
\nMedicalEthicsManual\u2013EthicsandMedicalResearch
\n114 115
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013Conclusion
\nRESPONSIBILITIES AND PRIVILEGES
\nOF PHYSICIANS
\nThis Manual has focused on the duties and responsibilities of
\nphysicians, and indeed that is the main substance of medical
\nethics. However, like all human
\nbeings, physicians have rights as
\nwell as responsibilities, and medical
\nethics would be incomplete if it did
\nnot consider how physicians should
\nbe treated by others, whether
\npatients, society or colleagues. This
\nperspective on medical ethics has become increasingly important
\nas physicians in many countries are experiencing great frustration
\nin practising their profession, whether because of limited resources,
\ngovernment and\/or corporate micro-management of healthcare
\ndelivery, sensationalist media reports of medical errors and
\nunethical physician conduct, or challenges to their authority and
\nskills by patients and other healthcare providers.
\nMedical ethics has in the past considered the rights of physicians
\nas well as their responsibilities. Previous codes of ethics such
\nas the 1847 version of the American Medical Association\u2019s Code
\nincluded sections on the obligations of patients and of the public
\nto the profession. Most of these obligations are outmoded, for
\nexample, \u201cThe obedience of a patient to the prescriptions of his
\nphysician should be prompt and implicit. He should never permit
\nhis own crude opinions as to their fitness, to influence his attention
\nto them.\u201d However, the statement, \u201cThe public ought\u2026 to entertain
\na just appreciation of medical qualifications\u2026 [and] to afford
\nevery encouragement and facility for the acquisition of medical
\neducation\u2026,\u201d is still valid. Rather than revising and updating these
\nsections, however, the AMA eventually eliminated them from its
\nCode of Ethics.
\nOver the years the WMA has adopted several policy statements on
\nthe rights of physicians and the corresponding responsibilities of
\nothers, especially governments, to respect these rights:
\n\u2022\t The 1984 Statement on Freedom toAttend Medical Meetings
\nasserts that \u201cthere should\u2026 be no barriers which will prevent
\nphysicians from attending meetings of the WMA, or other
\nmedical meetings, wherever such meetings are convened.\u201d
\n\u2022\t The 2006 Statement on Professional Responsibility for
\nStandards of Medical Care declares that \u201cany judgement
\non a physician\u2019s professional conduct or performance must
\nincorporate evaluation by the physician\u2019s professional peers
\nwho, by their training and experience, understand the complexity
\nof the medical issues involved.\u201d The same statement condemns
\n\u201cany procedures for considering complaints from patients which
\nfail to be based upon good faith evaluation of the physician\u2019s
\nactions or omissions by the physician\u2019s peers.\u201d
\n\u2022\t The 1997 Declaration Concerning Support for Medical
\nDoctors Refusing to Participate in, or to Condone, the Use
\nof Torture or Other Forms of Cruel, Inhuman or Degrading
\nTreatment commits the WMA\u201cto support and protect, and to call
\nupon its National Medical Associations to support and protect,
\nphysicians who are resisting involvement in such inhuman
\nprocedures or who are working to treat and rehabilitate victims
\nthereof, as well as to secure the right to uphold the highest
\nethical principles including medical confidentiality\u2026.\u201d
\n\u2022\t The 2014 Statement on Ethical Guidelines for the
\nInternational Migration of Health Workers calls on every
\ncountry to \u201cdo its utmost to retain its physicians in the profession
\nas well as in the country by providing them with the support they
\nneed to meet their personal and professional goals, taking into
\naccount the country\u2019s needs and resources\u201d and to ensure that
\n\u201c…like all human
\nbeings, physicians
\nhave rights as well as
\nresponsibilities\u201d
\nMedicalEthicsManual\u2013EthicsandMedicalResearch
\n116 117
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013Conclusion
\n\u201c…physicians
\nsometimes need also
\nto be reminded of the
\nprivileges they enjoy.\u201d
\n\u201cPhysicians who are working, either permanently or temporarily,
\nin a country other than their home country\u2026 be treated fairly in
\nrelation to other physicians in that country (for example, equal
\nopportunity career options and equal payment for the same
\nwork).\u201d
\nAlthough such advocacy on behalf
\nof physicians is necessary, given the
\nthreats and challenges listed above,
\nphysicians sometimes need also to be
\nreminded of the privileges they enjoy.
