ETHICS IN MEDICINE, A LECTURE DELIVERED AT THE PUMSA/PUMGRAD RE-UNION WEEK BY NIMI D BRIGGS on NOVEMBER, 2011
From1986, when it turned out its first batch of graduates, the College of Health Sciences of the University of Port Harcourt has so far produced 1,858 medical doctors, while over 500 students are currently receiving training in its various departments, also to become doctors. Sprouting from the thoughts and philosophy of the Foundation Vice-Chancellor of the University, the late Professor Donald Ekong, a Chemist of immense standing and the Foundation Provost of the College, the late Professor Theodore Francis, a Physician of international repute, the College, as part of a Unique University, “was born in a spirit of surging enthusiasm” and also in an atmosphere of “aspiration and confidence”
That the quality of scholarship has been high, is evidenced by the rapid advancement the graduates of the College have made in their chosen fields of human endeavor within and outside the country; furthermore, obtaining the degrees of the College does not come cheap. Therefore, my understanding of the purpose of a re-union between the graduates of the College and its current students is to bring the two groups into a consultative and interactive milieu for mutual benefits, especially under the theme of Career Prospects In Medicine. Commencing such an interactive discussion with a talk on what is right or wrong in medical practice, which, after all, is what ethics is all about, is, to my mind, remarkably appropriate, as without ethics, the best practices that unite us all as doctors, vanish.
Accordingly, I count myself privileged to have been requested to kick-start this discussion on Career Prospects In Medicine with a talk on Ethics in Medicine and I thank the authorities of the Port Harcourt University Medical Students Association (PUMSA) for the honour.
My treatment of the topic will be brief; among other reasons, to avail others the opportunity to make their own contributions. An attempt will be made to explain the concept of ethics together with its components. This will then be applied to the discipline of Medicine and the elements of medical ethics elucidated. A few examples of ethical violations in medicine and human experimentation will be cited and penalties for such dreadful actions discussed, which will lead to the review of some cases of malpractices in our country.. Attention will thereafter be drawn to some ethical dilemmas that may face doctors in the course of their practice and a few closing remarks made by way of conclusion which will incorporate an exhortation I had made to some doctors at a previous similar occasion.
ETHICS AND ITS COMPONENTS
Ethics is a Science of Philosophy which deals with the moral content of human actions. It seeks to judge human behaviours and actions as good or bad, just or unjust, virtuous or vicious based on their own merit and values and not necessarily because of religious dogma. Since arriving at such judgment could be complex, components of ethical interpretations are broad and varied and apply to all facets of human activities – warfare, sports, the professions, daily living to mention just a few. They include such issues as moral character, obligation, reciprocity, reparation, beneficence, nonmalficence, concern, altruism, aesthetics, equity, equality, sympathy, empathy, discrimination and etiquette. In fact so strong is the consideration of ethics in everyday life, that Human Right issues are now regarded as ethical issues – slavery, gender discrimination, torture, racism and so on. However, our brief for today’s lecture is on Ethics in Medicine and we shall now divert our attention to that matter for the balance of this lecture.
ETHICS IN MEDICINE
The rules of professional and personal conduct as well as moral values by which doctors, all over the world, are expected to live and carry out their work, evolved slowly over a long period of time. Medicine, as a profession, is both a Science and an Art. Whereas the scientific content is ensured by the curricula and acquisition of knowledge in various universities, it is ethics that gives guidelines on how the scientific knowledge so acquired, should be applied and used, including how the physician should conduct his personal and professional life – the art part of the profession.
CODE OF BEHAVIOUR FOR DOCTORS
Several doctors in antiquity, including those in ancient Egypt, like Imhotep (c. 2,600 BC), Prime Minister to Pharaoh, who was so famous that after his death he was worshipped as a god, had indicated some code of behaviour for those who at that time, were practicing some form of medicine. But it is to Hippocrates (460-377 B.C.) of the Island of Cos in ancient Greece, revered as the father of medicine and without question the most famous physician in antiquity, that a prescription for the code of conduct and behaviour of doctors is generally ascribed, despite all the disagreement about its authorship. This prescription was encapsulated into an oath on which Ethics in Medicine is anchored and all the varieties of oaths or self-commitments which doctors currently make derive from it.
