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2 1
Ethics Manual
of Medical Ethics
WORLD MEDICAL ASSOCIATION
Medical
Medical Ethics Manual Principal Features
World Medical Association
Medical Ethics
Manual
of Contents
Ethics
2005 by The World Medical Association, Inc.
TABLE OF CONTENTS
of Medical
All rights reserved. Up to 10 copies of this document may be
Table
made for your non-commercial personal use, provided that Acknowledgments ...................................................................................4
Features
credit is given to the original source. You must have prior written
Ethics Manual
permission for any other reproduction, storage in a retrieval Foreword ........................................................................................................5
Principal
system or transmission, in any form or by any means. Requests Introduction..................................................................................................7
for permission should be directed to The World Medical
What is medical ethics?
Medical
Association, B.P. 63, 01212 Ferney-Voltaire Cedex, France;
Ethics
of Contents
Confidentiality Ethics review committee approval
of Medical
Beginning-of-life issues Scientific merit
Table
End-of-life issues Social value
Features
Back to the case study Risks and benefits
Ethics Manual
Informed consent
Principal
Chapter Three - Physicians and Society................................62 Confidentiality
Objectives Conflict of roles
Medical
Case study Honest reporting of results
Ethics
Foreword
ACKNOWLEDGMENTS FOREWORD
of Medical
Ethics Manual
Dr. Delon Human
The WMA Ethics Unit is profoundly grateful to the following Secretary General
Medical Features
individuals for providing extensive and thoughtful comments on World Medical Association
earlier drafts of this Manual:
Introduction
Ethics
foster individual ethical reflection as well as discussion within team
INTRODUCTION
of Medical
settings.
Manual
WHAT IS MEDICAL ETHICS?
As physicians, we know what a privilege it is to be involved in the
Features
patient-physician relationship, a unique relationship which facilitates Consider the following medical cases, which could have taken place
PrincipalEthics
an exchange of scientific knowledge and care within a framework of in almost any country:
Introduction
Ethics
the patients that obviously bother the assisting nurses. As a more physician should always ask for a patients consent to serve as a
of Medical
junior staff member, Dr. C is reluctant to criticize the surgeon research subject). Others are much more difficult, especially those
for which no consensus has developed or where all the alternatives
Manual
personally or to report him to higher authorities. However, he
Features
feels that he must do something to improve the situation. have drawbacks (for example, rationing of scarce healthcare
PrincipalEthics
resources).
4. Dr. R, a general practitioner in a small rural town, is approached
Introduction
Ethics
that, as we will see in Chapter Two, are fundamental to medical application of these principles in
of Medical
ethics. specific situations is often problematic, The study of ethics
since physicians, patients, their family prepares medical
Manual
As an academic discipline, medical ethics has developed its own
Features
members and other healthcare students to recognize
specialized vocabulary, including many terms that have been
personnel may disagree about what difficult situations and
PrincipalEthics
borrowed from philosophy. This Manual does not presuppose any to deal with them in a
is the right way to act in a situation.
Ethics is learned in the family, not in medical school. MEDICAL ETHICS, MEDICAL
PROFESSIONALISM, HUMAN RIGHTS AND LAW
Medical ethics is learned by observing how senior physicians act,
not from books or lectures. As will be seen in Chapter One, ethics has been an integral part
of medicine at least since the time of Hippocrates, the fifth century
Ethics is important, but our curriculum is already too crowded and
B.C.E. (before the Christian era) Greek physician who is regarded
there is no room for ethics teaching.
as a founder of medical ethics. From Hippocrates came the concept
These are some of the common reasons given for not assigning of medicine as a profession, whereby physicians make a public
ethics a major role in the medical school curriculum. Each of them promise that they will place the interests of their patients above their
is partially, but only partially, valid. Increasingly throughout the own interests (cf. Chapter Three for further explanation). The close
world medical schools are realising that they need to provide their relationship of ethics and professionalism will be evident throughout
students with adequate time and resources for learning ethics. They this Manual.
have received strong encouragement to move in this direction from
In recent times medical ethics has been greatly influenced by
organizations such as the World Medical Association and the World
developments in human rights. In a pluralistic and multicultural
Federation for Medical Education (cf. Appendix C).
world, with many different moral traditions, the major international
The importance of ethics in medical education will become apparent human rights agreements can provide a foundation for medical
throughout this Manual. To summarize, ethics is and always has ethics that is acceptable across national and cultural boundaries.
been an essential component of medical practice. Ethical principles Moreover, physicians frequently have to deal with medical problems
such as respect for persons, informed consent and confidentiality resulting from violations of human rights, such as forced migration
are basic to the physician-patient relationship. However, the and torture. And they are greatly affected by the debate over whether
12 13
Introduction
Ethics
healthcare is a human right, since the answer to this question in any
of Medical
particular country determines to a large extent who has access to
CONCLUSION
medical care. This Manual will give careful consideration to human
Manual
Medicine is both a science and an art.
Features
rights issues as they affect medical practice.
Science deals with what can be observed
PrincipalEthics
Medical ethics is also closely related to law. In most countries there and measured, and a competent physician
ThroughoutThisalmost
Manualall ofcan
recorded historyonly
provide and a
in basic
virtually every
part introduction to amedical
of the world, being ethics
physician has meantand some special.
something of
its central issues. It is intended to give you
People come to physicians for help with their most pressing needs
an appreciation of the need for continual
relief from pain and suffering and restoration of health and well-
reflection on the ethical dimension of
being. They allowand
medicine, physicians to see,on
especially touch
howandto
manipulate
deal with every
part ofthe
theirethical
bodies, issues
even the that
most intimate. They do
you will encounter this because
theyintrust their own
your physicians to act inA
practice. their best
list ofinterests.
resources is
provided in Appendix B to help you deepen
your knowledge of this field.
14 15
OBJECTIVES
After working through this chapter you should be able to:
explain why ethics is important to medicine
identify the major sources of medical ethics
recognize different approaches to ethical decision-making,
A Day in the Life of a French General Practitioner including your own.
Gilles Fonlupt/Corbis
16 17
I solemnly pledge myself to consecrate my life to the Besides its adherence to these three core values, medical ethics
service of humanity;
differs from the general ethics applicable to everyone by being
I will give to my teachers the respect and gratitude which publicly professed in an oath such as the World Medical Association
is their due; Declaration of Geneva and/or a code. Oaths and codes vary
I will practise my profession with conscience and dignity; from one country to another and even within countries, but they
The health of my patient will be my first consideration; have many common features, including promises that physicians
I will respect the secrets which are confided in me, even will consider the interests of their patients above their own, will
after the patient has died; not discriminate against patients on the basis of race, religion
or other human rights grounds, will protect the confidentiality of
I will maintain by all the means in my power, the honour and
the noble traditions of the medical profession; patient information and will provide emergency care to anyone in
need.
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, WHO DECIDES WHAT IS ETHICAL?
creed, ethnic origin, gender, nationality, political affiliation,
race, sexual orientation, or social standing to intervene Ethics is pluralistic. Individuals disagree among themselves about
between my duty and my patient; what is right and what is wrong, and even when they agree, it
I will maintain the utmost respect for human life from its can be for different reasons. In some societies, this disagreement
beginning even under threat and I will not use my medical is regarded as normal and there is a great deal of freedom to
knowledge contrary to the laws of humanity; act however one wants, as long as it does not violate the rights
I make these promises solemnly, freely and upon my of others. In more traditional societies, however, there is greater
honour. agreement on ethics and greater social pressure, sometimes backed
by laws, to act in certain ways rather than others. In such societies
20 21
Ethics
and Patients
CHAPTER TWO
of Medical
PHYSICIANS AND PATIENTS
Medical
Medical Ethics Ethics
Manual Physicians
Manual Features
Principal
OBJECTIVES
After working through this chapter you should be able to:
explain why all patients are deserving of respect and equal
treatment;
identify the essential elements of informed consent;
explain how medical decisions should be made for patients
who are incapable of making their own decisions;
explain the justification for patient confidentiality and
recognise legitimate exceptions to confidentiality;
recognize the principal ethical issues that occur at the
beginning and end of life;
summarize the arguments for and against the practice of
euthanasia/assisted suicide and the difference between
these actions and palliative care or forgoing treatment.
Compassionate doctor
Jose Luis Pelaez, Inc./CORBIS
36 37
Ethics
and Patients
Equally problematic are other aspects of the relationship, such as
of Medical
CASE STUDY #1 the physicians obligation to maintain patient confidentiality in an era
Physicians
Dr. P, an experienced and skilled surgeon, of computerized medical records and managed care, and the duty to
Manual Features
is about to finish night duty at a medium- preserve life in the face of requests to hasten death.
sized community hospital. A young woman is
brought to the hospital by her mother, who This section will deal with six topics that pose particularly vexing
Principal
leaves immediately after telling the intake problems to physicians in their daily practice: respect and
nurse that she has to look after her other equal treatment; communication
Ethics
children. The patient is bleeding vaginally
Manual
and consent; decision-making for The health of my
and is in a great deal of pain. Dr. P examines
Medical
incompetent patients; confidentiality; patient will be my first
her and decides that she has had either a
Medical Ethics
miscarriage or a self-induced abortion. He beginning-of-life issues; and end-of- consideration
does a quick dilatation and curettage and tells life issues.
the nurse to ask the patient whether she can
afford to stay in the hospital until it is safe
RESPECT AND EQUAL TREATMENT
for her to be discharged. Dr. Q comes in to
replace Dr. P, who goes home without having The belief that all human beings deserve respect and equal treatment
spoken to the patient. is relatively recent. In most societies disrespectful and unequal
treatment of individuals and groups was accepted as normal and
natural. Slavery was one such practice that was not eradicated
in the European colonies and the USA until the 19th century and
WHATS SPECIAL ABOUT THE PHYSICIAN-
still exists in some parts of the world. The end of institutional
PATIENT RELATIONSHIP?
discrimination against non-whites in countries such as South Africa
The physician-patient relationship is the cornerstone of medical is much more recent. Women still experience lack of respect and
practice and therefore of medical ethics. As noted above, the unequal treatment in most countries. Discrimination on the basis
Declaration of Geneva requires of the physician that The health of age, disability or sexual orientation is widespread. Clearly, there
of my patient will be my first consideration, and the International remains considerable resistance to the claim that all people should
Code of Medical Ethics states, A physician shall owe his patients be treated as equals.
complete loyalty and all the resources of his science. As discussed
in Chapter One, the traditional interpretation of the physician-patient The gradual and still ongoing conversion of humanity to a belief
relationship as a paternalistic one, in which the physician made in human equality began in the 17th and 18th centuries in Europe
the decisions and the patient submitted to them, has been widely and North America. It was led by two opposed ideologies: a new
rejected in recent years, both in ethics and in law. Since many interpretation of Christian faith and an anti-Christian rationalism.
patients are either unable or unwilling to make decisions about their The former inspired the American Revolution and Bill of Rights;
medical care, however, patient autonomy is often very problematic. the latter, the French Revolution and related political developments.
38 39
Ethics
and Patients
Under these two influences, democracy very gradually took hold towards and treatment of patients. The case study described at
of Medical
and began to spread throughout the world. It was based on a belief the beginning of this chapter illustrates this problem. As noted in
Physicians
in the political equality of all men (and, much later, women) and the Chapter One, compassion is one of the core values of medicine
Manual Features
consequent right to have a say in who should govern them. and is an essential element of a good therapeutic relationship.
Compassion is based on respect for the patients dignity and values
In the 20th century there was considerable elaboration of the concept
Principal
but goes further in acknowledging and responding to the patients
of human equality in terms of human rights. One of the first acts of
vulnerability in the face of illness and/or disability. If patients sense
Ethics
the newly established United Nations was to develop the Universal
the physicians compassion, they will be more likely to trust the
Manual
Declaration of Human Rights (1948), which states in article 1, All
Medical
physician to act in their best interests, and this trust can contribute
human beings are born free and equal in dignity and rights. Many
Medical Ethics
to the healing process.
other international and national bodies have produced statements of
rights, either for all human beings, for all citizens in a specific country, The trust that is essential to the physician-patient relationship has
or for certain groups of individuals (childrens rights, patients generally been interpreted to mean that
rights, consumers rights, etc.). Numerous organizations have physicians should not desert patients
in ending a
been formed to promote action on these statements. Unfortunately, whose care they have undertaken. physician-patient
though, human rights are still not respected in many countries. The WMAs International Code of relationship
Medical Ethics implies that the only physicians
The medical profession has had somewhat conflicting views should be prepared to
reason for ending a physician-patient
on patient equality and rights over the years. On the one hand, justify their decision,
relationship is if the patient requires
physicians have been told not to permit considerations of age, to themselves, to the
another physician with different patient and to a third
disease or disability, creed, ethnic origin, gender, nationality, political
skills: A physician shall owe his party if appropriate.
affiliation, race, sexual orientation, or social standing to intervene
patients complete loyalty and all the
between my duty and my patient (Declaration of Geneva). At the
resources of his science. Whenever
same time physicians have claimed the right to refuse to accept a
an examination or treatment is beyond the physicians capacity he
patient, except in an emergency. Although the legitimate grounds for
should summon another physician who has the necessary ability.
such refusal include a full practice, (lack of) educational qualifications
However, there are many other reasons for a physician wanting to
and specialization, if physicians do not have to give any reason for
terminate a relationship with a patient, for example, the physicians
refusing a patient, they can easily practise discrimination without
moving or stopping practice, the patients refusal or inability to pay
being held accountable. A physicians conscience, rather than the
for the physicians services, dislike of the patient and the physician
law or disciplinary authorities, may be the only means of preventing
for each other, the patients refusal to comply with the physicians
abuses of human rights in this regard.
recommendations, etc. The reasons may be entirely legitimate, or
Even if physicians do not offend against respect and human equality they may be unethical. When considering such an action, physicians
in their choice of patients, they can still do so in their attitudes should consult their Code of Ethics and other relevant guidance
40 41
Ethics
and Patients
documents and carefully examine their motives. They should be on the Professional Responsibility of Physicians in Treating
of Medical
prepared to justify their decision, to themselves, to the patient and to AIDS Patients puts it this way:
Physicians
a third party if appropriate. If the motive is legitimate, the physician
AIDS patients are entitled to
Manual Features
should help the patient find another suitable physician or, if this is
competent medical care with A person who
not possible, should give the patient adequate notice of withdrawal
compassion and respect for human is afflicted with AIDS
Principal
of services so that the patient can find alternative medical care. If the
dignity. needs competent,
motive is not legitimate, for example, racial prejudice, the physician
compassionate
Ethics
A physician may not ethically refuse
should take steps to deal with this defect. treatment.
