Prof. Dr. Sumbul Shamim, Dean, Faculty of Pharmaceutical Sciences & Principal, Dow College of Pharmacy, Dow University of Health Sciences, Karachi
“If we believe men have any personal rights at all as human beings, they have an absolute right to such a measure of good health as society, and society alone is able to give them” – Aristotle
Health systems as defined by World Health Organization (WHO) “all the activities whose primary purpose is to promote, restore or maintain health”. When we move into the 21stcentury, the promotion and protection of human rights is gaining greater momentum. The WHO constitution 1946 stated:
“The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”
Ethics are standards of conduct (or social norms) that prescribe behavior.Ethics as a field of study is a normative discipline whose main goals are prescriptive and evaluative rather than descriptive and explanatory. So Ethicists are different from social scientists. Ethicists (or moral philosophers) study standards of conduct.
But standards of conduct do not describe our actual behavior, since people often violate widely accepted standards. For Example, most people accept the idea that one ought to tell the truth, yet many people lie all of the time. Even though people lie all of the time, we indicate our endorsement of honesty as a standard of conduct by defending honesty in public, by teaching our children/students to be honesty, and by expressing our disapproval of lying.
In thinking about standards of conduct, it will be useful to distinguish between “ethics” and “morality”.
Morality consists of a society’s most general standards. These standards apply to all people in society regardless of their professional or institutional roles. Moral standards include those rules that most people learn in childhood, e.g. “don’t lie, cheat, steal, harm other people, etc.” Many ethicists maintain that moral duties and obligations override other ones: so, “if I have a moral duty not to lie, then I should not lie even if my employment requires me to lie.”
So that we can see, moral standards distinguish between right and wrong, good and bad, virtue and vice, justice and injustice.
Ethics are not general standards of conduct but the standards of a particular profession, occupation, institution, or group within society. The word “ethics”, when used in this way, usually serves as a modifier for another word, e.g. business ethics, medical ethics, sports ethics, military ethics, etc. They are all professional ethics.
Professional ethics are standards of conduct that apply to people who occupy a professional occupation or role.
A person who enters a profession acquires ethical obligations because society trusts them to provide valuable goods and services that cannot be provided unless their conduct conforms to certain standards.
Professionals who fail to live up to their ethical obligations betray this trust. Professional ethics studied by ethicists include medical ethics.
The expressions “professional ethics” and “medical ethics” were coined by Thomas Percival.
Medical ethics is a special kind of ethics only as it relates to a particular realm of facts and concerns and not because it embodies or appeals to some special moral principles or methodology.
It is applied ethics. It consists of the same moral principles and rules that we would appeal to and argue for, in ordinary circumstances.
It is just that in medical ethics these familiar moral rules are being applied to situations peculiar to the medical world.
Bioethics could be defined as the study of ethical issues and decision-making associated with the use of living organisms
Bioethics includes both medical ethics and environmental ethics. Bioethics is learning how to balance different benefits, risks and duties.
Clinical ethics is a practical discipline that provides a structured approach for identifying , analyzing, and resolving ethical issues in clinical medicine.
Clinical medical ethics is a practical and applied discipline that aims to improve patient care and patient outcomes by focusing on reaching a right and good decision in individual cases.
It focuses on the doctor-patient relationship and takes account of the ethical and legal issues that patients, doctors, and hospitals must address to reach good decisions for individual patients.
Clinical ethics emphasizes that in practicing good clinical medicine, physicians must combine scientific and technical abilities with ethical concerns for the personal values of the patients who seek their help.
“never being selfish but always ready to help others” have become the principal values of medical ethics.
Dr. Francis Peabody’s famous quote says “the secret of the care of the patient is in caring for the patient.” This helps to remind us that the purpose of the health care enterprise is to serve our patients and their loved ones. Serving our patients and their loved ones means understanding what is important — what matters most to them, what their fears are, what their hopes are, what they are hoping medical care can do for them. The only way to learn these central factors about our patients is to sit down and ask, and then to listen. This takes time and focused attention, something that is in ever-scarcer supply in modern medicine.
Patients, families and healthcare professionals occasionally face complicated decisions about medical treatments. These decisions may clash with a patient and/or family morals, religious beliefs or healthcare plan. In this risky situation medical ethics is not only considerate review of how to act in the best interest of patients and their family but also about making good choices based on beliefs and values regarding life, health, and suffering. In the past, only a few individual physicians devoted themselves to medical ethics. Beginning in the second half of twentieth century, the field undergoes explosive expansion and experts from numerous disciplines entered in medical ethics. The swift advances in medical diagnosis and treatment and the introduction of new technologies have created numerous new ethical problems, resulting in the maturation of medical ethics as a specialty in its own right.
