Medical Deontology: The fading science and need of the hour

Basics of medical ethics (medical deontology) 1

Notwithstanding the unprecedented advances the medical science has achieved, the fundamental value system of it’s practitioners has crumbled to a great extent. The principles and the foundations of the noble profession at present are very shaky and wobbly. The need and greed of lucre is the ‘principal principle’ which seems to be ruling this ‘materialistic’ world. Original guidelines of the Fathers of Medicine seem to be slowly fading away. Therefore it is the necessity in these testing times to introspect deeply and reinvent the vanishing science of ‘Medical Deontology’.

Medical ethics (Latin ethica, from Greek ethice – teaching of morals), or Medical Deontology (Greek deon – ‘duty’ or ‘obligation’; the term ‘deontology’ has been in wide use in the domestic medical literature over past years) is a system of moral principles that apply values and judgments to the practice of medicine. In fact one can visualize it as a “ set of ethical standards and principles of behaviour of medical practitioners while executing their professional duties, professional ethics of medical workers and principles of behavior of medical personnel, directed toward maximum benefit of treatment.”

Medical deontology includes problems of observing medical confidentiality, the problem of the extent of the medical worker’s responsibility for the life and health of the patient, and problems of relationships of medical workers to each other.

In accordance with medical deontology, in relation to the patient, the medical worker must evince maximum attention and apply all his knowledge in order to restore the patient to health or bring relief to him in his sufferings; he must convey to the patient only information about his health that will be beneficial to him and establish contact between the patient and the physician. He must avoid in the presence of the patient, conversations and discussions with colleagues, personnel, and with the patient himself concerning his illness, which sometimes produce the development of iatrogenic diseases. An international code of medical ethics was ratified (1949) by the World Medical Association in Geneva.

There are two main types of duties of medical practitioners, viz;Scientific - the section of medical science studying ethical and moral aspects of medical workers’ activity; Practical – the area of medical practice the tasks of which are the formation and application of ethical standards and rules of the professional medical activities.

As a scholarly discipline, medical deontology/ medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology.

Historical AspectsIf one is very keen on tracing the origins of this very ethereal science, then the ancient sources concerning medical ethics and deontology , we come across a plethora of literature from circumspective and varied backgrounds, viz; “The Laws of Hammurabi” (laws of Ancient Babylon, 18th century B. C.), “About the physician”, "The Oath" and "The Law" by Hippocrates (5-4 centuries B. C.), Indian “The Book of Life” (“Ayurveda” – 5-4 centuries B. C.). The term "ethics", meaning “a concept of human morals” was introduced by Aristotle (384-322 B. C.).As we progress towards the middle Ages: “The Canon of Medical Science” and “Ethics” by Ibn Sina (Avicenna, 10-11 centuries), the medical school of Salerno (1213) are encountered. The concepts have been dealt in greater details by likes of Jeremy Bentham (English philosopher, lawyer, priest; 1748-1832), who introduced the notion of deontology as meaning “… the teaching on the due behaviour of a person while achieving his end” (18 century). Some references in Russian medicine, e.g “The Word Concerning Piety and Moral Qualities of a Hippocratic Physician” and “The Word Concerning the Ways of Teaching and Learning the Practical Medicine” by Matvey Yakovlevich Mudrov (1776-1831), “Letters from Heidelberg” and “The Diary of an Old Doctor” by Nikolay Ivanovich Pirogov (1810-1881) are noteworthy. The controversial Nuremberg process(1947), which depicts the verdict to the Nazi physicians, “The Nuremberg Code”, postulates not legal, but also moral regulations of medical experiments. Post 1947 - the World Medical Association was created. Its main action was the adoption of “The Geneva Declaration” – the oath of a physician – the doctor (1948), the International Code of Medical Ethics (1949), “The Helsinki Declaration of Human Rights” (1964), “The Helsinki-Tokyo Declaration” (1975), and “The International Declaration on Human Rights” (1983).

The premises of the Medical Deontology

The medical ethics studies and defines the solution of various problems of inter-personal mutual relations in three basic directions:

medical worker – patient, medical worker – relatives of the patient, medical worker – medical worker.