Manual
to treat a patient whose condition is
Medical
Many physicians, especially those in the public sector, often have no within the physicians current realm
Medical Ethics
choice of the patients they treat. Some patients are violent and pose of competence, solely because the
a threat to the physicians safety. Others can only be described as patient is seropositive.
obnoxious because of their antisocial attitudes and behaviour. Have Medical ethics do not permit categorical discrimination
such patients forsaken their right to respect and equal treatment, or against a patient based solely on his or her seropositivity.
are physicians expected to make extra, perhaps even heroic, efforts A person who is afflicted with AIDS needs competent,
to establish and maintain therapeutic relationships with them? With compassionate treatment. A physician who is not able
such patients, physicians must balance their responsibility for their to provide the care and services required by persons
own safety and well-being and that of their staff with their duty to with AIDS should make an appropriate referral to those
promote the well-being of the patients. They should attempt to find physicians or facilities that are equipped to provide
ways to honour both of these obligations. If this is not possible, such services. Until the referral can be accomplished, the
they should try to make alternative arrangements for the care of physician must care for the patient to the best of his or her
the patients. ability.
Another challenge to the principle of respect and equal treatment for The intimate nature of the physician-patient relationship can
all patients arises in the care of infectious patients. The focus here is give rise to sexual attraction. A fundamental rule of traditional
often on HIV/AIDS, not only because it is a life-threatening disease medical ethics is that such attraction must be resisted. The Oath
but also because it is often associated with social prejudices. of Hippocrates includes the following promise: Whatever houses
However, there are many other serious infections including some I may visit, I will come for the benefit of the sick, remaining free
that are more easily transmissible to healthcare workers than HIV/ of all intentional injustice, of all mischief and in particular of sexual
AIDS. Some physicians hesitate to perform invasive procedures on relations with both female and male persons. In recent years
patients with such conditions because of the possibility that they, many medical association have restated this prohibition of sexual
the physicians, might become infected. However, medical codes of relations between physicians and their patients. The reasons for
ethics make no exception for infectious patients with regard to the this are as valid today as they were in Hippocrates time, 2500 years
physicians duty to treat all patients equally. The WMAs Statement ago. Patients are vulnerable and put their trust in physicians to
42 43
Ethics
and Patients
treat them well. They may feel unable to resist sexual advances of physicians orders to the patient to comply with such and such a
of Medical
physicians for fear that their treatment will be jeopardized. Moreover, treatment. Nowadays communication requires much more of
Physicians
the clinical judgment of a physician can be adversely affected by physicians. They must provide patients with all the information they
Manual Features
emotional involvement with a patient. need to make their decisions. This involves explaining complex
medical diagnoses, prognoses and treatment regimes in simple
This latter reason applies as well to physicians treating their family
Principal
language, ensuring that patients understand the treatment options,
members, which is strongly discouraged in many medical codes of
including the advantages and disadvantages of each, answering
ethics. However, as with some other statements in codes of ethics,
Ethics
any questions they may have, and understanding whatever decision
Manual
its application can vary according to circumstances. For example,
the patient has reached and, if possible, the reasons for it. Good
Medical
solo practitioners working in remote areas may have to provide
communication skills do not come naturally to most people; they
Medical Ethics
medical care for their family members, especially in emergency
must be developed and maintained with conscious effort and
situations.
periodic review.
COMMUNICATION AND CONSENT Two major obstacles to good physician-patient communication are
differences of language and culture. If the physician and the patient
Informed consent is one of the central concepts of present-day do not speak the same language, an interpreter will be required.
medical ethics. The right of patients to make decisions about their Unfortunately, in many settings there are no qualified interpreters
healthcare has been enshrined in legal and ethical statements and the physician must seek out the best available person for the
throughout the world. The WMA Declaration on the Rights of the task. Culture, which includes but is much broader than language,
Patient states: raises additional communication issues. Because of different
cultural understandings of the nature and causes of illness, patients
The patient has the right to self-determination, to make free may not understand the diagnosis and treatment options provided
decisions regarding himself/herself. The physician will inform by their physician. In such circumstances physicians should make
the patient of the consequences of his/her decisions. A mentally every reasonable effort to probe their patients understanding of
competent adult patient has the right to give or withhold consent health and healing and communicate their recommendations to the
to any diagnostic procedure or therapy. The patient has the patients as best they can.
right to the information necessary to make his/her decisions.
The patient should understand clearly what is the purpose of If the physician has successfully communicated to the patient all the
any test or treatment, what the results would imply, and what information the patient needs and wants to know about his or her
would be the implications of withholding consent. diagnosis, prognosis and treatment options, the patient will then be
in a position to make an informed decision about how to proceed.
A necessary condition for informed consent is good communication Although the term consent implies acceptance of treatment, the
between physician and patient. When medical paternalism was concept of informed consent applies equally to refusal of treatment
normal, communication was relatively simple; it consisted of the or to choice among alternative treatments. Competent patients have
44 45
Ethics
and Patients
the right to refuse treatment, even diagnosis indicates a terminal illness. This privilege is open
of Medical
Competent patients when the refusal will result in disability to great abuse, and physicians should make use of it only in
have the right to refuse
Physicians
or death. extreme circumstances. They should start with the expectation
treatment, even when
Manual Features
that all patients are able to cope with the facts and reserve
the refusal will result in Evidence of consent can be explicit
disability or death. nondisclosure for cases in which they are convinced that more
or implicit (implied). Explicit consent
Principal
harm will result from telling the truth than from not telling it.
is given orally or in writing. Consent
is implied when the patient indicates In some cultures, it is widely held that the physicians obligation to
Ethics
Manual
a willingness to undergo a certain procedure or treatment by his or provide information to the patient does not apply when the diagnosis
Medical
her behaviour. For example, consent for venipuncture is implied by is a terminal illness. It is felt that such information would cause the
Medical Ethics
the action of presenting ones arm. For treatments that entail risk or patient to despair and would make the remaining days of life much
involve more than mild discomfort, it is preferable to obtain explicit more miserable than if there were hope of recovery. Throughout
rather than implied consent. the world it is not uncommon for family members of patients to
plead with physicians not to tell the patients that they are dying.
There are two exceptions to the requirement for informed consent
Physicians do have to be sensitive to cultural as well as personal
by competent patients:
factors when communicating bad news, especially of impending
Situations where patients voluntarily give over their decision- death. Nevertheless, the patients right to informed consent is
making authority to the physician or to a third party. Because of becoming more and more widely accepted, and the physician has a
the complexity of the matter or because the patient has complete primary duty to help patients exercise this right.
confidence in the physicians judgement, the patient may tell the
In keeping with the growing trend towards considering healthcare
physician, Do what you think is best. Physicians should not be
as a consumer product and patients as consumers, patients and
eager to act on such requests but should provide patients with
their families not infrequently demand access to medical services
basic information about the treatment options and encourage
that, in the considered opinion of physicians, are not appropriate.
them to make their own decisions. However, if after such
Examples of such services range from antibiotics for viral conditions
encouragement the patient still wants the physician to decide,
to intensive care for brain-dead patients to promising but unproven
the physician should do so according to the best interests of the
drugs or surgical procedures. Some patients claim a right to
patient.
any medical service that they feel can benefit them, and often
Instances where the disclosure of information would cause harm physicians are only too willing to oblige, even when they are
to the patient. The traditional concept of therapeutic privilege is convinced that the service can offer no medical benefit for
invoked in such cases; it allows physicians to withhold medical the patients condition. This problem is especially serious in
information if disclosure would be likely to result in serious situations where resources are limited and providing futile or
physical, psychological or emotional harm to the patient, for nonbeneficial treatments to some patients means that other
example, if the patient would be likely to commit suicide if the patients are left untreated.
46 47
Ethics
and Patients
Futile and nonbeneficial can be understood as follows. In some DECISION-MAKING FOR
of Medical
situations a physician can determine that a treatment is medically INCOMPETENT PATIENTS
Physicians
futile or nonbeneficial because it offers no reasonable hope of Many patients are not competent to make decisions for themselves.
Manual Features
recovery or improvement or because the patient is permanently
Examples include young children, individuals affected by certain
unable to experience any benefit. In other cases the utility and
psychiatric or neurological conditions, and those who are temporarily
Principal
benefit of a treatment can only be determined with reference to the
unconscious or comatose. These patients require substitute decision-
patients subjective judgement about his or her overall well-being.
Ethics
makers, either the physician or another person. Ethical issues arise
As a general rule a patient should be
Manual
in the determination of the appropriate substitute decision-maker
Medical
involved in determining futility in his or
The physician has and in the choice of criteria for decisions on behalf of incompetent
Medical Ethics
her case. In exceptional circumstances no obligation to offer
patients.
such discussions may not be in the a patient futile or
patients best interests. The physician nonbeneficial When medical paternalism prevailed, the physician was considered
has no obligation to offer a patient treatment. to be the appropriate decision-maker for incompetent patients.
futile or nonbeneficial treatment. Physicians might consult with family members about treatment
options, but the final decisions were theirs to make. Physicians have
The principle of informed consent incorporates the patients right been gradually losing this authority in many countries as patients
to choose from among the options presented by the physician.
are given the opportunity to name their own substitute decision-
To what extent patients and their families have a right to services
makers to act for them when they become incompetent. In addition,
not recommended by physicians is becoming a major topic of
some states specify the appropriate substitute decision-makers in
controversy in ethics, law and public policy. Until this matter is
descending order (e.g., husband or wife, adult children, brothers
decided by governments, medical insurance providers and/or
and sisters, etc.). In such cases physicians make decisions for
professional organisations, individual physicians will have to
patients only when the designated substitute cannot be found, as
decide for themselves whether they should accede to requests
often happens in emergency situations. The WMA Declaration on
for inappropriate treatments. They should refuse such requests if
the Rights of the Patient states the physicians duty in this matter
they are convinced that the treatment would produce more harm
as follows:
than benefit. They should also feel free to refuse if the treatment
is unlikely to be beneficial, even if it If the patient is unconscious or otherwise unable to express
Do patients have a is not harmful, although the possibility his/her will, informed consent must be obtained, whenever
right to services not of a placebo effect should not be possible, from a legally entitled representative where legally
recommended by discounted. If limited resources are relevant. If a legally entitled representative is not available,
physicians? an issue, they should bring this to the but a medical intervention is urgently needed, consent
attention of whoever is responsible for of the patient may be presumed, unless it is obvious and
allocating resources. beyond any doubt on the basis of the patients previous firm
48 49
Ethics
and Patients
expression or conviction that he/she would refuse consent to been communicated to the designated substitute decision-maker,
of Medical
the intervention in that situation. the physician or other members of the healthcare team. When
Physicians
an incompetent patients preferences are not known, treatment
Manual Features
Problems arise when those claiming to be the appropriate substitute decisions should be based on the patients best interests, taking into
decision-makers, for example different family members, do not account: (a) the patients diagnosis and prognosis; (b) the patients
agree among themselves or when they do agree, their decision
Principal
known values; (c) information received from those who are significant
is, in the physicians opinion, not in the patients best interests. In in the patients life and who could help in determining his or her best
Ethics
the first instance the physician can serve a mediating function, but interests; and (d) aspects of the patients culture and religion that
Manual
if the disagreement persists, it can be resolved in other ways, for would influence a treatment decision. This approach is less certain
Medical
example, by letting the senior member of the family decide or by than if the patient has left specific instructions about treatment,
Medical Ethics
voting. In cases of serious disagreement between the substitute but it does enable the substitute decision-maker to infer, in
decision-maker and the physician, the Declaration on the Rights light of other choices the patient has made and his or her approach
of the Patient offers the following advice: If the patients legally to life in general, what he or she would decide in the present
entitled representative, or a person authorized by the patient, forbids situation.
treatment which is, in the opinion of the physician, in the patients
best interest, the physician should challenge this decision in the Competence to make medical decisions can be difficult to assess,
relevant legal or other institution. especially in young people and those whose capacity for reasoning
has been impaired by acute or chronic illness. A person may be
The principles and procedures for informed consent that were competent to make decisions regarding some aspects of life but
discussed in the previous section are just as applicable to substitute not others; as well, competence can be intermittent -- a person
decision-making as to patients making their own decisions. may be lucid and oriented at certain times of the day and not at
Physicians have the same duty to provide all the information the others. Although such patients may not be legally competent,
their preferences should be taken into account when decisions
substitute decision-makers need to make their decisions. This
are being made for them. The Declaration on the Rights of the
involves explaining complex medical diagnoses, prognoses and
Patient states the matter thus: If a
treatment regimes in simple language, ensuring that the decision-
patient is a minor or otherwise legally
makers understand the treatment options, including the advantages
incompetent, the consent of a legally ...the patient must
and disadvantages of each, answering any questions they may
entitled representative, where legally be involved in the
have, and understanding whatever decision they reach and, if decision-making to
relevant, is required. Nevertheless
possible, the reasons for it. the fullest extent
the patient must be involved in the
allowed by his/her
decision-making to the fullest extent capacity
The principal criteria to be used for treatment decisions for an
allowed by his/her capacity.
incompetent patient are his or her preferences, if these are known.