\nPublic surveys in many countries
\nhave consistently shown that physicians are among the most highly
\nregarded and trusted occupational groups. They generally receive
\nhigher than average remuneration (much higher in some countries).
\nThey still have a great deal of clinical autonomy, although not as
\nmuch as previously. Many are engaged in an exciting search for
\nnew knowledge through participation in research. Most important,
\nthey provide services that are of inestimable value to individual
\npatients, particularly those who are vulnerable and most in need,
\nand to society in general. Few occupations have the potential to
\nbe more satisfying than medicine, considering the benefits that
\nphysicians provide \u2013 relief of pain and suffering, cure of illnesses,
\nand comfort of the dying. Fulfilment of their ethical duties may be a
\nsmall price to pay for all these privileges.
\nRESPONSIBILITIES TO ONESELF
\nThis Manual has classified physicians\u2019 ethical responsibilities
\naccording to their main beneficiaries: patients, society, and
\ncolleagues (including other health professionals). Physicians often
\nforget that they have responsibilities to themselves, and to their
\nfamilies, as well. In many parts of the world, being a physician
\nhas required devoting oneself to the practice of medicine with little
\n\u201cPhysicians often
\nforget that they have
\nresponsibilities to
\nthemselves, and to
\ntheir families,
\nas well.\u201d
\nconsideration for one\u2019s own health
\nand well-being. Working weeks of
\n60-80 hours are not uncommon and
\nvacations are sometimes considered
\nto be unnecessary luxuries. Although
\nmany physicians seem to do well
\nin these conditions, their families
\nmay be adversely affected. Other
\nphysicians clearly suffer from this pace of professional activity, with
\nresults ranging from chronic fatigue to substance abuse to suicide.
\nImpaired physicians are a danger to their patients, with fatigue
\nbeing an important factor in medical mishaps.
\nThe need to ensure patient safety, as well as to promote a healthy
\nlifestyle for physicians, is being addressed in some countries
\nby restrictions on the number of hours and the length of shifts
\nthat physicians in training may work. Some medical educational
\ninstitutions now make it easier for female physicians to interrupt
\ntheir training programmes for family reasons. Although measures
\nsuch as these can contribute to physician health and well-being,
\nthe primary responsibility for self-care rests with the individual
\nphysician. Besides avoiding such obvious health hazards as
\nsmoking, substance abuse and overwork, physicians should protect
\nand enhance their own health and well-being by identifying stress
\nfactors in their professional and personal lives and by developing
\nand practising appropriate coping strategies. When these fail,
\nthey should seek help from colleagues and appropriately qualified
\nprofessionals for personal problems that might adversely affect their
\nrelationships with patients, society or colleagues.
\nMedicalEthicsManual\u2013EthicsandMedicalResearch
\n118 119
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013Conclusion
\nTHE FUTURE OF MEDICAL ETHICS
\nThis Manual has focussed on the current state of medical ethics,
\nalthough with numerous references to its past. However, the present
\nis constantly slipping away and it is necessary to anticipate the
\nfuture if we are not to be always behind the times. The future of
\nmedical ethics will depend in large part on the future of medicine. In
\nthe first decades of the 21st
\ncentury, medicine is evolving at a very
\nrapid pace and it is difficult to predict how it will be practised by
\nthe time today\u2019s first-year medical students complete their training,
\nand impossible to know what further changes will take place
\nbefore they are ready to retire. The future will not necessarily be
\nbetter than the present, given widespread political and economic
\ninstability, environmental degradation, the continuing spread of HIV\/
\nAIDS and other potential epidemics. Although we can hope that
\nmedical progress will eventually benefit all countries and that the
\nethical problems they will face will be similar to those currently being
\ndiscussed in the wealthy countries, the reverse could happen \u2013
\ncountries that are wealthy now could deteriorate to the point where
\ntheir physicians have to deal with epidemics of tropical diseases and
\nsevere shortages of medical supplies.
