For more than 2,000 years, the medical profession has maintained a simple ethical standard focused on “avoiding harm to the patients,” shaped by the Hippocratic Oath, social morality and a variety of theological streams, cultures and traditions. Over the decades, the need to explore the moral dimension of rapid advances in medicine and science, combined with the desire to enhance public health, has led to the establishment of various international ethical codes and guidelines.
Medical ethics requires the physician to do what is best for the patients and place their interests before the interests of the physician. It is not about avoiding harm; rather, medical ethics comprises a set of norms and values and an ability to understand value proportions and perspectives. Above all, its purpose is to protect and defend human dignity and the rights of the patient.
The term “bioethics” is a prefix of two disciplines: biology and ethics. It was first coined by Fritz Jahr in 1927 in an article that sought to examine the “biological imperative,” expressing solidarity with the biosphere which hosts all living beings. Since then, the field of bioethics has attempted to address a broad swathe of human inquiry, ranging from debates over the boundaries of life and the allocation of scarce healthcare resources to the right to refuse medical care for religious or cultural reasons. It includes not only the philosophical study of the ethics of medicine but also such areas as medical law, medical anthropology, medical sociology, health politics, health economics and theology.
Ethical dilemmas
It is not uncommon to read news about patients and their relatives assaulting doctors in some hospital or the other, due to dissatisfaction with the quality of care provided. Litigation against medical professionals by patients is also becoming commonplace. And to think that, not very long ago, this very profession was treated as noble and doctors were considered next only to God! It often seems now that the regard for doctors is more due to fear than to any genuine respect for their profession.
Today, patients have lost trust in doctors (unless they are personally known to them) and believe that their decisions are driven by profit motive, not by welfare of patients. They assume that doctors always conduct unnecessary investigations and offer treatments that are costly and go on for a long time. It is indeed true that doctors in India mostly follow a paternalistic attitude in decision making – they believe that they have the right to take decisions on behalf of patients because of their domain knowledge. Many patients also feel that doctors do not have true empathy towards them and their medical problems. The doctors treat patients as mere cases, which is painful for them and their families.
Doctors, on the other hand, argue that while there may be some rogue elements in their profession, most of them work to the best of their ability and with utmost sincerity. A medical professional walks a tight rope because even the slightest mistake can have serious repercussions on patients and their families. Hence, the mistakes of the medical profession are not comparable to mistakes in any other profession.
It is a fact that India spends only one per cent of its GDP on healthcare. Faced with such glaring lack of medical infrastructure and facilities, it is unfair to blame everything on doctors. The supply of manpower in the health sector is much below what is required. The existing workforce is overworked and its efficiency is getting compromised. For most doctors, there is no time for activities like talking to patients at length, explaining their illness, discussing the various medical options and empathising with them in general. An average doctor works for about 80-100 hours per week. Scientific literature shows that if people work for more than 50 hours per week, their efficiency begins to fall to unacceptable levels. To compound such overwork, doctors also operate in a high-performance, high-stress environment.
Ethical standards help deliver good healthcare
Ethical standards help ensure good healthcare delivery by stating at the outset that the aim of medical care is to alleviate suffering. To give an example, recruiting highly qualified medical personnel and exposing them to continuous in-service training promotes their knowledge and skills in both medical care and medical ethics, and contributes to minimizing errors.
Second, medical care is built on the communication between medical workers on one side and patients and their families on the other. Ethical standards promote values that are essential to good communication, such as trust, accountability, mutual respect and fair medical care.
Third, ethical standards help build public support for medical care by creating trust in the quality and integrity of the healthcare setup and ensuring accountability.
Fourth, the field of healthcare involves medical workers from different disciplines. They need to operate in an environment characterized by trust, accountability, respect and fairness. Ethical standards promote the value of cooperation and collaborative work. Adherence to them can significantly facilitate a pleasant, healing environment for both patients and medical workers.
Ethics is culturally defined. Culture and tradition often outline medical ethics in the context where it should be applied. There are different approaches to implementing moral actions. Applied ethics involves culture and traditions and relies on academia to inform the medical profession of various ethical theories and principles.
Principles of bioethics
The following are the four commonly accepted principles of healthcare ethics (excerpted from Beauchamp and Childress).
Principle of respect for autonomy
Any notion of moral decision-making assumes that rational agents are involved in making informed and voluntary decisions. In healthcare decisions, respect for the autonomy of the patient would imply that the patient has the capacity to act intentionally, with understanding, and without any controlling influence that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction regarding healthcare
Principle of non-maleficence
The principle of non-maleficence mandates that medical practitioners should not intentionally create any harm or injury to the patient, either through acts of commission or omission. It is considered negligent if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well. This principle affirms the need for medical competence.
Principle of beneficence
The ordinary meaning of this principle is that healthcare providers have a duty to be of a benefit to the patient, as well as to take positive steps to prevent and remove harm from the patient. This principle is at the very heart of healthcare, implying that a suffering supplicant (the patient) can enter in a relationship with one whom society has licensed as competent to provide medical care, trusting that the physician’s chief objective is to help. The goal of providing benefit can be applied both to individual patients, and to the good of the society as a whole.
Principle of Justice
Justice in healthcare is usually defined as a form of fairness, or, as Aristotle said, "giving to each that which is his due." John Rawls (1999) and others claim that many of the inequalities we experience are a result of a "natural lottery" or "social lottery" for which the affected individual is not to blame. Therefore, society ought to help even the playing field by providing resources to overcome the disadvantaged situation. One of the most controversial issues in modern healthcare revolves around the question: "Who has the right to healthcare?" Or, stated another way, we as a society want to be beneficent and fair and provide a minimum level of healthcare for all citizens, regardless of their ability to pay.
These principles are useful in reflecting on moral problems and moving towards their ethical resolution.
Professional medical ethics involves expertise from fields such as philosophy, social sciences, medicine, research science, law and theology. The international guidelines acknowledge that the application of ethical standards needs to account for cultural values and traditions. However, it is important to state here that international guidelines are mere guidelines. They have no power over national conduct, which may be their primary weakness. It is not always advisable to rely on them when medical practitioners are facing critical ethical situations that may specifically relate to local beliefs. This gives rise to the need for ethical deliberation and reasoning, which in turn requires the sensitization of healthcare provider, right from undergraduate training in medicine, dentistry and nursing.
In this context, an important development is that the Amrita Institute of Medical Sciences based in Kochi has been awarded to set up a UNESCO Chair in Bioethics to promote the values of bioethics in healthcare settings in Kerala. It is the nodal centre for the SAARC region which would provide technical expertise for countries in India’s neighbourhood.
The Chair would be involved in imparting bioethical education in undergraduate medical, dental and nursing courses; sensitizing healthcare providers regarding ethical values for patient care; educating patients about their rights in healthcare; and providing training to clinical and research ethics committees for moral deliberations of the dilemma for patients, doctors or study participants.
(The author is bioethicist and public health expert, Amrita Institute of Medical Sciences, Kochi)