The preferences may be found in an advance directive or may have
50 51
Ethics
and Patients
Not infrequently, patients are unable to make a reasoned, well of the treatment or even outside of the
of Medical
thought-out decision regarding different treatment options due to the A physician shall treatment in regard to the life of men,
preserve absolute
Physicians
discomfort and distraction caused by their disease. However, they which on no account one must spread
confidentiality on all
Manual Features
may still be able to indicate their rejection of a specific intervention, abroad, I will keep to myself holding
he knows about his
an intravenous feeding tube, for example. In such cases, these patient even after such things shameful to be spoken
Principal
expressions of dissent should be taken very seriously, although they the patient has about. The Oath, and some more
need to be considered in light of the overall goals of their treatment died. recent versions, allow no exception
Ethics
plan. to this duty of confidentiality. For
Manual
example, the WMAs International
Medical
Patients suffering from psychiatric or neurological disorders who Code of Medical Ethics requires that A physician shall preserve
Medical Ethics
are judged to pose a danger to themselves or to others raise absolute confidentiality on all he knows about his patient even after
particularly difficult ethical issues. It is important to honour their the patient has died. However, other codes reject this absolutist
human rights, especially the right to freedom, to the greatest extent approach to confidentiality. The possibility that breaches of
possible. Nevertheless, they may have to be confined and/or treated confidentiality are sometimes justified calls for clarification of the
against their will in order to prevent harm to themselves or others. very idea of confidentiality.
A distinction can be made between involuntary confinement and
involuntary treatment. Some patient advocates defend the right The high value that is placed on confidentiality has three sources:
of these individuals to refuse treatment even if they have to be autonomy, respect for others and trust. Autonomy relates to
confined as a result. A legitimate reason for refusing treatment could confidentiality in that personal information about an individual
be painful experience with treatments in the past, for example, the belongs to him or her and should not be made known to others
severe side effects of psychotropic medications. When serving as without his or her consent. When an individual reveals personal
substitute decision-makers for such patients, physicians should information to another, a physician or nurse for example, or when
ensure that the patients really do pose a danger, and not just an information comes to light through a medical test, those in the know
annoyance, to others or to themselves. They should try to ascertain are bound to keep it confidential unless authorized to divulge it by
the patients preferences regarding treatment, and the reasons for the individual concerned.
these preferences, even if in the end the preferences cannot be Confidentiality is also important because human beings deserve
fulfilled. respect. One important way of showing them respect is by
preserving their privacy. In the medical setting, privacy is often
greatly compromised, but this is all the more reason to prevent
CONFIDENTIALITY
further unnecessary intrusions into a persons private life. Since
The physicians duty to keep patient information confidential has individuals differ regarding their desire for privacy, we cannot
been a cornerstone of medical ethics since the time of Hippocrates. assume that everyone wants to be treated as we would want to
The Hippocratic Oath states: What I may see or hear in the course be. Care must be taken to determine which personal information a
52 53
Ethics
and Patients
patient wants to keep secret and which he or she is willing to have As this WMA Declaration states, there are exceptions to the
of Medical
revealed to others. requirement to maintain confidentiality. Some of these are relatively
Physicians
non-problematic; others raise very difficult ethical issues for
Trust is an essential part of the physician-patient relationship. In
Manual Features
physicians.
order to receive medical care, patients have to reveal personal
information to physicians and others who may be total strangers Routine breaches of confidentiality occur frequently in most
Principal
to them---information that they would not want anyone else to healthcare institutions. Many individuals physicians, nurses,
laboratory technicians, students, etc. require access to a patients
Ethics
know. They must have good reason to trust their caregivers not to
Manual
divulge this information. The basis of this trust is the ethical and health records in order to provide adequate care to that person and,
Medical
legal standards of confidentiality that healthcare professionals are for students, to learn how to practise medicine. Where patients
Medical Ethics
expected to uphold. Without an understanding that their disclosures speak a different language than their caregivers, there is a need
will be kept secret, patients may withhold personal information. This for interpreters to facilitate communication. In cases of patients
can hinder physicians in their efforts to provide effective interventions who are not competent to make their own medical decisions, other
or to attain certain public health goals. individuals have to be given information about them in order to make
decisions on their behalf and to care for them. Physicians routinely
The WMA Declaration on the Rights of the Patient summarises
inform the family members of a deceased person about the cause
the patients right to confidentiality as follows:
of death. These breaches of confidentiality are usually justified,
All identifiable information about a patient's health status, but they should be kept to a minimum and those who gain access
medical condition, diagnosis, prognosis and treatment to confidential information should be made aware of the need not
and all other information of a personal kind, must be kept to spread it any further than is necessary for the patients benefit.
confidential, even after death. Exceptionally, the patients Where possible, patients should be informed that such breaches
relatives may have a right of access to information that occur.
would inform them of their health risks. Another generally accepted reason
Confidential information can only be disclosed if the patient for breaching confidentiality is to ...physicians should
comply with legal requirements. For view with a critical
gives explicit consent or if expressly provided for in the law. eye any legal
Information can be disclosed to other healthcare providers example, many jurisdictions have
requirement to breach
laws for the mandatory reporting of confidentiality and
only on a strictly "need to know" basis unless the patient
patients who suffer from designated assure themselves
has given explicit consent.
diseases, those deemed not fit to that it is justified
All identifiable patient data must be protected. The drive and those suspected of child before adhering to it.
protection of the data must be appropriate to the manner of abuse. Physicians should be aware of
its storage. Human substances from which identifiable data the legal requirements for the disclosure
can be derived must be likewise protected. of patient information where they work. However, legal requirements
54 55
Ethics
and Patients
can conflict with the respect for human rights that underlies medical likelihood of their occurrence. In cases of doubt, it would be wise for
of Medical
ethics. Therefore, physicians should view with a critical eye any the physician to seek expert advice.
Physicians
legal requirement to breach confidentiality and assure themselves
When a physician has determined that the duty to warn justifies an
Manual Features
that it is justified before adhering to it.
unauthorised disclosure, two further decisions must be made. Whom
If physicians are persuaded to comply with legal requirements to should the physician tell? How much should be told? Generally
Principal
disclose their patients medical information, it is desirable that they speaking, the disclosure should contain only that information
Ethics
discuss with the patients the necessity of any disclosure before it necessary to prevent the anticipated harm and should be directed
Manual
occurs and enlist their co-operation. For example, it is preferable only to those who need the information in order to prevent the harm.
Medical
that a patient suspected of child abuse call the child protection Reasonable steps should be taken to minimize the harm and offence
Medical Ethics
authorities in the physicians presence to self-report, or that the to the patient that may arise from the disclosure. It is recommended
physician obtain his or her consent before the authorities are notified. that the physician should inform the patient that confidentiality might
This approach will prepare the way for subsequent interventions. If be breached for his or her own protection and that of any potential
such co-operation is not forthcoming and the physician has reason victim. The patients co-operation should be enlisted if possible.
to believe any delay in notification may put a child at risk of serious
In the case of an HIV-positive patient, disclosure to a spouse or
harm, then the physician ought to immediately notify child protection
current sexual partner may not be unethical and, indeed, may be
authorities and subsequently inform the patient that this has been
justified when the patient is unwilling to inform the person(s) at risk.
done.
Such disclosure requires that all of the following conditions are
In addition to those breaches of confidentiality that are required met: the partner is at risk of infection with HIV and has no other
by law, physicians may have an ethical duty to impart confidential reasonable means of knowing the risk; the patient has refused to
information to others who could be at risk of harm from the patient. inform his or her sexual partner; the patient has refused an offer of
Two situations in which this can occur are when a patient tells a assistance by the physician to do so on the patients behalf; and the
psychiatrist that he intends to harm another person and when physician has informed the patient of his or her intention to disclose
a physician is convinced that an HIV-positive patient is going to the information to the partner.
continue to have unprotected sexual intercourse with his spouse or
The medical care of suspected and convicted criminals poses
other partners.
particular difficulties with regard to confidentiality. Although
Conditions for breaching confidentiality when not required by law physicians providing care to those in custody have limited
are that the expected harm is believed to be imminent, serious (and independence, they should do their best to treat these patients as
irreversible), unavoidable except by unauthorised disclosure, and they would any others. In particular, they should safeguard
greater than the harm likely to result from disclosure. In determining confidentiality by not revealing details of the patients medical
the proportionality of these respective harms, the physician needs condition to prison authorities without first obtaining the patients
to assess and compare the seriousness of the harms and the consent.
56 57
Ethics
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BEGINNING-OF-LIFE ISSUES ABORTION this has long been one of the most divisive
of Medical
issues in medical ethics, both for physicians and for
Many of the most prominent issues in medical ethics relate to the
Physicians
public authorities. The WMA Statement on Therapeutic
beginning of human life. The limited scope of this Manual means
Manual Features
Abortion acknowledges this diversity of opinion and belief
that these issues cannot be treated in detail here but it is worth
and concludes that This is a matter of individual conviction
listing them so that they can be recognized as ethical in nature and
Principal
and conscience which must be respected.
dealt with as such. Each of them has been the subject of extensive
Ethics
analysis by medical associations, ethicists and government advisory SEVERELY COMPROMISED NEONATES because of
Manual
bodies, and in many countries there are laws, regulations and extreme prematurity or congenital abnormalities, some
Medical
policies dealing with them. neonates have a very poor prognosis for survival. Difficult
Medical Ethics
decisions often have to be made whether to attempt to
CONTRACEPTION although there is increasing prolong their lives or allow them to die.
international recognition of a womans right to control her
RESEARCH ISSUES these include the production of new
fertility, including the prevention of unwanted pregnancies,
embryos or the use of spare embryos (those not wanted
physicians still have to deal with difficult issues such as
for reproductive purposes) to obtain stem cells for potential
requests for contraceptives from minors and explaining the
therapeutic applications, testing of new techniques for
risks of different methods of contraception.
assisted reproduction, and experimentation on foetuses.
ASSISTED REPRODUCTION for couples (and
individuals) who cannot conceive naturally there are various
END-OF-LIFE ISSUES
techniques of assisted reproduction, such as artificial
insemination and in-vitro fertilization and embryo transfer, End-of-life issues range from attempts to prolong the lives of dying
widely available in major medical centres. Surrogate or patients through highly experimental technologies, such as the
substitute gestation is another alternative. None of these implantation of animal organs, to efforts to terminate life prematurely
techniques is unproblematic, either in individual cases or through euthanasia and medically assisted suicide. In between these
for public policies. extremes lie numerous issues regarding the initiation or withdrawing
of potentially life-extending treatments, the care of terminally ill
PRENATAL GENETIC SCREENING genetic tests are patients and the advisability and use of advance directives.
now available for determining whether an embryo or foetus
Two issues deserve particular attention: euthanasia and assistance
is affected by certain genetic abnormalities and whether it
in suicide.
is male or female. Depending on the findings, a decision
can be made whether or not to proceed with pregnancy. EUTHANASIA means knowingly and intentionally performing
Physicians need to determine when to offer such tests and an act that is clearly intended to end another persons life and
how to explain the results to patients. that includes the following elements: the subject is a competent,
58 59
Ethics
and Patients
informed person with an incurable illness who has voluntarily of ethics. This prohibition was part of the Hippocratic Oath and
of Medical
asked for his or her life to be ended; the agent knows about has been emphatically restated by the WMA in its Declaration on
Physicians
the persons condition and desire to die, and commits the act Euthanasia:
Manual Features
with the primary intention of ending the life of that person; and
Euthanasia, that is the act of deliberately ending the life of a
the act is undertaken with compassion and without personal
patient, even at the patients own request or at the request of
Principal
gain.
close relatives, is unethical. This does not prevent the physician
Ethics
ASSISTANCE IN SUICIDE means knowingly and intentionally from respecting the desire of a patient to allow the natural
Manual
providing a person with the knowledge or means or both process of death to follow its course in the terminal phase
Medical
required to commit suicide, including counselling about lethal of sickness.
Medical Ethics
doses of drugs, prescribing such lethal doses or supplying the
The rejection of euthanasia and assisted suicide does not mean
drugs.
that physicians can do nothing for the patient with a life-threatening
Euthanasia and assisted suicide are often regarded as morally illness that is at an advanced stage and for which curative measures
equivalent, although there is a clear practical distinction, and in are not appropriate. In recent years there have been great advances
some jurisdictions a legal distinction, between them. in palliative care treatments for relieving pain and suffering and
improving quality of life. Palliative care can be appropriate for
Euthanasia and assisted suicide, according to these definitions,
patients of all ages, from a child with cancer to a senior nearing the
are to be distinguished from the withholding or withdrawal of
end of life. One aspect of palliative care that needs greater attention
inappropriate, futile or unwanted medical treatment or the provision
for all patients is pain control. All physicians who care for dying
of compassionate palliative care, even when these practices shorten
patients should ensure that they have
life.
adequate skills in this domain, as well
...physicians should
Requests for euthanasia or assistance in suicide arise as a result of as, where available, access to skilled
not abandon dying
pain or suffering that is considered by the patient to be intolerable. consultative help from palliative care patients but should
They would rather die than continue to live in such circumstances. specialists. Above all, physicians continue to provide
Furthermore, many patients consider that they have a right to die if should not abandon dying patients compassionate care
they so choose, and even a right to assistance in dying. Physicians but should continue to provide even when cure is no
compassionate care even when cure longer possible.
are regarded as the most appropriate instruments of death since
they have the medical knowledge and access to the appropriate is no longer possible.
drugs for ensuring a quick and painless death.