\nGiven the inherent unpredictability of the future, medical ethics
\nneeds to be flexible and open to change and adjustment, as indeed
\nit has been for some time now. However, we can hope that its basic
\nprinciples will remain in place, especially the values of compassion,
\ncompetence and autonomy, along with its concern for fundamental
\nhuman rights and its devotion to professionalism. Whatever
\nchanges in medicine occur as a result of scientific developments
\nand social, political and economic factors, there will always be sick
\npeople needing cure if possible and care always. Physicians have
\ntraditionally provided these services along with others such as health
\npromotion, disease prevention and health system management.
\nAlthough the balance among these activities may change in the
\nfuture, physicians will likely continue to play an important role in
\nall of them. Since each activity involves many ethical challenges,
\nphysicians will need to keep informed about developments in
\nmedical ethics just as they do in other aspects of medicine.
\nThis is the end of the Manual but for the reader it should be just
\none step in a life-long immersion in medical ethics. To repeat what
\nwas stated in the Introduction, this Manual provides only a basic
\nintroduction to medical ethics and some of its central issues. It
\nis intended to give you an appreciation of the need for continual
\nreflection on the ethical dimension of medicine, and especially on
\nhow to deal with the ethical issues that you will encounter in your
\nown practice. The list of resources provided in Appendix B can help
\nyou deepen your knowledge of this field.
\n120 121
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nsuch an arrangement. The term, hierarchy, is also used to refer to the top
\nleaders of an organization.
\nJustice \u2013 fair treatment of individuals and groups. As Chapter Three points
\nout, there are different understandings of what constitutes fair treatment in
\nhealthcare.
\nManaged healthcare \u2013 an organizational approach to healthcare in which
\ngovernments, corporations or insurance companies decide what services
\nwill be provided, who will provide them (specialist physicians, general
\npractitioner physicians, nurses, other health professionals, etc.), where
\nthey will be provided (clinics, hospitals, the patient\u2019s home, etc.), and other
\nrelated matters.
\nNon-maleficence \u2013 literally, not doing wrong. Physicians and medical
\nresearchers are to avoid inflicting harm on patients and research subjects.
\nPalliative care \u2013 an approach to the care of patients, especially those who
\nare likely to die in the relatively near future from serious, incurable disease,
\nthat focuses on the patient\u2019s quality of life, especially pain control. It can
\nbe provided in hospitals, special institutions for dying patients (commonly
\ncalled hospices), or in the patient\u2019s home.
\nPhysician \u2013 an individual who is qualified to practise medicine. In some
\ncountries, physicians are distinguished from surgeons, and the term
\n\u2018doctor\u2019 is used to designate both. However, \u2018doctor\u2019 is used by members
\nof other health professions, such as dentists and veterinarians, as well as
\nby all those who have obtained a Ph.D. or other \u2018doctoral\u2019 degree. The term
\n\u2018medical doctor\u2019 is more precise but not widely used. The WMA uses the
\nterm \u2018physician\u2019 for all those who are qualified to practise medicine, no
\nmatter what their specialty, and this Manual does the same.
\nPlagiarism \u2013 a form of dishonest behaviour whereby a person copies the
\nwork of someone else, for example, all or part of a published article, and
\nsubmits it as if it were the person\u2019s own work (i.e., without indicating its
\nsource).
\nPluralistic \u2013 having several or many different approaches or features: the
\nopposite of singular or uniform.
\nProfess \u2013 to state a belief or a promise in public. It is the basis of the terms
\n\u2018profession\u2019, \u2018professional\u2019 and \u2018professionalism\u2019.
\nAPPENDIX A \u2013 GLOSSARY
\nAccountable \u2013 answerable to someone for something (e.g., employees
\nare accountable to their employers for the work they do). Accountability
\nrequires being prepared to provide an explanation for something one has
\ndone or has not done.