Enormous development has been achieved in the medical field during the last few decades and more is projected in the following decades. Advances in diagnostic imaging and biological testing techniques as well as in medical forecasting based on genetic testing are ongoing. Advances in surgical and medical cures, organ and tissue transplantation, artificial organs, cloning, tissue culture techniques, molecular biology and information technology are reported almost daily. “Modern Medical Ethics” is based on concept derived from various disciplines, including the biomedical sciences, the behavioral sciences, philosophy, religion and law. Modern medical ethics is essentially a form of applied ethics, which seeks to clarify ethical questions that characterize the practice of medicine and to justify and weigh the various practical options and considerations. Thus medical ethics is the application general ethical principles to ethical issues. The application of such an ethic is not specific to medicine but also relates to economy, law, journalism, and their like.
Medical ethics is now not only part of the curriculum in institutes of the health professions including Medicine and Pharmacy in developed countries but also research institutes of medical ethics have been established at all levels. In developed nations the medical literature has proliferated, with numerous books and journals devoted entirely to the subject. In such countries common citizen is also vitally interested in this subject, and public lectures, newspaper articles, legal discussions and legislation on medical ethical issues are frequent. Within Canada, EU, United States, and somehow gulf countries, Modern Medical Ethics has emerged as a new professional. The individuals normally have specialized in one or more the fields of philosophy, ethics, law, religion and medicine, and serve as advisor in hospitals to physicians, patients and their families. They also effort to resolve difficult ethical questions posed to them by the medical team or by patients and their families.
The era has changed now, the healthcare practice and patients are more attentive of their healthcare rights. In Pakistan patients have now begun to question their physicians for their right to know their options, their planned treatment and possible obstacles. Because of the need in modern medicine to be knowledgeable in medical ethics and because health care professionals are exposed to medical ethical issues throughout their studies, it has become necessary to teach Modern Medical Ethics in colleges and universities of the health care professions. Ethics, equity and respect for human rights must be incorporated in all aspect of health care and its application should be made as adequate as possible as it is our responsibility being engaged in health care profession.
On government level the government agency or ministry is responsible for human subjects’ oversight. The government of Pakistan approved the constitution of the National Bioethics Committee (NBC) in 2004. NBC’s purpose is to “promote and facilitate ethical health services delivery and health research.” NBC’s Secretariat is the Pakistan Medical Research Council (PMRC), which is under Pakistan’s Ministry of Health (MoH) or Drug Regulatory Authority of Pakistan (DRAP)
NBC initially had a limited role in human subjects oversight, but is expanding its role in response to the growing number of situations in which existing human subjects rules prove to be unclear. One of NBC’s functions is to review research protocols.
Pakistan’s Drugs Control Organization is involved in the implementation of the Drugs (Research) Rules (1978). The Drugs Control Organization performs drug registration and quality control, as well as participating in the regulation of drug research.
Ethics is an understanding of the nature of conflicts arising from moral imperatives and how best we may deal with them. Specifically it deals with conflicts in potential outcome (consequences of actions) or with duties and obligations.
Ethics does NOT decide what is morally right or wrong; rather it considers how we should act best in the light of our duties and obligations as moral agents. Clinicians have specific duties of care to their patients and to society.
It is generally held that clinicians should always act in the best interest of their patients; but sometimes there is a conflict between obligations to a patient and those perceived to be owed to the community or to other patients. It may not always be the case that what the clinician believes is in the best interest of the patient is what the patient wishes or will consent to. Central to modern medical ethics is a respect for patient autonomy and the fundamental principle of informed consent.
Medical Ethics is a practical subject as well as a branch of moral philosophy.
Ethics is an integral part of good medical practice. It is an essential branch of medicine.
Ethics deals with the choices we make and our actions in relation to those choices. It deals with choices made by both clinicians and patients and the duties and obligations of clinicians to their patients. Medical ethics also deals with the choices made by society, the distribution of resources and access to health care and the dilemmas arising from them.
Ethics deals with choices. Where there are no choices there is no need for ethics. There are almost always choices to consider and there is almost always a need for ethics.
Any choice we make involves ethics, although sometimes we may not realise or consider it. How we live involves choices affecting ourselves and others with both the potential for benefit and for harm (consequences). How we feed ourselves, clothe ourselves, keep ourselves warm, travel to work etc. All these choices have consequences for others.
Ethics is also about duties and obligations: to whom we have duties, how extensive they are, how best they may be discharged and how we deal with conflicting duties and obligations Patients have duties and obligations too, which is why we should respect them as moral agents. Parents have duties of care to their children; and sometimes a clinician’s duty to a child patient may conflict with those of the parents, and this needs an ethical approach to resolve.
Ethical practice involves a systematic approach to decision making and actions, considering the interests of all affected by the decision.
In those situations where you consider you have a duty to people other than your patient, a key issue is how best you discharge these duties in the best interest of both parties. A duty of care is paramount in the relationship between clinician and patient. For example, if a clinician must breech confidentiality of a patient, they should consider not only whether they should do so but also how they should do so in the best interest of their patient.