The approach of death presents many other ethical challenges
Physicians are understandably reluctant to implement requests for patients, substitute decision-makers and physicians. The
for euthanasia or assistance in suicide because these acts are possibility of prolonging life through recourse to drugs, resuscitative
illegal in most countries and are prohibited in most medical codes interventions, radiological procedures and intensive care requires
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Ethics
and Patients
decisions about when to initiate these treatments and when to
of Medical
withdraw them if they are not working. BACK TO THE CASE STUDY
Physicians
As discussed above in relation to communication and consent,
Manual Features
According to the analysis of the physician-
competent patients have the right to refuse any medical treatment,
patient relationship presented in this chapter,
even if the refusal results in their death. Individuals differ greatly
Principal
Dr. Ps conduct was deficient in several
with regard to their attitude towards dying; some will do anything to
respects: (1) COMMUNICATION he
prolong their lives, no matter how much pain and suffering it involves,
Ethics
made no attempt to communicate with the
Manual
while others so look forward to dying that they refuse even simple
patient regarding the cause of her condition,
Medical
measures that are likely to keep them alive, such as antibiotics for
treatment options or her ability to afford to
Medical Ethics
bacterial pneumonia. Once physicians have made every effort to
stay in the hospital while she recovered;
provide patients with information about the available treatments and
(2) CONSENT he did not obtain her
their likelihood of success, they must respect the patients decisions
informed consent to treatment:
about the initiation or continuation of any treatment.
(3) COMPASSION his dealings with her
End-of-life decision-making for incompetent patients presents displayed little compassion for her plight.
greater difficulties. If patients have clearly expressed their wishes in His surgical treatment may have been highly
advance, for example in an advance directive, the decision will be competent and he may have been tired at the
easier, although such directives are often very vague and need to be end of a long shift, but that does not excuse
interpreted with respect to the patients actual condition. If patients the breaches of ethics.
have not adequately expressed their wishes, the appropriate
substitute decision-maker must use another criterion for treatment
decisions, namely, the best interests of the patient.
Ethics
and Society
CHAPTER THREE
of Medical
PHYSICIANS AND SOCIETY
Medical
Medical Ethics Ethics
Manual Physicians
ManualFeatures
Principal
OBJECTIVES
After working through this chapter you should be able to:
recognize conflicts between the physicians obligations
to patients and to society and identify the reasons for the
conflicts
identify and deal with the ethical issues involved in allocating
scarce medical resources
recognize physician responsibilities for public and global
Looking AIDS in the Face health.
Gideon Mendel/CORBIS
64 65
Ethics
and Society
to use these privileges primarily for the benefit of others and only
of Medical
CASE STUDY #2 secondarily for its own benefit.
Physicians
Dr. S is becoming increasingly frustrated with Medicine is today, more than ever
ManualFeatures
patients who come to her either before or Medicine is today,
before, a social rather than a strictly
after consulting another health practitioner for more than ever before,
individual activity. It takes place in a
Principal
the same ailment. She considers this to be a a social rather than
waste of health resources as well as counter- context of government and corporate
a strictly individual
Ethics
productive for the health of the patients. organisation and funding. It relies activity.
Manual
She decides to tell these patients that she on public and corporate medical
Medical
will no longer treat them if they continue research and product development for
Medical Ethics
to see other practitioners for the same
its knowledge base and treatments. It requires complex healthcare
ailment. She intends to approach her national
medical association to lobby the government
institutions for many of its procedures. It treats diseases and
to prevent this form of misallocation of illnesses that are as much social as biological in origin.
healthcare resources.
The Hippocratic tradition of medical ethics has little guidance to offer
with regard to relationships with society. To supplement this tradition,
WHATS SPECIAL ABOUT THE PHYSICIAN- present-day medical ethics addresses the issues that arise beyond
SOCIETY RELATIONSHIP? the individual patient-physician relationship and provides criteria
and processes for dealing with these issues.
Medicine is a profession. The term profession has two distinct,
although closely related, meanings: (1) an occupation that is To speak of the social character of medicine immediately raises
characterized by dedication to the well-being of others, high moral the question what is society? In this Manual the term refers to
standards, a body of knowledge and skills, and a high level of a community or nation. It is not synonymous with government;
autonomy; and (2) all the individuals who practise that occupation. governments should, but often do not, represent the interests of
The medical profession can mean either the practice of medicine society, but even when they do, they are acting for society, not as
or physicians in general. society.
Medical professionalism involves not just the relationship between Physicians have various relationships with society. Because society,
a physician and a patient, as discussed in Chapter Two, and and its physical environment, are important factors in the health
relationships with colleagues and other health professionals, which of patients, both the medical profession in general and individual
will be treated in Chapter Four. It also involves a relationship with physicians have significant roles to play in public health, health
society. This relationship can be characterized as a social contract education, environmental protection, laws affecting the health or
whereby society grants the profession privileges, including exclusive well-being of the community, and testimony at judicial proceedings.
or primary responsibility for the provision of certain services and a As the WMA Declaration on the Rights of the Patient puts it:
high degree of self-regulation, and in return, the profession agrees Whenever legislation, government action or any other administration
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Ethics
and Society
or institution denies patients [their] rights, physicians should pursue At one end of the spectrum are requirements for mandatory reporting
of Medical
appropriate means to assure or to restore them. Physicians are of patients who suffer from designated diseases, those deemed not
Physicians
also called upon to play a major role in the allocation of societys fit to drive or those suspected of child abuse. Physicians should fulfil
ManualFeatures
scarce healthcare resources, and sometimes they have a duty to these requirements without hesitation, although patients should be
prevent patients from accessing services to which they are not informed that such reporting will take place.
Principal
entitled. Implementing these responsibilities can raise ethical
At the other end of the spectrum are requests or orders by the police
conflicts, especially when the interests of society seem to conflict
Ethics
or military to take part in practices that violate fundamental human
with those of individual patients.
Manual
rights, such as torture. In its 2003 Resolution on the Responsibility
Medical
of Physicians in the Denunciation of Acts of Torture or Cruel
Medical Ethics
DUAL LOYALTY or Inhuman or Degrading Treatment of which They are Aware,
the WMA provides specific guidance to physicians who are in this
When physicians have responsibilities and are accountable both to situation. In particular, physicians should guard their professional
their patients and to a third party and when these responsibilities and independence to determine the best interests of the patient and
accountabilities are incompatible, they find themselves in a situation should observe, as far as possible, the normal ethical requirements
of dual loyalty. Third parties that demand physician loyalty include of informed consent and confidentiality. Any
governments, employers (e.g., hospitals and managed healthcare breach of these requirements must
organizations), insurers, military officials, police, prison officials and Physicians should
be justified and must be disclosed to
report to the
family members. Although the WMA International Code of Medical the patient. Physicians should report appropriate authorities
Ethics states that A physician shall owe his patients complete to the appropriate authorities any any unjustified
loyalty, it is generally accepted unjustified interference in the care of interference in
...physicians may in that physicians may in exceptional their patients, especially if fundamental the care of their
exceptional situations situations have to place the interests human rights are being denied. If the patients, especially if
have to place the of others above those of the patient. fundamental human
authorities are unresponsive, help
interests of others rights are being
The ethical challenge is to decide may be available from a national
above those of the denied.
patient.
when and how to protect the patient medical association, the WMA and
in the face of pressures from third human rights organizations.
parties.
Closer to the middle of the spectrum are the practices of some
Dual loyalty situations comprise a spectrum ranging from those managed healthcare programmes that limit the clinical autonomy
where societys interests should take precedence to those where of physicians to determine how their patients should be treated.
the patients interests are clearly paramount. In between is a large Although such practices are not necessarily contrary to the best
grey area where the right course of action requires considerable interests of patients, they can be, and physicians need to consider
discernment. carefully whether they should participate in such programmes. If
68 69
Ethics
and Society
they have no choice in the matter, for example, where there are no the existing resources be rationed in some manner. Healthcare
of Medical
alternative programmes, they should advocate vigorously for their rationing, or resource allocation as it is more commonly referred to,
Physicians
own patients and, through their medical associations, for the needs takes place at three levels:
ManualFeatures
of all the patients affected by such restrictive policies.
At the highest (macro) level, governments decide how much
A particular form of a dual loyalty issue faced by physicians is of the overall budget should be allocated to health; which
Principal
the potential or actual conflict of interest between a commercial healthcare expenses will be provided at no charge and which
Ethics
organization on the one hand and patients and/or society on the will require payment either directly from patients or from their
Manual
other. Pharmaceutical companies, medical device manufacturers medical insurance plans; within the health budget, how much
Medical
and other commercial organizations frequently offer physicians will go to remuneration for physicians, nurses and other heath
Medical Ethics
gifts and other benefits that range from free samples to travel and care workers, to capital and operating expenses for hospitals
accommodation at educational events to excessive remuneration and other institutions, to research, to education of health
for research activities (see Chapter Five). A common underlying professionals, to treatment of specific conditions such as
motive for such company largesse is to convince the physician to tuberculosis or AIDS, and so on.
prescribe or use the companys products, which may not be the best
At the institutional (meso) level, which includes hospitals,
ones for the physicians patients and/or may add unnecessarily to a
clinics, healthcare agencies, etc., authorities decide how to
societys health costs. The WMAs 2004 Statement Concerning the
allocate their resources: which services to provide; how much to
Relationship between Physicians and Commercial Enterprises
spend on staff, equipment, security, other operating expenses,
provides guidelines for physicians in
renovations, expansion, etc.
such situations and many national
...physicians should
medical associations have their resolve any conflict At the individual patient (micro) level, healthcare providers,
own guidelines. The primary ethical between their own especially physicians, decide what tests should be ordered,
principle underlying these guidelines interests and those of whether a referral to another physician is needed, whether the
is that physicians should resolve any their patients in their patient should be hospitalised, whether a brand-name drug is
conflict between their own interests patients favour.
required rather than a generic one, etc. It has been estimated
and those of their patients in their that physicians are responsible for initiating 80% of healthcare
patients favour. expenditures, and despite the growing encroachment of
managed care, they still have considerable discretion as to
RESOURCE ALLOCATION which resources their patients will have access.
In every country in the world, including the richest ones, there is The choices that are made at each level have a major ethical
an already wide and steadily increasing gap between the needs component, since they are based on values and have significant
and desires for healthcare services and the availability of resources consequences for the health and well-being of individuals and
to provide these services. The existence of this gap requires that communities. Although individual physicians are affected by
70 71
Ethics
and Society
decisions at all levels, they have the greatest involvement at antibiotics is just one example of
of Medical
One way that
the micro-level. Accordingly, this will be the focus of what a practice that is both wasteful
physicians can
Physicians
follows. and harmful. Many other common exercise their
ManualFeatures
treatments have been shown in responsibility for
As noted above, physicians were traditionally expected to act solely
randomized clinical trials to be the allocation of
in the interests of their own patients, without regard to the needs resources is by
Principal
of others. Their primary ethical values of compassion, competence ineffective for the conditions for
avoiding wasteful and
which they are used. Clinical practice inefficient practices,
Ethics
and autonomy were directed towards serving the needs of their own
guidelines are available for many
Manual
patients. This individualistic approach to medical ethics survived the even when patients
Medical
transition from physician paternalism to patient autonomy, where the medical conditions; they help to request them.
Medical Ethics
will of the individual patient became the main criterion for deciding distinguish between effective and
what resources he or she should receive. More recently, however, ineffective treatments. Physicians
another value, justice, has become an important factor in medical should familiarize themselves with these guidelines, both to
decision-making. It entails a more conserve resources and to provide optimal treatment to their
social approach to the distribution ...physicians are patients.
of resources, one that considers the responsible not
just for their own
A type of allocation decision that many physicians must make
needs of other patients. According is the choice between two or more patients who are in need of
patients but, to a
to this approach, physicians are certain extent, for a scarce resource such as emergency staff attention, the one
responsible not just for their own others as well. remaining intensive care bed, organs for transplantation, high-tech
patients but, to a certain extent, for radiological tests, and certain very expensive drugs. Physicians who
others as well. exercise control over these resources must decide which patients
This new understanding of the physicians role in allocating will have access to them and which will not, knowing full well that
resources is expressed in many national medical association codes those who are denied may suffer, and even die, as a result.
of ethics and, as well, in the WMA Declaration on the Rights of
Some physicians face an additional conflict in allocating resources,
the Patient, which states: In circumstances where a choice must
in that they play a role in formulating general policies that affect
be made between potential patients for a particular treatment which
their own patients, among others. This conflict occurs in hospitals
is in limited supply, all such patients are entitled to a fair selection
and other institutions where physicians hold administrative positions
procedure for that treatment. That choice must be based on medical
or serve on committees where policies are recommended or
criteria and made without discrimination.
determined. Although many physicians attempt to detach themselves
One way that physicians can exercise their responsibility for the from their preoccupation with their own patients, others may try to
allocation of resources is by avoiding wasteful and inefficient use their position to advance the cause of their patients over others
practices, even when patients request them. The overuse of with greater needs.
72 73
Ethics
and Society
In dealing with these allocation issues, physicians must not she practises. Some countries, such
of Medical
...choice will depend
only balance the principles of compassion and justice but, in doing on the physicians as the U.S.A., favour the libertarian
Physicians
so, must decide which approach to justice is preferable. There are own personal morality approach; others, e.g., Sweden, are
ManualFeatures
several such approaches, including the following: as well as the socio- known for their egalitarianism; while
political environment still others, such as South Africa, are
LIBERTARIAN resources should be distributed according to in which he or she
Principal
attempting a restorative approach.
market principles (individual choice conditioned by ability and practises.