\nAdvance directive \u2013 a statement, usually in writing, that indicates how
\na person would want to be treated, or not treated, if they are no longer
\nable to make their own decisions (for example, if they are unconscious or
\ndemented). It is one form of advance care planning; another is choosing
\nsomeone to act as one\u2019s substitute decision-maker in such situations. Some
\ncountries have legislation on advance directives.
\nAdvocate \u2013 (verb) to speak out or take action on behalf of another person or
\ngroup; (noun) someone who acts in this way. Physicians serve as advocates
\nfor their patients when they call on governments or health insurance officials
\nto provide services that their patients need but cannot easily obtain on their
\nown.
\nAnaesthetist \u2013 in some countries the title, anaesthesiologist, is used
\ninstead.
\nBeneficence \u2013 literally, \u2018doing good\u2019. Physicians are expected to act in the
\nbest interests of their patients.
\nBioethics\/biomedical ethics \u2013 two equivalent terms for the study of moral
\nissues that occur in medicine, healthcare and the biological sciences. It has
\nfour major subdivisions: clinical ethics, which deals with issues in patient
\ncare (cf. Chapter Two of this Manual); research ethics, which deals with
\nthe protection of human subjects in healthcare research (cf. Chapter Five
\nof this Manual); professional ethics, which deals with the specific duties
\nand responsibilities that are required of physicians and other healthcare
\nprofessions (medical ethics is one type of professional ethics); and public
\npolicy ethics, which deals with the formulation and interpretation of laws
\nand regulations on bioethical issues.
\nConsensus \u2013 general, but not necessarily unanimous, agreement.
\nHierarchy \u2013 an orderly arrangement of people according to different levels
\nof importance from highest to lowest. Hierarchical is the adjective describing
\nMedicalEthicsManual\u2013AppendixA
\n122 123
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nRational \u2013 based on the human capacity for reasoning, i.e., to be able to
\nconsider the arguments for and against a particular action and to make a
\ndecision as to which alternative is better.
\nSurrogate or substitute gestation \u2013 a form of pregnancy in which a woman
\nagrees to gestate a child and give it up at birth to another individual or
\ncouple who in most cases have provided either the sperm (via artificial
\ninsemination) or the embryo (via in vitro fertilization and embryo transfer).
\nValue \u2013 (verb) to consider something to be very important; (noun) something
\nthat is considered to be very important.
\nVirtue \u2013 a good quality in people, especially in their character and behaviour.
\nSome virtues are particularly important for certain groups of people, for
\nexample, compassion for physicians, courage for fire-fighters, truthfulness
\nfor witnesses, etc.
\nWhistle-blower \u2013 someone who informs people in authority or the public that
\nan individual or an organization is doing something unethical or illegal. (The
\nexpression comes from the world of sport, where a referee or umpire blows
\na whistle to signal an infraction of the rules.)
\nAPPENDIX B \u2013 SELECTED MEDICAL ETHICS
\nRESOURCES ON THE INTERNET
\nWorld Medical Association Policy Handbook
\n(https:\/\/www.wma.net\/en\/30publications\/10policies\/) \u2013 contains the full text
\nof all WMA policies (in English, French and Spanish)
\nWorld Medical Association Ethics Resources
\n(https:\/\/www.wma.net\/en\/20activities\/10ethics\/index.html) \u2013 includes the
\nfollowing sections:
\n\u2022\t WMA courses
\n\u2022\t Medical ethics organizations, including their codes of ethics
\n\u2022\t Medical ethics education
\n\u2022\t Ethics and medical professionalism
\nUNESCO Bioethics Educational Resources
\n(http:\/\/www.unesco.org\/new\/en\/social-and-human-sciences\/themes\/
\nbioethics\/ethics-education-programme\/activities\/educational-resources\/)
\nNational Ethics Committees Database
\n(http:\/\/apps.who.int\/ethics\/nationalcommittees\/) \u2013 a collection of statements
\non ethical issues indexed by country and topic
\nU.S. National Institutes of Health Bioethics Resources on the Web
\n(http:\/\/bioethics.od.nih.gov\/)
\nKennedy Institute of Ethics, Georgetown University, Bioethics Research
\nLibrary (https:\/\/bioethics.georgetown.edu\/)
\nMedicalEthicsManual\u2013AppendixB
\n124 125
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nAPPENDIX C
\nWORLD MEDICAL ASSOCIATION
\nResolution on the Inclusion of Medical Ethics and Human Rights in
\nthe Curriculum of Medical Schools World-Wide
\n(Adopted by the 51st World Medical Assembly,
\nTel Aviv, Israel, October 1999)
\n1.\t Whereas Medical Ethics and Human Rights form an integral part of the
\nwork and culture of the medical profession, and
\n2.\t Whereas Medical Ethics and Human Rights form an integral part of the
\nhistory, structure and objectives of the World Medical Association,
\n3.\t It is hereby resolved that the WMA strongly recommend to Medical
\nSchools world-wide that the teaching of Medical Ethics and Human
\nRights be included as an obligatory course in their curricula.
