SELECTED STUDIES

 

Ethics is to do 'with how we ought to live', to do with rights and wrongs and the way 
we conduct ourselves. It is to do with the 'values' that are important to a society.

- Socrates

 

MEDICAL ETHICS

By Prof. Refaat Kamel, MD, FACS, FICS 
Former World President of International College of Surgeons 

Lecture given at the Conjoined meeting of Cairo Tropical Surgery Institute 
with the Royal College of Surgeons Ireland (Cairo, October 2002)

International College of Surgeons

 

Medical ethics is concerned with doing what is right in the circumstances where the components of the problem are not purely technical. Ethics is neither like mathematics nor science. In ethics, only actions can be right or wrong, as determined by what can seem a confusing blend of reason, experience, intentions, tastes and fashions. All these influence ethical decisions but none is paramount over another. 

What are Ethics?

Although some consider that there are "absolute values," others would argue that values are relative and are affected by the local context. Values in communities in rural India for example, are likely to be different from values in rural France. Or are they?

Whose values and perspectives should be considered? Are all values important? And how are we going to deal with the conflicts that arise when values between different places and cultures conflict? With 'globalization' comes the potential for the rapid transfer of' 'values' from one community to another.

Of the US $56 billion spent annually on medical research worldwide, at least 90% of this amount is spent on the health needs of the richest countries, which represent a mere 10% of the world's population. Only 10% of this research therefore, addresses the needs of 90% of the world's population (WHO, 1996). The annual health budget in most developing countries is less than US$ 10 per person. Health care therefore, and research into healthcare, are conducted within a globalized value system that allows this differential to exist but at the same time struggles to find ways of changing it to make it more equitable.

One difficulty around ethics and bioethics (the term to link the broad field of ethics healthcare), is the realization that what is considered 'ethical' at one point in time, will be considered 'unethical' at a later date, indicating how we are unable to see the 'whole picture' at a particular juncture in time.

A reaction to the events of the Holocaust during the Second World War led to the Nuremberg Code for research. Declaration of Human rights in 1948. We are fortunate that in the 21st century that there are ethical declarations and guidelines that have been created to deal with the complex interactions between individuals, the societies in which they live, the healthcare they receive, and the research that is conducted on their behalf to investigate health and disease.

The four bio-ethical principles are:

History of informed medical consent

Even though a fair amount is known about the codes of medical ethics and practice and physician-patient relationships in ancient civilizations, there is little evidence that the formalized practice of legally binding informed medical consent existed before the late 19th century. I report a documented case of legal informed medical consent, which is dated November 10, 1677.

While reviewing court records published in a book by N.S. al-Humsi, the author found a copy of the following document.


Case: Extraction of hernia of Christian Ya'coub, son of Ghanim, by the Christian Nichola, son of Yani, on the Twelfth Day of the month of Sha'ban, of the lunar year 1088.

The reason why this document has been written down is that the Christian Ya'coub, son of Ghanim, the Monk in Ballamand Monastery, province of Tripoli, presented himself at the Tripoli-Syri, Holy Sharia Council and hired and engaged the Christian surgeon Nichola, son of Yani, to extract his (Ya'coub's) hernia on the right side in return for a fee of ten piasters. After the hired has undertaken to extract the hirer's hernia and treat it with ointments, the aforementioned hirer asked people to duly and legally bear witness that if the hirer died as a result of fate and God's divine decree because of his being treated by the hired, the latter shall not be held as guarantor for him, and the hirer has also relieved the son any responsibility for his death and blood money; and that the hirer or his heir after him shall not be entitled to any related claims made against aforesaid surgeon.

Effected and written down on the 12th day of the holy month of Sha'ban of the year 1088.

Witnesses: Mawlana Sheikh Mustafa - may his grace be augmented. Mawlana Sheikh Mohammad, scribe of the original copy. Mohammed Shalabi, interpreter. Hussein Buluk Bashi. Haj Ramadan, Chief Court usher.

This documented which was recorded during the Ottoman Empire, attests to the existence of an established practice of legal contracts between physician and patient, which is drawn up and signed in the presence of witnesses. It is interesting to note that the contract was not limited to the surgical procedure but also included postoperative treatment and physician fees.

Quotes in history on medical ethics

Life is short, art is long, the right opportunity is fleeting, experience is deplorable, and judgment is hard.

If an operation is considered necessary, one should act at the beginning. Once the illness has reached a peak, its best left alone.

What cannot be cured by medicaments is cured by the knife, what the knife cannot cure is cured with the searing-iron, and whatever this cannot cure must be considered incurable.

Even if they regard their illness as serious, many patients regain health simply through satisfaction with an understanding doctor.

Whatever I see or hear, in practicing my profession or apart from it, and which ought not to be spread about, I will hold secret and never reveal.

Some ethical issues

The rapid advance in technology in Northern countries, has spawned the development of new drugs to combat HIV infection. But these drugs are expensive. In addition, they need sophisticated technological systems to support their use, to prevent both the side effects for patients, and the development of drug resistance.

Perspectives, opinions, and statements on the ethics of research and practice require a forum for discussion and a means for finding a resolution to potential differences.

This is to do with the ethical process, which currently has its focus in its work of the ethics committee.


International Guidelines

Another precedent may be found in the part physicians have played in evaluating who is and who is not to be given costly long-term renal dialysis. Certainly, this has required pacing relative values on human lives. And prepare to apply ethics in a rational development for the fulfillment and betterment of mankind in what is almost certain to be a biologically oriented world society.

Ethics Committees

Ethics and ethical guidelines assist doctors in dealing with dilemmas that arise, as healthcare work becomes increasingly diverse and complex. How do we respect the differences and perspectives of other cultures and countries while at the same time remaining true to our own values and perspectives? Our globalized world has increasing need of 'ethics' as a tool to assist us in choosing the most appropriate ways to improve the health of individuals and communities in all parts of the globe.

WHAT IF YOU HAD TO DECIDE?

What is right? What is wrong? Who makes these tough choices?

Dr. Refaat Kamel is a professor of surgery in Ain Shams University. He has a plethora of publications and researches. He is co-editor with his colleague Prof. Lumley of the new textbook entitled, "Tropical Surgery" which will be published in 2004 by Springer-Verlag. His email is rkamel2001@yahoo.com


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