Many health planners promote
Ethics
willingness to pay, with limited charity care for the destitute);
utilitarianism. Despite their differences,
Manual
Medical
UTILITARIAN resources should be distributed according to two or more of these concepts of justice often coexist in national
health systems, and in these countries physicians may be able to
Medical Ethics
the principle of maximum benefit for all;
choose a practice setting (e.g., public or private) that accords with
EGALITARIAN resources should be distributed strictly their own approach.
according to need;
In addition to whatever roles physicians may have in allocating
RESTORATIVE resources should be distributed so as to existing healthcare resources, they also have a responsibility
favour the historically disadvantaged. to advocate for expansion of
these resources where they are ...physicians
As noted above, physicians have been gradually moving away from
insufficient to meet patient needs. ...have a responsibility
the traditional individualism of medical ethics, which would favour to advocate for
This usually requires that physicians
the libertarian approach, towards a more social conception of their expansion of these
work together, in their professional
role. Even if the libertarian approach is generally rejected, however, resources where they
associations, to convince decision-
medical ethicists have reached no consensus on which of the other are insufficient to
makers in government and elsewhere meet patient
three approaches is superior. Each one clearly has very different
of the existence of these needs and needs.
results when applied to the issues mentioned above, that is,
how best to meet them, both within
deciding what tests should be ordered, whether a referral to another
their own countries and globally.
physician is needed, whether the patient should be hospitalised,
whether a brand-name drug is required rather than a generic one,
PUBLIC HEALTH
who gets the organ for transplantation, etc. The utilitarian approach
is probably the most difficult for individual physicians to practise, 20th century medicine witnessed the emergence of an unfortunate
since it requires a great deal of data on the probable outcomes of division between public health and other healthcare (presumably
different interventions, not just for the physicians own patients but private or individual health). It is unfortunate because, as noted
for all others. The choice between the other two (or three, if the above, the public is made up of individuals, and measures designed
libertarian is included) will depend on the physicians own personal to protect and enhance the health of the public result in health
morality as well as the socio-political environment in which he or benefits for individuals.
74 75
Ethics
and Society
Confusion also arises if public health is taken to mean publicly- important factors in the health of individuals but social factors such
of Medical
funded healthcare (i.e., healthcare funded through a countrys as housing, nutrition and employment are equally, if not more,
Physicians
taxation system or a compulsory universal insurance system) and significant. Physicians are seldom able to treat the social causes
ManualFeatures
seen as the opposite of privately-funded healthcare (i.e., healthcare of their individual patients illnesses, although they should refer the
paid for by the individual or through private health insurance and patients to whatever social services are available. However, they can
Principal
usually not universally available). contribute, even if indirectly, to long-term solutions to these problems
by participating in public health and health education activities,
Ethics
The term public health, as understood here, refers both to the health
monitoring and reporting environmental hazards, identifying and
Manual
of the public and also to the medical specialty that deals with health
Medical
publicizing adverse health effects from social problems such as
from a population perspective rather than on an individual basis.
abuse and violence, and advocating for improvements in public
Medical Ethics
There is a great need for specialists
health services.
in this field in every country to advise all physicians need to
on and advocate for public policies be aware of the social Sometimes, though, the interests of public health may conflict with
that promote good health as well as and environmental those of individual patients, for example, when a vaccination that
to engage in activities to protect the determinants that carries a risk of an adverse reaction will prevent an individual from
public from communicable diseases influence the health transmitting a disease but not from contracting it, or when notification
status of their
and other health hazards. The practice is required for certain contagious diseases, for cases of child or
individual patients.
of public health (sometimes called elder abuse, or for conditions that may render certain activities, such
public health medicine or community as driving a car or piloting an aircraft, dangerous to the individual
medicine) relies heavily for its scientific basis on epidemiology, and to others. These are examples of dual-loyalty situations as
which is the study of the distribution and determinants of health and described above. Procedures for dealing with these and related
disease in populations. Indeed, some physicians go on to take extra situations are discussed under confidentiality in Chapter Two of
academic training and become medical epidemiologists. However, this Manual. In general, physicians should attempt to find ways to
all physicians need to be aware of the social and environmental minimise any harm that individual patients might suffer as a result
determinants that influence the health status of their individual of meeting public health requirements. For example, when reporting
patients. As the WMA Statement on Health Promotion notes: is required, the patients confidentiality should be protected to the
Medical practitioners and their professional associations have an greatest extent possible while fulfilling the legal requirements.
ethical duty and professional responsibility to act in the best interests
A different type of conflict between the interests of individual
of their patients at all times and to integrate this responsibility with a
patients and those of society arises when physicians are asked to
broader concern for and involvement in promoting and assuring the
assist patients to receive benefits to which they are not entitled, for
health of the public.
example, insurance payments or sick-leave. Physicians have been
Public health measures such as vaccination campaigns and vested with the authority to certify that patients have the appropriate
emergency responses to outbreaks of contagious diseases are medical condition that would qualify them for such benefits. Although
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Ethics
and Society
some physicians are unwilling to deny requests from patients for in the poorest countries, which have resulted in certain success
of Medical
certificates that do not apply in their circumstances, they should stories such as the elimination of smallpox and (hopefully) polio,
Physicians
rather help their patients find other means of support that do not the gap in health status between high and low-income countries
ManualFeatures
require unethical behaviour. continues to widen. This is partly due to HIV/AIDS, which has had
its worst effects in poor countries, but it is also due to the failure
Principal
GLOBAL HEALTH of low-income countries to benefit from the increase in wealth that
the world as a whole has experienced during the past decades.
Ethics
The recognition that physicians have responsibilities to the society
Although the causes of poverty are largely political and economic
Manual
in which they live has been expanded in recent years to include a
Medical
responsibility for global health. This term has been defined as health and are therefore far beyond the control of physicians and their
Medical Ethics
problems, issues and concerns that transcend national boundaries, associations, physicians do have to deal with the ill-health that is
that may be influenced by circumstances or experiences in other the result of poverty. In low-income countries physicians have few
countries, and that are best addressed by cooperative actions and resources to offer these patients and are constantly faced with the
solutions. Global health is part of the much larger movement of challenge of allocating these resources in the fairest way. Even in
globalization that encompasses information exchange, commerce, middle- and high-income countries, though, physicians encounter
politics, tourism and many other human activities. patients who are directly affected by globalization, such as refugees,
and who sometimes do not have access to the medical coverage
The basis of globalization is the recognition that individuals and that citizens of those countries enjoy.
societies are increasingly interdependent. This is clearly evident
with regard to human health, as the rapid spread of diseases Another feature of globalization is the international mobility of health
such as influenza and SARS has shown. Such epidemics require professionals, including physicians. The outflow of physicians from
international action for their control. The failure to recognize and developing to highly industrialized countries has been advantageous
treat highly contagious diseases by a physician in one country can for both the physicians and the receiving countries but not so for the
have devastating effects on patients in other countries. For this exporting countries. The WMA, in its Ethical Guidelines for the
reason, the ethical obligations of physicians extend far beyond their International Recruitment of Physicians, states that physicians
individual patients and even their should not be prevented from leaving their home or adopted country
The failure to communities and nations. to pursue career opportunities in another country. It does, however,
recognize and treat
highly contagious call on every country to do its utmost to educate an adequate
The development of a global view of
diseases by a physician number of physicians, taking into account its needs and resources,
health has resulted in an increasing
in one country can have and not to rely on immigration from other countries to meet its need
devastating effects
awareness of health disparities
for physicians.
on patients in other throughout the world. Despite large-
countries. scale campaigns to combat premature Physicians in the industrialized countries have a long tradition
mortality and debilitating morbidity of providing their experience and skills to developing countries.
78 79
Ethics
and Society
This takes many forms: emergency medical aid coordinated by
of Medical
organizations such as the Red Cross and Red Crescent Societies BACK TO THE CASE STUDY
Physicians
and Mdecins sans Frontires, short-term surgical campaigns
ManualFeatures
to deal with conditions such as cataracts or cleft palates, visiting According to the analysis of the physician-
faculty appointments in medical schools, short- or long-term medical society relationship presented in this chapter,
Dr. S is right to consider the impact on
Principal
research projects, provision of medicines and medical equipment,
etc. Such programmes exemplify the positive side of globalization society of her patient
s behaviour.
Ethics
and serve to redress, at least partially, the movement of physicians Even if the consultations with the other
Manual
health practitioner occur outside of the health
Medical
from poorer to wealthier countries.
system in which Dr. S works and therefore do
Medical Ethics
not entail any financial cost to society,
the patient is taking up Dr. S
s time that could
be devoted to other patients in need of her
services. However, physicians such as
Dr. S must be cautious in dealing with
situations such as this. Patients are often
unable to make fully rational decisions for a
variety of reasons and may need considerable
time and health education to come to an
understanding of what is in the best interests
of themselves and of others. Dr. S is also
right to approach her medical association to
seek a societal solution to this problem,
since it affects not just herself and this one
patient but other physicians and patients
as well.
80 81
Ethics
Colleagues
CHAPTER FOUR
Medical
PHYSICIANS AND COLLEAGUES
Ethics Manual
MedicalManual
Medical Ethics Features ofand
Physicians
Principal
OBJECTIVES
After working through this chapter you should be able to:
describe how physicians should behave towards one
another
justify reporting unethical behaviour of colleagues
identify the main ethical principles relating to cooperation
with others in the care of patients
explain how to resolve conflicts with other healthcare
Medical team going over a case providers
Pete Saloutos/CORBIS
82 83
Ethics
Colleagues
This chapter will deal with ethical issues that arise in both internal
Medical
CASE STUDY #3 and external hierarchies. Some issues are common to both; others
Features ofand
Dr. C, a newly appointed anaesthetist in a are found only in one or the other. Many of these issues are relatively
Physicians
city hospital, is alarmed by the behaviour of new, since they result from recent changes in medicine and health-
the senior surgeon in the operating room. care. A brief description of these changes is in order, since they pose
Principal
The surgeon uses out-of-date techniques major challenges to the traditional exercise of medical authority.
Ethics Manual
that prolong operations and result in greater
post-operative pain and longer recovery With the rapid growth in scientific knowledge and its clinical
MedicalManual
times. Moreover, he makes frequent crude applications, medicine has become increasingly complex. Individual
jokes about the patients that obviously bother physicians cannot possibly be experts in all their patients diseases
Medical Ethics
the assisting nurses. As a more junior staff
and potential treatments and they need the assistance of other
member, Dr. C is reluctant to criticize the
specialist physicians and skilled health professionals such as
surgeon personally or to report him to higher
authorities. However, he feels that he must do nurses, pharmacists, physiotherapists, laboratory technicians,
something to improve the situation. social workers and many others. Physicians need to know how to
access the relevant skills that their patients require and that they
themselves lack.
CHALLENGES TO MEDICAL AUTHORITY
As discussed in Chapter Two, medical paternalism has been
Physicians belong to a profession gradually eroded by the increasing recognition of the right of patients
that has traditionally functioned in Physicians belong to make their own medical decisions. As a result, a cooperative
an extremely hierarchical fashion, to a profession that model of decision-making has replaced the authoritarian model
has traditionally
both internally and externally. that was characteristic of traditional
functioned in an
Internally, there are three overlapping extremely hierarchical medical paternalism. The same ...a cooperative model
hierarchies: the first differentiates fashion thing is happening in relationships of decision-making
among specialties, with some being between physicians and other has replaced the
authoritarian model
considered more prestigious, and health professionals. The latter
that was characteristic
better remunerated, than others; the second is within specialties, are increasingly unwilling to follow
of traditional medical
with academics being more influential than those in private or public physicians orders without knowing paternalism.
practice; the third relates to the care of specific patients, where the the reasons behind the orders. They
primary caregiver is at the top of the hierarchy and other physicians, see themselves as professionals with
even those with greater seniority and/or skills, serve simply as specific ethical responsibilities towards patients; if their perception
consultants unless the patient is transferred to their care. Externally, of these responsibilities conflicts with the physicians orders, they
physicians have traditionally been at the top of the hierarchy of feel that they must question or even challenge the orders. Whereas
caregivers, above nurses and other health professionals. under the hierarchical model of authority, there was never any doubt
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Ethics
Colleagues
about who was in charge and who should prevail when conflict In the Hippocratic tradition of medical ethics, physicians owe special
Medical
occurred, the cooperative model can give rise to disputes about respect to their teachers. The Declaration of Geneva puts it this
Features ofand
appropriate patient care. way: I will give to my teachers the respect and gratitude which is
Physicians
their due. Although present-day medical education involves multiple
Developments such as these are changing the rules of the game student-teacher interactions rather than the one-on-one relationship
for the relationships of physicians with their medical colleagues and
Principal
of former times, it is still dependent on the good will and dedication
Ethics Manual
other health professionals. The remainder of this chapter will identify of practising physicians, who often receive no remuneration for their
some problematic aspects of these relationships and suggest ways teaching activities. Medical students and other medical trainees
MedicalManual
of dealing with them. owe a debt of gratitude to their teachers, without whom medical
education would be reduced to self-instruction.
Medical Ethics
RELATIONSHIPS WITH PHYSICIAN For their part, teachers have an
COLLEAGUES, TEACHERS AND STUDENTS obligation to treat their students ...teachers have an
respectfully and to serve as good obligation to treat their
As members of the medical profession, physicians have traditionally role models in dealing with patients. students respectfully
been expected to treat each other more as family members than The so-called hidden curriculum of and to serve as good
as strangers or even as friends. The WMA Declaration of Geneva role models in dealing
medical education, i.e., the standards
includes the pledge, My colleagues will be my sisters and brothers. with patients.
of behaviour exhibited by practising
The interpretation of this requirement has varied from country to physicians, is much more influential
country and over time. For example, where fee-for-service was the than the explicit curriculum of medical
principal or only form of remuneration for physicians, there was a ethics, and if there is a conflict between the requirements of ethics
strong tradition of professional courtesy whereby physicians did and the attitudes and behaviour of their teachers, medical students
not charge their colleagues for medical treatment. This practice has are more likely to follow their teachers example.
declined in countries where third-party reimbursement is available.