\nWORLD FEDERATION FOR MEDICAL EDUCATION (WFME):
\nGlobal Standards for Quality Improvement \u2013 Basic Medical Education
\n(http:\/\/wfme.org\/standards\/bme\/78-new-version-2012-quality-
\nimprovement-in-basic-medical-education-english\/file\/) )
\nThese standards, which all medical schools are expected to meet, include
\nthe following references to medical ethics:
\n1.4\t Educational Outcomes
\n\t The medical school must define the intended educational outcomes
\nthat students should exhibit upon graduation…. Outcomes\u2026 would
\ninclude documented knowledge and understanding of\u2026 medical
\nethics, human rights and medical jurisprudence relevant to the practice
\nof medicine.
\n2.4\t Behavioural and Social Sciences and Medical Ethics
\n\t The medical school must in the curriculum identify and incorporate
\nthe contributions of the behavioural sciences, social sciences, medical
\nethics and medical jurisprudence\u2026. Medical ethics deals with moral
\nissues in medical practice such as values, rights and responsibilities
\nrelated to physician behavior and decision making\u2026. The identification
\nand incorporation of the behavioural and social sciences, medical
\nethics and medical jurisprudence would provide the knowledge,
\nconcepts, methods, skills and attitudes necessary for understanding
\nsocio-economic, demographic and cultural determinants of causes,
\ndistribution and consequences of health problems as well as knowledge
\nabout the national health care system and patients\u2019 rights. This would
\nenable analysis of health needs of the community and society, effective
\ncommunication, clinical decision making and ethical practices.
\n2.5\t Medical Research and Scholarship \u2013 Clinical Sciences and Skills
\n\t Clinical skills include history taking, physical examination,
\ncommunication skills, procedures and investigations, emergency
\npractices, and prescription and treatment practices. Professional skills
\nwould include patient management skills, team-work\/team leadership
\nskills and inter-professional training. Appropriate clinical responsibility
\nwould include activities related to health promotion, disease prevention
\nand patient care.
\n6.4\t Medical Research and Scholarship
\n\t The medical school should ensure that interaction between medical
\nresearch and education\u2026 encourages and prepares students to
\nengage in medical research and development.
\nMedicalEthicsManual\u2013AppendixC
\n126 127
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nAPPENDIX D \u2013 STRENGTHENING ETHICS
\nTEACHING IN MEDICAL SCHOOLS
\nSome medical schools have very little ethics teaching while others have
\nhighly developed programs. Even in the latter ones, however, there is always
\nroom for improvement. Here is a process that can be initiated by anyone,
\nwhether medical student or faculty member, who wants to strengthen the
\nteaching of medical ethics in his or her institution.
