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GENERAL PRACTITIONER'S SECTION
MEDICAL ETHICS : BOON OR BANE?
P MADHOK
Antiquarians tell us that ethics is as old as medicine and medicine as old as mankind.The founding fathers of medicine like Susruta and Charaka in India and Hippocrates in Greece taught medicine by apprenticeship. Because of the close relationship and the freedom that the doctor enjoys with the patients it was necessary that a code of behaviour and morality be formulated. The Hippocratic Oath was designed in 1500 BC and remains the mother of all oaths inspite of having been modified many times. Based on three principles of Beneficence patient must benefit, Non Maleficence do no harm, and Autonomy patient must be free to accept or reject medical advice, it has remained the core of ethical teachings. The Oath has moved with the times. During World War II experiments were conducted on unwilling prisoners, doctors participated in torture and development of new drugs required double blind studies on humans, not always voluntarily. This necessitated changes in the Hippocratic Oath. The final form was recommended after the declaration of Helsinki (1965). The modified form is as follows and has been recommended by the MCI.
1. I solemnly pledge myself to consecrate my life to the service of humanity.
2. I will practice my profession with conscience and dignity.
3. I will maintain by all the means in my power the honour and the noble traditions of the medical profession.
4. Even under threat, I will not use my medical knowledge contrary to the laws of humanity.
5. I will give to my teachers the respect and gratitude which is their due.
6. My colleagues will be my brothers.
7. The health of my patient will be my first consideration.
8. I will maintain the utmost respect for human life from the time of conception.
9. I will respect the secrets which are confided in me, even after the patient has died.
10. I will not permit considerations of age, sex, religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
A feature of the past three decades has been the development of Activism. Human Rights supporters demanded the patient’s right to full information. Informed consent and punishing medical negligence was accepted. This led to the passing of The Consumer Protection Act (1996). Animal rights supporters made it difficult to use laboratory animals for experimentation.
Two lacunae in the Hippocratic Oath still remain.
1. The sanctity of human life and prohibition of abortion : These cases come in direct clash with governments trying to control population. Abortion is legal in our country.
2. Research : Nobody can deny that science has progressed by leaps and bounds in the last 50 years. Our elders never knew the range of medicines available to cure fatal diseases e.g. Cancer. Who would imagine that minimal access surgery would change the concept of operations. Diagnosis has become more accurate, thanks to the newer imaging techniques. Several methods (options) of treatment are now available for the same disease.All this would not have happened if people were bogged down with the older concept of the Hippocratic Oath. Risks had to be taken. Maleficence had to be balanced with Beneficence. Sometimes Autonomy also had to be nose-led, when patients cannot choose between equals or similar alternatives. This must ofcourse be done by altruistic and paternal thoughts.
Where do we stand now? As we see it science cannot develop without technology. Technology comes largely from non medicos. Should technology be allowed to over shadow medicine? Transplant of organs will soon become a commonly performed operation. Who will donate? Can we buy an organ from a normal person who may wish to donate for his own personal reasons, after informed consent.
Who will pay for life long immunosuppression and/or its complications? Robotic surgery is another development, just round the corner. This will enable a surgeon to operate on patients from a long distance!! Should there be a separate Oath for such advances?
Some people (including doctors) feel that the Hippocratic Oath has become irrelevant in the modern scenario. Greed not need is the driving force. Health care has largely moved into the hands of the Corporates. They are not bound by Medical Ethics. Profit; not service is the motive.
Development of horizontal and vertical specialisation in every field has resulted in more and more doctors knowing less and less about their patients. Many have become laboratory and computer dependant. The doctor-patient relationship is seriously compromised.
Is ethics relevant?
It is exactly because of the chaotic conditions, modern advances have created that Bio Ethics becomes absolutely necessary. There must be a code of ethics between doctor-patient, doctor-doctor and even doctor-institution. Good ethical practices will remove the need of the Consumer Protection Act. To inculcate ethics in ones clinical attitude it must start from the beginning. It must start from Medical School. This is a Universal practice. Some have questioned whether taking the Hippocratic Oath is necessary. I would say, yes. Ministes, Judges, Club President etc all over the world take an Oath before assuming office. Why shouldn’t the doctor - before he embarks on his chosen profession. The medical man must grow up knowing that he has a duty to society and to eachother.
MALARIA CAN WORSEN AFTER INITIAL GOOD PRESENTATION
Patients with malaria caused by Plasmodium falciparum can develop severe complications even
though they seem well at initial presentation. Moore and colleagues present two cases where
patients’ conditions deteriorated sharply despite treatment. They recommend clinicians consider
three points. Firstly, severe malaria can occur with low parasitaemia since the peripheral load may
not reflect the total parasite load. Secondly, normal investigations at presentation do not exclude
the risk of later complications. Thirdly, the assumption that people native to endemic regions are
immune to the disease is not always correct.
BMJ, 2003; 326 : 808.