Teachers have a particular obligation not to require students to
Besides the positive requirements to treat ones colleagues engage in unethical practices. Examples of such practices that
respectfully and to work cooperatively to maximize patient care, have been reported in medical journals include medical students
the WMA International Code of Medical Ethics contains two obtaining patient consent for medical treatment in situations where
restrictions on physicians relationships with one another: (1) paying a fully qualified health professional should do this, performing pelvic
or receiving any fee or any other consideration solely to procure examinations on anaesthetized or newly dead patients without
the referral of a patient; and (2) stealing patients from colleagues. consent, and performing unsupervised procedures that, although
A third obligation, to report unethical or incompetent behaviour by minor (e.g., I-V insertion), are considered by some students to
colleagues, is discussed below. be beyond their competence. Given the unequal power balance
between students and teachers and the consequent reluctance of
86 87
Ethics
Colleagues
students to question or refuse such for example, by appointing lay members to regulatory authorities.
Medical
Students concerned
orders, teachers need to ensure that The main requirement for self-regulation, however, is wholehearted
about ethical aspects
Features ofand
of their education
they are not requiring students to act support by physicians for its principles and their willingness to
Physicians
should have access unethically. In many medical schools, recognise and deal with unsafe and unethical practices.
to such mechanisms there are class representatives or
This obligation to report incompetence, impairment or misconduct
Principal
where they can raise medical student associations that,
Ethics Manual
concerns of ones colleagues is emphasised in codes of medical ethics. For
among their other roles, may be
example, the WMA International Code of Medical Ethics states
able to raise concerns about ethical
MedicalManual
that A physician shall... strive to expose those physicians deficient
issues in medical education. Students
in character or competence, or who engage in fraud or deception.
concerned about ethical aspects of their education should have
Medical Ethics
The application of this principle is seldom easy, however. On the
access to such mechanisms where they can raise concerns without
one hand, a physician may be tempted to attack the reputation of
necessarily being identified as the whistle-blower, as well as access
a colleague for unworthy personal motives, such as jealousy, or in
to appropriate support if it becomes necessary to take the issue to
retaliation for a perceived insult by the colleague. A physician may
a more formal process.
also be reluctant to report a colleagues misbehaviour because of
For their part, medical students are expected to exhibit high friendship or sympathy (there but for the grace of God go I). The
standards of ethical behaviour as appropriate for future physicians. consequences of such reporting can be very detrimental to the one
They should treat other students as colleagues and be prepared to who reports, including almost certain hostility on the part of the
offer help when it is needed, including corrective advice in regard accused and possibly other colleagues as well.
to unprofessional behaviour. They should also contribute fully to Despite these drawbacks to reporting wrongdoing, it is a professional
shared projects and duties such as study assignments and on-call duty of physicians. Not only are they responsible for maintaining
service. the good reputation of the profession,
but they are often the only ones who ...reporting
REPORTING UNSAFE OR colleagues to the
recognise incompetence, impairment
UNETHICAL PRACTICES
or misconduct. However, reporting disciplinary authority
should normally be a
Medicine has traditionally taken pride in its status as a self- colleagues to the disciplinary authority
last resort after other
regulating profession. In return for the privileges accorded to it by should normally be a last resort after alternatives have
society and the trust given to its members by their patients, the other alternatives have been tried and been tried and found
medical profession has established high standards of behaviour for found wanting. The first step might be wanting
its members and disciplinary procedures to investigate accusations to approach the colleague and say
of misbehaviour and, if necessary, to punish the wrongdoers. This that you consider his or her behaviour
system of self-regulation has often failed, and in recent years unsafe or unethical. If the matter can be resolved at that level,
steps have been taken to make the profession more accountable, there may be no need to go farther. If not, the next step might be to
88 89
Ethics
Colleagues
discuss the matter with your and/or the offenders supervisor and COOPERATION
Medical
leave the decision about further action to that person. If this tactic is
Medicine is at the same time a highly individualistic and a highly
Features ofand
not practical or does not succeed, then it may be necessary to take
cooperative profession. On the one hand, physicians are quite
Physicians
the final step of informing the disciplinary authority.
possessive of their patients. It is claimed, with good reason, that
the individual physician-patient relationship is the best means of
Principal
RELATIONSHIPS WITH OTHER HEALTH attaining the knowledge of the patient and continuity of care that
Ethics Manual
PROFESSIONALS are optimal for the prevention and treatment of illness. The retention
MedicalManual
Chapter Two on relationships with patients began with a discussion of patients also benefits the physician, at least financially. At the
of the great importance of respect and equal treatment in the same time, as described above, medicine is highly complex and
Medical Ethics
physician-patient relationship. The principles set forth in that specialized, thus requiring close cooperation among practitioners
discussion are equally relevant for relationships with co-workers. In with different but complementary knowledge and skills. This tension
particular, the prohibition against discrimination on grounds such as between individualism and cooperation has been a recurrent theme
age, disease or disability, creed, ethnic origin, gender, nationality, in medical ethics.
political affiliation, race, sexual orientation, or social standing
The weakening of medical paternalism
(WMA Declaration of Geneva) is applicable in dealings with all
has been accompanied by the The weakening of
those with whom physicians interact in caring for patients and other
disappearance of the belief that medical paternalism
professional activities. has been accompanied
physicians own their patients. The
by the disappearance
Non-discrimination is a passive characteristic of a relationship. traditional right of patients to ask for
of the belief that
Respect is something more active and positive. With regard to other a second opinion has been expanded physicians own their
healthcare providers, whether physicians, nurses, auxiliary health to include access to other healthcare patients.
workers, etc., it entails an appreciation of their skills and experience providers who may be better able
insofar as these can contribute to the care of patients. All healthcare to meet their needs. According to
providers are not equal in terms of their education and training, but the WMA Declaration on the Rights
they do share a basic human equality as well as similar concern for of the Patient, The physician has an obligation to cooperate in
the well-being of patients. the coordination of medically indicated care with other healthcare
providers treating the patient. However, as noted above, physicians
As with patients, though, there are legitimate grounds for refusing are not to profit from this cooperation by fee-splitting.
to enter or for terminating a relationship with another healthcare
provider. These include lack of confidence in the ability or integrity These restrictions on the physicians ownership of patients need
of the other person and serious personality clashes. Distinguishing to be counterbalanced by other measures that are intended to
these from less worthy motives can require considerable ethical safeguard the primacy of the patient-physician relationship. For
sensitivity on the physicians part. example, a patient who is being treated by more than one physician,
90 91
Ethics
Colleagues
which is usually the case in a hospital, should, wherever possible, the population in Africa and Asia and increasingly so in Europe and
Medical
have one physician coordinating the care who can keep the patient the Americas. Although some would consider the two approaches
Features ofand
informed about his or her overall progress and help the patient make as complementary, in many situations they may be in conflict.
Physicians
decisions. Since at least some of the traditional and alternative interventions
have therapeutic effects and are sought out by patients, physicians
Whereas relationships among physicians are governed by generally
Principal
should explore ways of cooperation with their practitioners. How this
Ethics Manual
well-formulated and understood rules, relationships between can be done will vary from one country to another and from one type
physicians and other healthcare professionals are in a state of flux of practitioner to another. In all such interactions the well-being of
MedicalManual
and there is considerable disagreement about what their respective patients should be the primary consideration.
roles should be. As noted above, many nurses, pharmacists,
Medical Ethics
physiotherapists and other professionals consider themselves to be
CONFLICT RESOLUTION
more competent in their areas of patient care than are physicians
and see no reason why they should not be treated as equals to Although physicians can experience many different types of conflicts
physicians. They favour a team approach to patient care in which with other physicians and healthcare providers, for example, over
the views of all caregivers are given equal consideration, and office procedures or remuneration,
they consider themselves accountable to the patient, not to the the focus here will be on conflicts
...uncertainty and
physician. Many physicians, on the other hand, feel that even if the about patient care. Ideally, healthcare
diverse viewpoints
team approach is adopted, there has to be one person in charge, can give rise to decisions will reflect agreement
and physicians are best suited for that role given their education disagreement about among the patient, physicians and
and experience. the goals of care or all others involved in the patients
the means of achieving care. However, uncertainty and
Although some physicians may resist challenges to their traditional, those goals. diverse viewpoints can give rise to
almost absolute, authority, it seems certain that their role will disagreement about the goals of
change in response to claims by both patients and other healthcare care or the means of achieving those
providers for greater participation in medical decision-making. goals. Limited healthcare resources and organisational policies may
Physicians will have to be able to justify their recommendations to also make it difficult to achieve consensus.
others and persuade them to accept these recommendations. In
Disagreements among healthcare providers about the goals of
addition to these communication skills, physicians will need to be
care and treatment or the means of achieving those goals should
able to resolve conflicts that arise among the different participants in
be clarified and resolved by the members of the healthcare team
the care of the patient.
so as not to compromise their relationships with the patient.
A particular challenge to cooperation in the best interests of patients Disagreements between healthcare providers and administrators
results from their recourse to traditional or alternative health providers with regard to the allocation of resources should be resolved within
(healers). These individuals are consulted by a large proportion of the facility or agency and not be debated in the presence of the
92 93
Ethics
Colleagues
patient. Since both types of conflicts are ethical in nature, their
Medical
resolution can benefit from the advice of a clinical ethics committee BACK TO THE CASE STUDY
Features ofand
or an ethics consultant where such resources are available. Dr. C is right to be alarmed by the behaviour
Physicians
Dr. C issenior
of the right to be alarmed
surgeon in theby the behaviour
operating room.
The following guidelines can be useful for resolving such conflicts: of the senior surgeon in the operating room.
Not only is he endangering the health of the
Conflicts should be resolved as informally as possible, for Not onlybut
is he
he endangering the healthtoof the
Principal
patient is being disrespectful both
Ethics Manual
example, through direct negotiation between the persons patient but he
the patient is being
and disrespectful
his colleagues. Dr. Cto has
both
who disagree, moving to more formal procedures only the
an patient
ethical and
duty histocolleagues.
not ignore thisDr. C has
behaviour
MedicalManual
when informal measures have been unsuccessful. anbut
ethical
to doduty not to ignore
something about this behaviour
it. As a first
but to
step, hedo something
should about it.
not indicate anyAssupport
a first
The opinions of all those directly involved should be elicited
Medical Ethics
step,
for thehe should not
offensive indicate for
behaviour, anyexample,
support
and given respectful consideration.
for the offensive
by laughing behaviour,
at the forthinks
jokes. If he example,
that
The informed choice of the patient, or authorized substitute
by laughing at the jokes. If he thinks
discussing the matter with the surgeon mightthat
decision-maker, regarding treatment should be the primary
discussing the matter
be effective, withgo
he should theahead
surgeon
andmight
do
consideration in resolving disputes.
be effective, he should go ahead and do
this. Otherwise, he may have to go directly
If the dispute is about which options the patient should be this. Otherwise, he may have to go directly
to higher authorities in the hospital. If they
offered, a broader rather than a narrower range of options is
are unwilling to deal with the situation, they
to higher authorities in the hospital. If then
usually preferable. If a preferred treatment is not available are
he unwilling to deal
can approach thewith the situation,
appropriate then
physician
because of resource limitations, the patient should normally he can approach the ask
appropriate physician
licensing body and it to investigate.
be informed of this. licensing body and ask it to investigate.
If, after reasonable effort, agreement or compromise cannot
be reached through dialogue, the decision of the person
with the right or responsibility for making the decision
should be accepted. If it is unclear or disputed who has
the right or responsibility to make the decision, mediation,
arbitration or adjudication should be sought.
Ethics
Research
CHAPTER FIVE
of Medical
and Medical
ETHICS AND MEDICAL RESEARCH
Medical
Medical ManualManual
Ethics Ethics Features
Ethics
Principal
OBJECTIVES
After working through this chapter you should be able to:
identify the main principles of research ethics
know how to balance research and clinical care
satisfy the requirements of ethics review committees
Sleeping sickness is back
Robert Patric/CORBIS SYGMA
96 97
Ethics
Research
techniques. Great progress has been made in this area over the
of Medical
CASE STUDY #4 past 50 years and today there is more medical research underway
and Medical
Dr. R, a general practitioner in a small rural than ever before. Nevertheless, there are still many unanswered
Features
town, is approached by a contract research questions about the functioning of the human body, the causes of
diseases (both familiar and novel ones) and the best ways to prevent
Ethics
organization (C.R.O.) to participate in a
Principal
clinical trial of a new non-steroidal anti- or cure them. Medical research is the only means of answering
inflammatory drug (NSAID) for osteoarthritis.
ManualManual
these questions.
She is offered a sum of money for each
patient that she enrols in the trial. The C.R.O. In addition to seeking a better understanding of human physiology,
Ethics Ethics
representative assures her that the trial medical research investigates a wide variety of other factors in
has received all the necessary approvals,
Medical
human health, including patterns of disease (epidemiology), the
including one from an ethics review
organization, funding and delivery of healthcare (health systems
Medical
committee. Dr. R has never participated in
a trial before and is pleased to have this research), social and cultural aspects of health (medical sociology
opportunity, especially with the extra money. and anthropology), law (legal medicine) and ethics (medical ethics).
She accepts without inquiring further about The importance of these types of research is being increasingly
the scientific or ethical aspects of the trial. recognized by funding agencies, many of which have specific
programs for non-physiological medical research.