\n1. \t Become familiar with the decision-making structure in the institution
\n\u2022\t Dean
\n\u2022\t Curriculum Committee
\n\u2022\t Faculty Council
\n\u2022\t Influential faculty members
\n2. \t Seek support from others
\n\u2022\t Students
\n\u2022\t Faculty
\n\u2022\t Key administrators
\n\u2022\t National medical association
\n\u2022\t National physician regulatory body
\n3. \t Make a strong case
\n\u2022\tWMA Resolution on the Inclusion of Medical Ethics and Human
\nRights in the Curriculum of Medical Schools World-Wide
\n\u2022\tWFME Global Standards for Quality Improvement \u2013 Basic Medical
\nEducation
\n\u2022\t Examples from other medical schools
\n\u2022\t Research ethics requirements
\n\u2022\t Anticipate objections (e.g., overcrowded curriculum)
\n4. \t Offer to help
\n\u2022\t Provide suggestions for structure, content, faculty and student
\nresources (cf. WMA Ethics web page on medical ethics education
\nresources: www.wma.net\/en\/20activities\/10ethics\/40education\/
\nindex.html)
\n\u2022\t Liaise with other medical ethics programmes, the WMA, etc.
\n5.\t Ensure continuity
\n\u2022\t Advocate for a permanent medical ethics committee
\n\u2022\t Recruit younger students
\n\u2022\t Recruit additional faculty
\n\u2022\t Engage new faculty and key administrators
\nMedicalEthicsManual\u2013AppendixD
\n128 129
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nAPPENDIX E \u2013 ADDITIONAL CASE STUDIES
\nMedicalEthicsManual\u2013AppendixE
\nCONTRACEPTIVE ADVICE
\nTO A TEENAGER
\nSara is 15 years old. She lives in a town where
\nsexual assaults are becoming more and more
\nfrequent. She comes to your clinic asking for a
\nprescription for oral contraceptives to protect her
\nfrom pregnancy in case she is the victim of a sexual
\nassault. Pregnancy would terminate her education
\nand make it very difficult to find a husband. Sara
\ntells you that she does not want her parents to
\nknow that she will be using contraceptives because
\nthey will think that she intends to have sex with a
\nboyfriend. You are suspicious of Sara\u2019s motives but
\nyou admire her determination to avoid pregnancy.
\nYou advise her to come to the clinic with her
\nparents for a general discussion of the issue with
\nyou. Three days later she returns alone and tells
\nyou that she tried to speak to her parents about the
\nissue but they refused to discuss it.
\nNow what should you do?
\nA PREMATURE INFANT*
\nMax was born during the 23rd week of pregnancy.
\nHe is ventilated because his lungs are very
\nimmature. Moreover, he suffers from cerebral
\nbleeding because his vessel tissue is still unstable.
\nIt is unlikely that he will actually survive the next
\nfew weeks. If he does, he will probably be severely
\nhandicapped both mentally and physically.
\nMax\u2019s condition worsens when he develops
\na serious infection of the bowel. It might be
\npossible to extract the inflamed part of the bowel
\noperatively, which would preserve his small chance
\nof survival. His parents refuse to consent because
\nthey do not want Max to suffer from the operation
\nand they feel that his quality of life will never be
\nsufficient. As the treating physician you think that
\nthe operation should be done, and you wonder how
\nto deal with the parents\u2019refusal.
\n*
\n\t Suggested by Dr. Gerald Neitzke and Ms. Mareike Moeller, Medizinische
\nHochschule Hannover, Germany
\n130 131
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013AppendixE
\nHIV INFECTION*
\nMr. S is married and the father of two school
\nchildren. He is treated in your clinic for a rare form
\nof pneumonia that is often associated with AIDS.
\nHis blood test results show that he is indeed
\nHIV-positive. Mr. S says that he wants to decide
\nhimself if and when he will tell his wife about the
\ninfection. You indicate that it could be life-saving
\nfor his wife to protect herself from infection.
\nBesides, it would be important for her to have an
\nHIV test herself. In case of a positive test result she
\nwould then have the opportunity to take drugs to
\nslow down the outbreak of the disease and\u202fthereby
\nprolong her life. Six weeks later, Mr. S comes into
\nyour clinic for a control investigation. Answering
\nyour question he says that he hasn\u2019t informed his
\nwife yet. He doesn\u2019t want her to know about his
\nhomosexual contacts because he fears that she
\nwould end their relationship and the family would
\nshatter. But to protect her he has had only
\n\u201csafer sex\u201d with her. As the treating physician,
\nyou wonder whether you should inform Mrs. S
\nof the HIV status of her husband against his will
\nso that she would have the opportunity to start
\ntreatment if needed.