Such qualities as compassion, kindness, keenness and responsiveness, care and attentive attitude to the patient should be inherent in any worker of medical sphere. It was Ibn Sina who had already demanded a special approach to the patient: “You should know that every separate person possesses the special nature inherent in him personally. It seldom happens, or it is absolutely impossible, that somebody would have the nature identical with his”In the ancient Indian medicine physician used to tell to his disciples: “You now leave your passions, anger, greed, madness, vanity, pride, envy, roughness, buffoonery, falsity, laziness and any vicious behaviour. From now on, you will have your hair and your nails shortly cut, wear red clothes, conduct a pure life”.

PRIMUM NON NOCERE (Latin) - FIRST, DO NO HARM – this maxim is the main ethical principle in medicine.

The moral responsibility of medical worker means his observance to all the principles of medical ethics. Wrong diagnostics, treatment, behaviour of doctor and representatives of middle-ranking and junior medical personnel may lead to physical and moral sufferings of patients. Such actions

of medical worker, as disclosure of medical secret, refusal to give medical aid, infringement of personal life’s inviolability and so forth are inadmissible.

Values in medical ethics

Six of the values that commonly apply to medical ethics discussions are:

Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.) The principle of autonomy recognizes the rights of individuals to self determination. This is rooted in society’s respect for individuals’ ability to make informed decisions about personal matters.

Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.) The term beneficence refers to actions that promote the wellbeing of others. In the medical context, this means taking actions that serve the best interests of patients.

Non-maleficence - concept of non-maleficence is embodied by the phrase, "first, do no harm," or the Latin, primum non nocere. Many consider that should be the main or primary consideration (hence primum): that it is more important not to harm your patient, than to do them good.

Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

Dignity - the patient (and the person treating the patient) have the right to dignity[4].

Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee Syphilis Study.

It has been argued that mainstream medical ethics is biased by the assumption of a framework in which individuals are not simply free to contract with one another to provide whatever medical treatment is demanded, subject to the ability to pay. Because a high proportion of medical care is typically provided via the welfare state, and because there are legal restrictions on what treatment may be provided and by whom, an automatic divergence may exist between the wishes of patients and the preferences of medical practitioners and other parties. Tassano[3] has questioned the idea that Beneficence might in some cases have priority over Autonomy. He argues that violations of Autonomy more often reflect the interests of the state or of the supplier group than those of the patient.

We can add some principles such as Medical privacy - allows a person to keep their medical records from being revealed

to others. Confidentiality - is commonly applied to conversations between doctors and

patients. This concept is commonly known as patient-physician privilege. Legal

protections prevent physicians from revealing their discussions with patients, even under oath in court.

Fidelity - is the quality of being faithful or loyal to one’s patients as if it is the service rendered in relation with the cause of ‘Lord Almighty’.

Veracity- Truth telling or Obligation to full and honest disclosure, of the information, concerns or any such matter, in context with a patient’s health/ disease state to himself/herself and their near and dear ones.

A physician should behave according to these principles while he(she) treats his(her) patient. These principles were also moral virtues of a physician in the past. The importance of these principles has been pointed out in the books of medical ethics up to now5.

It is a conviction, passionate belief and moral principle of the author to try and adhere to these principles as solemnly and sincerely as possible. It is recommended to all the practicing, experienced and conscientious doctors to try to inculcate these values, goals, moral attitude and aptitude in the future generation of medical professionals.

Conflict of interest

I confirm that there is no conflicts of interest related to this editorial

Prof. Mridul M. Panditrao

Consultant,

Department of Anesthesiology and Intensive care

Public Hospital authority’s Rand Memorial Hospital

Freeport, Grand Bahama, The Bahamas

References

1. Ministry of Health of the Republic of Tajikistan, Dushanbe, Shevchenko street 69tel: (992 37 600-60-02; presscenter_mz@mail.ru

2. Autonomy and paternalism in medicine. [Med J Aust. 1993 Dec 6-20] - PubMed Result 3. Tassano, Fabian. The Power of Life or Death: Medical Coercion and the Euthanasia

Debate. Foreword by Thomas Szasz, MD. London: Duckworth, 1995. Oxford: Oxford Forum, 1999.

4. Ryan CJ. Ethical issues, part 2: ethics, psychiatry, and end-of-life issues. Psychiatr Times. 2010;27(6):26-27.

5. Ünver AS. Tıbbi Deontoloji Derslerinden Kısa Bahisler ( Short Topics on Lectures Medical Deontology). İstanbul: Kader Basımevi, 1945: 12-20.)

[ Author wants to declare that, in preparation of this article, liberal use of materials from varied sources of literature inclusive of Wikipedia has been utilized.]