Ethics
Research
is to take part in a research project, either as a medical student or The rapid increase in recent years in the number of ongoing trials
of Medical
following qualification. has required finding and enrolling ever-larger numbers of patients
and Medical
to meet the statistical requirements of the trials. Those in charge
The most common method of research for practising physicians is
Features
of the trials, whether independent physicians or pharmaceutical
the clinical trial. Before a new drug can be approved by government-
companies, now rely on many other physicians, often in different
Ethics
mandated regulatory authorities, it must undergo extensive testing
Principal
countries, to enrol patients as research subjects.
for safety and efficacy. The process begins with laboratory studies
ManualManual
followed by testing on animals. If this proves promising, the four Although such participation in research is valuable experience for
steps, or phases, of clinical research, are next: physicians, there are potential problems that must be recognized
Ethics Ethics
and avoided. In the first place, the physicians role in the physician-
Phase one research, usually conducted on a relatively small
Medical
patient relationship is different from the
number of healthy volunteers, who are often paid for their researchers role in the researcher-
Medical
...the physicians
participation, is intended to determine what dosage of the drug role in the physician- research subject relationship, even
is required to produce a response in the human body, how the patient relationship if the physician and the researcher
body processes the drug, and whether the drug produces toxic is different from the are the same person. The physicians
or harmful effects. researchers role in the
primary responsibility is the health and
researcher-research
Phase two research is conducted on a group of patients who subject relationship well-being of the patient, whereas the
have the disease that the drug is intended to treat. Its goals are researchers primary responsibility is
to determine whether the drug has any beneficial effect on the the generation of knowledge, which
disease and has any harmful side effects. may or may not contribute to the research subjects health and well-
being. Thus, there is a potential for conflict between the two roles.
Phase three research is the clinical trial, in which the drug is When this occurs, the physician role must take precedence over the
administered to a large number of patients and compared to researcher. What this means in practice will be evident below.
another drug, if there is one for the condition in question, and/or
Another potential problem in combining these two roles is conflict
to a placebo. Where possible, such trials are double-blinded,
of interest. Medical research is a well-funded enterprise, and
i.e., neither research subjects nor their physicians know who is
physicians are sometimes offered considerable rewards for
receiving which drug or placebo.
participating. These can include cash payments for enrolling
Phase four research takes place after the drug is licensed and research subjects, equipment such as computers to transmit the
marketed. For the first few years, a new drug is monitored for side research data, invitations to conferences to discuss the research
effects that did not show up in the earlier phases. Additionally, findings, and co-authorship of publications on the results of the
the pharmaceutical company is usually interested in how well research. The physicians interest in obtaining these benefits can
the drug is being received by physicians who prescribe it and sometimes conflict with the duty to provide the patient with the best
patients who take it. available treatment. It can also conflict with the right of the patient
100 101
Ethics
Research
to receive all the necessary information to make a fully informed document was revised over the next ten years and eventually was
of Medical
decision whether or not to participate in a research study. adopted as the Declaration of Helsinki (DoH) in 1964. It was further
and Medical
revised in 1975, 1983, 1989, 1996 and 2000. The DoH is a concise
These potential problems can be overcome. The ethical values of
Features
summary of research ethics. Other, much more detailed, documents
the physician compassion, competence, autonomy apply to the
have been produced in recent years on research ethics in general
Ethics
medical researcher as well. So there is no inherent conflict between
Principal
(e.g., Council for International Organizations of Medical Sciences,
the two roles. As long as physicians understand and follow the basic
ManualManual
International Ethical Guidelines for Biomedical Research
rules of research ethics, they should have no difficulty participating
Involving Human Subjects, 1993, revised in 2002) and on specific
in research as an integral component of their clinical practice.
Ethics Ethics
topics in research ethics (e.g., Nuffield Council on Bioethics [UK],
The Ethics of Research Related to Healthcare in Developing
Medical
ETHICAL REQUIREMENTS Countries, 2002).
Medical
The basic principles of research ethics are well established. It was Despite the different scope, length and authorship of these
not always so, however. Many prominent medical researchers documents, they agree to a very large extent on the basic principles
in the 19th and 20th centuries conducted experiments on patients of research ethics. These principles have been incorporated in
without their consent and with little if any concern for the patients the laws and/or regulations of many countries and international
well-being. Although there were some statements of research ethics organizations, including those that deal with the approval of drugs
dating from the early 20th century, they did not prevent physicians in and medical devices. Here is a brief description of the principles,
Nazi Germany and elsewhere from performing research on subjects taken primarily from the DoH:
that clearly violated fundamental human rights. Following World
War Two, some of these physicians were tried and convicted by a Ethics Review Committee
special tribunal at Nuremberg, Germany. The basis of the judgment Approval ...every proposal
is known as the Nuremberg Code, which has served as one of the for medical research
Paragraphs 13 and 14 of the DoH on human subjects
foundational documents of modern research ethics. Among the ten
stipulate that every proposal for must be reviewed
principles of this Code is the requirement of voluntary consent if a and approved by an
medical research on human subjects
patient is to serve as a research subject. independent ethics
must be reviewed and approved by
committee before
The World Medical Association was established in 1947, the an independent ethics committee
it can proceed.
same year that the Nuremberg Code was set forth. Conscious before it can proceed. In order to
of the violations of medical ethics before and during World War obtain approval, researchers must
Two, the founders of the WMA immediately took steps to ensure explain the purpose and methodology of the project; demonstrate
that physicians would at least be aware of their ethical obligations. how research subjects will be recruited, how their consent will
In 1954, after several years of study, the WMA adopted a set of be obtained and how their privacy will be protected; specify how
Principles for Those in Research and Experimentation. This the project is being funded; and disclose any potential conflicts of
102 103
Ethics
Research
interest on the part of the researchers. The ethics committee may there should be an expectation that important scientific knowledge
of Medical
approve the project as presented, require changes before it can will be the result.
and Medical
start, or refuse approval altogether. Many committees have a further
To ensure scientific merit, paragraph 11 requires that the project be
Features
role of monitoring projects that are underway to ensure that the
based on a thorough knowledge of the literature on the topic and on
researchers fulfil their obligations and they can if necessary stop a
Ethics
previous laboratory and, where appropriate, animal research that
Principal
project because of serious unexpected adverse events.
gives good reason to expect that the proposed intervention will be
ManualManual
The reason why ethics committee approval of a project is required efficacious in human beings. All research on animals must conform
to ethical guidelines that minimize the number of animals used and
Ethics Ethics
is that neither researchers nor research subjects are always
knowledgeable and objective enough to determine whether a prevent unnecessary pain. Paragraph 15 adds a further requirement
Medical
project is scientifically and ethically appropriate. Researchers need that only scientifically qualified persons should conduct research
Medical
to demonstrate to an impartial expert committee that the project is on human subjects. The ethics review committee needs to be
worthwhile, that they are competent to conduct it, and that potential convinced that these conditions are fulfilled before it approves the
research subjects will be protected against harm to the greatest project.
extent possible.
Social Value
One unresolved issue regarding ethics committee review is whether ...social value has
a multi-centre project requires committee approval at each centre or One of the more controversial emerged as an
whether approval by one committee is sufficient. If the centres are requirements of a medical research important criterion
for judging whether
in different countries, review and approval is generally required in project is that it contribute to the well-
a project should be
each country. being of society in general. It used to funded.
be widely agreed that advances in
Scientific Merit scientific knowledge were valuable
in themselves and needed no further justification. However,
Paragraph 11 of the DoH requires
as resources available for medical research are increasingly
...medical research that medical research involving
inadequate, social value has emerged as an important criterion for
involving human human subjects must be justifiable on
judging whether a project should be funded.
subjects must be scientific grounds. This requirement
justifiable on is meant to eliminate projects that Paragraphs 18 and 19 of the DoH clearly favour the consideration of
scientific grounds are unlikely to succeed, for example, social value in the evaluation of research projects. The importance
because they are methodologically of the projects objective, understood as both scientific and social
inadequate, or that, even if successful, importance, should outweigh the risks and burdens to research
will likely produce trivial results. If patients are being asked to subjects. Furthermore, the populations in which the research is
participate in a research project, even where risk of harm is minimal, carried out should benefit from the results of the research. This is
104 105
Ethics
Research
especially important in countries where there is potential for unfair unknown, then the researcher should not proceed with the project
of Medical
treatment of research subjects who undergo the risks and discomfort until some reliable data are available, for example, from laboratory
and Medical
of research while the drugs developed as a result of the research studies or experiments on animals.
Features
only benefit patients elsewhere.
Ethics
The social worth of a research project is more difficult to determine Informed Consent
Principal
than its scientific merit but that is not a good reason for ignoring The first principle of the Nuremberg The voluntary
ManualManual
it. Researchers, and ethics review committees, must ensure that consent of the human
Code reads as follows: The voluntary
subject is absolutely
patients are not subjected to tests that are unlikely to serve any
Ethics Ethics
consent of the human subject is essential.
useful social purpose. To do otherwise would waste valuable health absolutely essential. The explanatory
Medical
resources and weaken the reputation of medical research as a paragraph attached to this principle
major contributing factor to human health and well-being.
Medical
requires, among other things, that the research subject should have
sufficient knowledge and comprehension of the elements of the
Risks and Benefits subject matter involved as to enable him to make an understanding
Once the scientific merit and social and enlightened decision.
If the risk is entirely worth of the project have been
unknown, then the The DoH goes into some detail about informed consent. Paragraph
established, it is necessary for the
researcher should 22 specifies what the research subject needs to know in order to
researcher to demonstrate that the
not proceed with the make an informed decision about participation. Paragraph 23 warns
project until some risks to the research subjects are not
against pressuring individuals to participate in research, since
reliable data are unreasonable or disproportionate to
in such circumstances the consent may not be entirely voluntary.
available the expected benefits of the research,
Paragraphs 24 to 26 deal with research subjects who are unable
which may not even go to the
to give consent (minor children, severely mentally handicapped
research subjects. A risk is the potential
individuals, unconscious patients). They can still serve as research
for an adverse outcome (harm) to occur. It has two components: (1)
subjects but only under restricted conditions.
the likelihood of the occurrence of harm (from highly unlikely to very
likely), and (2) the severity of the harm (from trivial to permanent The DoH, like other research ethics documents, recommends that
severe disability or death). A highly unlikely risk of a trivial harm informed consent be demonstrated by having the research subject
would not be problematic for a good research project. At the other sign a consent form (paragraph 22). Many ethics review committees
end of the spectrum, a likely risk of a serious harm would be require the researcher to provide them with the consent form they
unacceptable unless the project provided the only hope of treatment intend to use for their project. In some countries these forms have
for terminally ill research subjects. In between these two extremes, become so long and detailed that they no longer serve the purpose
paragraph 17 of the DoH requires researchers to adequately assess of informing the research subject about the project. In any case, the
the risks and be sure that they can be managed. If the risk is entirely process of obtaining informed consent does not begin and end with
106 107
Ethics
Research
the form being signed but must involve a careful oral explanation of precedence. This means, among other things, that the physician
of Medical
the project and all that participation in it will mean to the research must be prepared to recommend that the patient not take part in a
and Medical
subject. Moreover, research subjects should be informed that they research project if the patient seems to be doing well with the current
Features
are free to withdraw their consent to participate at any time, even treatment and the project requires that patients be randomized
after the project has begun, without any sort of reprisal from the to different treatments and/or to a placebo. Only if the physician,
Ethics
Principal
researchers or other physicians and without any compromise of on solid scientific grounds, is truly uncertain whether the patients
ManualManual
their healthcare. current treatment is as suitable as a proposed new treatment, or
even a placebo, should the physician ask the patient to take part in
Ethics Ethics
Confidentiality the research project.
...research subjects
Medical
As with patients in clinical care, have a right to privacy
research subjects have a right to Honest Reporting of Results
with regard to their
Medical
privacy with regard to their personal personal health It should not be necessary to require that research results be reported
health information. Unlike clinical information accurately, but unfortunately there have been numerous recent
care, however, research requires the accounts of dishonest practices in the publication of research results.
disclosure of personal health information Problems include plagiarism, data fabrication, duplicate publication
to others, including the wider scientific community and sometimes and gift authorship. Such practices may benefit the researcher, at
the general public. In order to protect privacy, researchers must least until they are discovered, but they
ensure that they obtain the informed consent of research subjects can cause great harm to patients, who
...there have been
to use their personal health information for research purposes, may be given incorrect treatments
numerous recent
which requires that the subjects are told in advance about the based on inaccurate or false research accounts of dishonest
uses to which their information is going to be put. As a general reports, and to other researchers, who practices in the
rule, the information should be de-identified and should be stored may waste much time and resources publication of
and transmitted securely. The WMA Declaration on Ethical trying to follow up the studies. research results
Considerations Regarding Health Databases provides further
guidance on this topic. Whistle-blowing
Ethics
Research
regulators are seeing the need to detect and punish unethical they are working. All these issues will require much further analysis
of Medical
research and are beginning to appreciate the role of whistle-blowers and discussion before general agreement is achieved.
and Medical
in achieving this goal.
Despite all these potential problems, medical research is a valuable
Features
Junior members of a research team, such as medical students, may and rewarding activity for physicians and medical students as well
Ethics
find it especially difficult to act on suspicions of unethical research, as for the research subjects themselves. Indeed, physicians and
Principal
since they may feel unqualified to judge the actions of senior medical students should consider serving as research subjects so
ManualManual
researchers and will likely be subject to punishment if they speak that they can appreciate the other side of the researcher-research
out. At the very least, however, they should refuse to participate subject relationship.
Ethics Ethics
in practices that they consider clearly unethical, for example, lying
Medical
to research subjects or fabricating data. If they observe others
engaging in such practices, they should take whatever steps they
Medical
can to alert relevant authorities, either directly or anonymously.