\nTREATING A PRISONER
\nAs part of your medical duties you spend one day every two
\nweeks seeing inmates in a nearby prison. Yesterday you
\ntreated a prisoner with multiple abrasions on his face and trunk.
\nWhen you asked what caused the injuries, the patient replied
\nthat he had been attacked by prison staff during interrogation
\nwhen he refused to answer their questions. Although this is the
\nfirst such case you have experienced, you have heard of similar
\ncases from your colleagues. You are convinced that you should
\ndo something about the problem but the patient refuses to
\nauthorize you to disclose information about himself for fear of
\nretaliation from the prison authorities. Furthermore, you are not
\ncertain that the prisoner has told you the truth; the guard who
\nbrought him to you said that he had been in a fight with another
\nprisoner. You have a good relationship with the prison staff and
\ndo not want to harm it by making unsubstantiated accusations
\nof mistreatment of prisoners. What should you do?
\n132 133
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthicsMedicalEthicsManual\u2013AppendixE
\nEND-OF-LIFE DECISION
\nAn 80-year old woman is admitted to your hospital from a
\nnursing home for treatment of pneumonia. She is frail and
\nmildly demented. You treat the pneumonia successfully but
\njust before she is to be discharged back to the nursing home,
\nshe suffers a stroke that leaves her paralysed on her right
\nside and unable to feed herself. A feeding tube is inserted that
\napparently causes her discomfort and after she has made
\nseveral attempts to pull it out with her left arm, a restraint is
\nplaced on the arm. She is otherwise unable to express her
\nwishes. A search for children or other relatives who could help
\nmake decisions about her treatment is unsuccessful. After
\nseveral days you conclude that her condition is unlikely to
\nimprove and that the only ways to relieve her suffering are to
\nsedate her or to withdraw the feeding tube and
\nallow her to die. What should you do?
\nCOLLECTIONS OF CASE STUDIES
\nUNESCO Chair in Bioethics collections of case studies \u2013
\nhttp:\/\/research.haifa.ac.il\/~medlaw\/ (UNESCO Chair)
\nWHO Casebook on Ethical Issues in International Health Research \u2013
\nhttp:\/\/whqlibdoc.who.int\/publications\/2009\/9789241547727_eng.pdf?ua=1
\nOther collections \u2013 http:\/\/bioethics.od.nih.gov\/casestudies.html#other
\n134 135
\nMedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics
\nNOTES
\nMedicalEthicsManual
\nSenior Woman
\nReceiving Medical Exam
\n\u00a9 Peter M. Fisher\/CORBIS
\n136
\nThe World Medical Association (WMA) is the global
\nrepresentative voice of physicians, regardless of their
\nspecialty, location, or practice setting. The WMA\u2019s
\nmission is to serve humanity by endeavouring to achieve the
\nhighest possible standards of medical care, ethics, science,
\neducation, and health-related human rights for all people.
\nThe World Medical Association
\nB.P. 63, 01212 Ferney-Voltaire Cedex, France
\nemail: wma@wma.net \u2022 fax: (+33) 450 40 59 37
\nwebsite: www.wma.net
\nISBN 978-92-990079-0-7<\/p>\n"},"caption":{"rendered":"

Ethics_manual_3rd_Nov2015_en 3rd edition 2015 2 1 MedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics WORLD MEDICAL ASSOCIATION World Medical Association MedicalEthicsManual Medical student holding a newborn \u00a9 Roger Ball\/CORBIS Medical Ethics Manual 3rd edition 2015 2 1 MedicalEthicsManual\u2013PrincipalFeaturesofMedicalEthics \u00a9 2015 by The World Medical Association, Inc. All rights reserved. Up to 10 copies of this document may be made for your non-commercial […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":902,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/Ethics_manual_3rd_Nov2015_en.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3704"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=3704"}]}}