Unresolved Issues
Ethics
Research
of Medical
BACK TO THE CASE STUDY
and Medical
Dr. R should not have accepted so quickly.
Features
She should first find out more about the
Ethics
project and ensure that it meets all the
Principal
requirements for ethical research.
ManualManual
In particular, she should ask to see the
protocol that was submitted to the ethics
Ethics Ethics
review committee and any comments or
conditions that the committee put on the
Medical
project. She should only participate in
Medical
projects in her area of practice, and she
should satisfy herself about the scientific
merit and social value of the project. If she
is not confident in her ability to evaluate
the project, she should seek the advice of
colleagues in larger centres. She should
ensure that she acts in the best interests of
her patients and only enrols those who will
not be harmed by changing their current
treatment to the experimental one or to a
placebo. She must be able to explain the
alternatives to her patients so they can give
fully informed consent to participate or not
to participate. She should not agree to enrol
a fixed number of patients as subjects since
this could lead her to pressure patients to
agree, perhaps against their best interests.
She should carefully monitor the patients in
the study for unexpected adverse events and
be prepared to adopt rapid corrective action.
Finally, she should communicate to her
patients the results of the research as they
become available.
112
Don Mason/CORBIS
Man Hiking on Steep Incline
CONCLUSION
CHAPTER SIX
113
Medical
Medical
Ethics Ethics Principal
ManualManual
Medical Features
Ethics
Ethicsand of Medical
Manual
Medical Ethics
Conclusion
Research
114 115
Ethics
Conclusion
Research
RESPONSIBILITIES AND PRIVILEGES Over the years the WMA has adopted several policy statements on
of Medical
OF PHYSICIANS the rights of physicians and the corresponding responsibilities of
Medical
Manual
others, especially governments, to respect these rights:
This Manual has focused on the duties and responsibilities of
Features
and
physicians, and indeed that is the main substance of medical The 1984 Statement on Freedom to Attend Medical Meetings
Ethics
Ethics
ethics. However, like all human asserts that there should be no barriers which will prevent
Principal
Medical
beings, physicians have rights as physicians from attending meetings of the WMA, or other
...like all human
ManualManual
beings, physicians well as responsibilities, and medical medical meetings, wherever such meetings are convened.
have rights as well as ethics would be incomplete if it did
Ethics Ethics
The 1986 Declaration on Physician Independence and
responsibilities not consider how physicians should
Professional Freedom states, Physicians must have
Medical
be treated by others, whether
the professional freedom to care for their patients without
patients, society or colleagues. This
Medical
interference and Physicians must have the professional
perspective on medical ethics has become increasingly important
freedom to represent and defend the health needs of patients
as physicians in many countries are experiencing great frustration
against all who would deny or restrict needed care for those who
in practising their profession, whether because of limited resources,
are sick or injured.
government and/or corporate micro-management of healthcare
delivery, sensationalist media reports of medical errors and unethical The 1995 Statement on Professional Responsibility for
physician conduct, or challenges to their authority and skills by Standards of Medical Care declares that any judgement
patients and other healthcare providers. on a doctors professional conduct or performance must
incorporate evaluation by the doctors professional peers who,
Medical ethics has in the past considered the rights of physicians
by their training and experience, understand the complexity of
as well as their responsibilities. Previous codes of ethics such
the medical issues involved. The same statement condemns
as the 1847 version of the American Medical Associations Code
any procedures for considering complaints from patients or
included sections on the obligations of patients and of the public
procedures for compensating patients, which fail to be based
to the profession. Most of these obligations are outmoded, for
upon good faith evaluation of the doctors actions or omissions
example, The obedience of a patient to the prescriptions of his
by the physicians peers.
physician should be prompt and implicit. He should never permit
his own crude opinions as to their fitness, to influence his attention The 1997 Declaration Concerning Support for Medical
to them. However, the statement, The public ought to entertain Doctors Refusing to Participate in, or to Condone, the Use
a just appreciation of medical qualifications [and] to afford of Torture or Other Forms of Cruel, Inhuman or Degrading
every encouragement and facility for the acquisition of medical Treatment commits the WMA to support and protect, and to call
education, is still valid. Rather than revising and updating these upon its National Medical Associations to support and protect,
sections, however, the AMA eventually eliminated them from its physicians who are resisting involvement in such inhuman
Code of Ethics. procedures or who are working to treat and rehabilitate victims
116 117
Ethics
Conclusion
Research
thereof, as well as to secure the right to uphold the highest RESPONSIBILITIES TO ONESELF
of Medical
ethical principles including medical confidentiality.
Medical
This Manual has classified physicians
Manual
The 2003 Statement on Ethical Guidelines for the ethical responsibilities according to Physicians often
Features
and
International Recruitment of Physicians calls on every their main beneficiaries: patients, forget that they have
Ethics
Ethics
responsibilities to
country to do its utmost to retain its physicians in the profession society, and colleagues (including
Principal
themselves, and to
Medical
as well as in the country by providing them with the support they other health professionals). their families,
ManualManual
need to meet their personal and professional goals, taking into Physicians often forget that they have as well.
account the countrys needs and resources and to ensure that responsibilities to themselves, and to
Ethics Ethics
Physicians who are working, either permanently or temporarily, their families, as well. In many parts
Medical
in a country other than their home country be treated fairly in of the world, being a physician has required devoting oneself to the
relation to other physicians in that country (for example, equal practice of medicine with little consideration for ones own health
Medical
opportunity career options and equal payment for the same and well-being. Working weeks of 60-80 hours are not uncommon
work). and vacations are considered to be unnecessary luxuries. Although
many physicians seem to do well in these conditions, their families
Although such advocacy on behalf ...physicians may be adversely affected. Other physicians clearly suffer from
of physicians is necessary, given the sometimes need also
this pace of professional activity, with results ranging from chronic
threats and challenges listed above, to be reminded of the
privileges they enjoy. fatigue to substance abuse to suicide. Impaired physicians are a
physicians sometimes need also to
danger to their patients, with fatigue being an important factor in
be reminded of the privileges they
medical mishaps.
enjoy. Public surveys in many countries
have consistently shown that physicians are among the most highly The need to ensure patient safety, as well as to promote a healthy
regarded and trusted occupational groups. They generally receive lifestyle for physicians, is being addressed in some countries by
higher than average remuneration (much higher in some countries). restrictions on the number of hours and the length of shifts that
They still have a great deal of clinical autonomy, although not as physicians and trainees may work. Some medical educational
much as previously. Many are engaged in an exciting search for new institutions now make it easier for female physicians to interrupt
knowledge through participation in research. Most important, they their training programmes for family reasons. Although measures
provide services that are of inestimable value to individual patients, such as these can contribute to physician health and well-being,
particularly those who are vulnerable and most in need, and to the primary responsibility for self-care rests with the individual
society in general. Few occupations have the potential to be more physician. Besides avoiding such obvious health hazards as
satisfying than medicine, considering the benefits that physicians smoking, substance abuse and overwork, physicians should protect
provide relief of pain and suffering, cure of illnesses, and comfort and enhance their own health and well-being by identifying stress
of the dying. Fulfilment of their ethical duties may be a small price to factors in their professional and personal lives and by developing
pay for all these privileges. and practising appropriate coping strategies. When these fail,
118 119
Ethics
Conclusion
Research
they should seek help from colleagues and appropriately qualified people needing cure if possible and care always. Physicians have
of Medical
professionals for personal problems that might adversely affect their traditionally provided these services along with others such as health
Medical
Manual
relationships with patients, society or colleagues. promotion, disease prevention and health system management.
Features
Although the balance among these activities may change in the
Ethicsand
THE FUTURE OF MEDICAL ETHICS future, physicians will likely continue to play an important role in
Ethics
Principal
all of them. Since each activity involves many ethical challenges,
Medical
This Manual has focussed on the current state of medical ethics,
ManualManual
physicians will need to keep informed about developments in
although with numerous references to its past. However, the present
medical ethics just as they do in other aspects of medicine.
is constantly slipping away and it is necessary to anticipate the
Ethics Ethics
future if we are not to be always behind the times. The future of This is the end of the Manual but for the reader it should be just
Medical
medical ethics will depend in large part on the future of medicine. one step in a life-long immersion in medical ethics. To repeat what
In the first decade of the 21st century, medicine is evolving at a very was stated in the Introduction, this Manual provides only a basic
Medical
rapid pace and it is difficult to predict how it will be practised by the introduction to medical ethics and some of its central issues. It
time todays first-year medical students complete their training, and is intended to give you an appreciation of the need for continual
impossible to know what further changes will take place before they reflection on the ethical dimension of medicine, and especially on
are ready to retire. The future will not necessarily be better than how to deal with the ethical issues that you will encounter in your
the present, given widespread political and economic instability, own practice. The list of resources provided in Appendix B can help
environmental degradation, the continuing spread of HIV/AIDS and you deepen your knowledge of this field.
other potential epidemics. Although we can hope that the benefits of
medical progress will eventually spread to all countries and that the
ethical problems they will face will be similar to those currently being
discussed in the wealthy countries, the reverse could happen
countries that are wealthy now could deteriorate to the point where
their physicians have to deal with epidemics of tropical diseases and
severe shortages of medical supplies.
Ethics
Appendix A
APPENDIX A - GLOSSARY such an arrangement. The term, hierarchy, is also used to refer to the top
of Medical
leaders of an organization.
Manual
Accountable answerable to someone for something (e.g., employees Justice fair treatment of individuals and groups. As Chapter Three points
Features
are accountable to their employers for the work they do). Accountability out, there are different understandings of what constitutes fair treatment in
PrincipalEthics
requires being prepared to provide an explanation for something one has healthcare.
done or has not done.
Hierarchy an orderly arrangement of people according to different levels Profess to state a belief or a promise in public. It is the basis of the terms
of importance from highest to lowest. Hierarchical is the adjective describing profession, professional and professionalism.
122 123
Ethics
Appendix B
Rational based on the human capacity for reasoning, i.e., to be able to APPENDIX B MEDICAL ETHICS RESOURCES
of Medical
consider the arguments for and against a particular action and to make a ON THE INTERNET
decision as to which alternative is better.
Manual
Features
Surrogate or substitute gestation a form of pregnancy in which a woman General
PrincipalEthics
agrees to gestate a child and give it up at birth to another individual or
World Medical Association Policy Handbook (www.wma.net/e/policy/
couple who in most cases have provided either the sperm (via artificial
handbook.htm) contains the full text of all WMA policies (in English,
Beginning-of-life issues
Human cloning www.who.int/ethics/topics/cloning/en/
Assisted reproduction www.who.int/reproductive-health/infertility/report_
content.htm
End-of-life issues
Resources www.nih.gov/sigs/bioethics/endoflife.html
Education for Physicians on End-of-life Care www.ama-assn.org/ama/
pub/category/2910.html
Palliative care www.hospicecare.com/Ethics/ethics.htm
Opposition to euthanasia www.euthanasia.com/
124 125
Ethics
Appendix C
HIV/AIDS APPENDIX C
of Medical
Resources www.wits.ac.za/bioethics/
WORLD MEDICAL ASSOCIATION
Manual
UNAIDS www.unaids.org/en/in+focus/hiv_aids_human_rights/
Features
unaids+activities+hr.asp
Resolution on the Inclusion of Medical Ethics and Human Rights in
PrincipalEthics
the Curriculum of Medical Schools World-Wide
Relations with commercial enterprises
(Adopted by the 51st World Medical Assembly,
Ethics
Appendix D
Participation in patient care would include teamwork with other health APPENDIX D - STRENGTHENING ETHICS
of Medical
professions. TEACHING IN MEDICAL SCHOOLS
Manual
4.4 Educational Resources Research
Features
Some medical schools have very little ethics teaching while others have
The interaction between research and education activities should
highly developed programs. Even in the latter ones, however, there is always
Ethics
encourage and prepare students to engage in medical research and
room for improvement. Here is a process that can be initiated by anyone,
Principal
development.
Ethics
Appendix E
5. Ensure continuity APPENDIX E - ADDITIONAL CASE STUDIES
of Medical
Advocate for a permanent medical ethics committee
Recruit younger students
Manual
Recruit additional faculty
Features
CONTRACEPTIVE ADVICE
Engage new faculty and key administrators
PrincipalEthics
TO A TEENAGER
Sara is 15 years old. She lives in a town where
Ethics
Appendix
of Medical E
A PREMATURE INFANT* HIV INFECTION*
Manual
Max was born during the 23rd week of pregnancy. Mr. S is married and the father of two school
Features
He is ventilated because his lungs are very children. He is treated in your clinic for a rare form
PrincipalEthics
immature. Moreover, he suffers from cerebral of pneumonia that is often associated with AIDS.
bleeding because his vessel tissue is still unstable. His blood test results show that he is indeed
*
Suggested by Dr. Gerald Neitzke and Ms. Mareike Moeller, Medizinische
Hochschule Hannover, Germany
132 133
Ethics
Appendix
of Medical E
TREATING A PRISONER END-OF-LIFE DECISION
Manual
As part of your medical duties you spend one An 80-year old woman is admitted to your hospital
Features
day every two weeks seeing inmates in a nearby from a nursing home for treatment of pneumonia.
PrincipalEthics
prison. Yesterday you treated a prisoner with She is frail and mildly demented. You treat the
multiple abrasions on his face and trunk. When pneumonia successfully but just before she is to be
Ethics Manual
Ethics
COLLECTIONS OF CASE STUDIES
of Medical
UNESCO Chair in Bioethics informed consent case studies http://research.
Medical
haifa.ac.il/~medlaw/ (UNESCO Chair)
Senior Woman
Receiving Medical Exam
Peter M. Fisher/CORBIS
136
ISBN 92-990028-1-9