Known by his name, the Hippocratic Oath contains most of the constituents that should guide the conduct and practice of a medical doctor. Written about 400 B.C, it was not until 1508 that it was first administered to a set of graduating medical students at the University of Wittenberg in Germany, the same year that Martin Luther, of the protestant/Lutheran faith, became a Professor. Let us quickly examine the original version of the oath and what its content connotes.
- I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: Covenant with what one takes dearly. It was the gods at the time of Hippocrates. It could be any of the Holy Books now – the Bible; the Koran.
- To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art. Covenant with teachers. Pledge of collegiality and brotherhood.
- I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. The good of the patient is the core intent of medicine and at no time must harm be done to the patient – primium, non nocere.
- I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. The sanctity of human life must be recognized by all doctors and they should do all in their ability not to destroy human lives even from the time of conception.
- But I will preserve the purity of my life and my arts. Doctors are to conduct themselves with great respect and practise their profession with immense dignity.
- I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. This was when the physicians refused to accept the surgeons (barbers) as doctors. This situation has since changed.
- In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves .Re-emphasizing the personal conduct expected of a doctor.
- All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. Covenant of absolute confidentiality even after the death of the patient.
- If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot. Responsibility of the people to the doctor who does his work well.
|Despite the disputes regarding exact authorship and dates, there is consensus that the Hippocratic Oath profoundly influenced the practice of medicine across recorded history. For the first time, there was a complete separation between killing and healing, as prior to that time, the magician, sorcerer, shaman and doctor could be one and the same person The appearance of the Oath represented a clear dividing line after which medicine was unalterably committed to protecting life and never deliberately killing. The Oath represented the gold standard of moral and ethical behavior to which all physicians who took it were bound and when violated, as it was massively during the second world war in Nazi Germany, the darkest chapters in medical history were written, culminating in physicians in the dock charged with and found guilty of “crimes against humanity”.
Medicine responded vigorously to those violations and betrayals and at Geneva in 1948, after the second World War, the unchanging principle of the Oath was restated in the unanimously adopted Medical Declaration of Geneva by the World Medical Association with an additional statement “I will maintain the utmost respect for human life from the time of its conception”. This position was finally adopted by the General Assembly of the Association in September 1948 and amended by the 22nd World Medical Assembly in Sydney, Australia in August 1968. The new document that emerged from these processes is now known as the Physician Oath and it is this oath that is currently administered to graduating medical students in many countries, including Nigeria.
- I solemnly pledge to consecrate my life to the service of humanity;
- I will give to my teachers the respect and gratitude which are their due;
- I will practise my profession with conscience and dignity;
- The health of my patient will be my first consideration;
- I will respect the secrets which are confided in me, even after the patient has died;
- I will maintain by all means in my power, the honour and the noble traditions of the medical profession;
- My Colleagues will be my brothers;
- I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
- I will maintain the utmost respect for human life from the time of conception;
- Even under threat, I will not use my medical knowledge contrary to the laws of humanity;
- I make these promises solemnly, freely and upon my honour.
Between these two oaths, the essentials of Ethics in Medicine become evident:
- Doctors must understand that their job is a calling for which they must show the highest sense of responsibility at all times, placing the interest and well-being of their patient above all other considerations. In this regard, the patient’s welfare is supreme law.
- They must respect and differ to their teachers and show brotherly love to their colleagues.
- They must be absolutely frank and honest in dealing with their patients.
- First, and above all, they must do no harm. They must not do anything that leaves a patient worse than they met him and they must be sure that they are competent in the procedure they wish to carry out on a patient.
- They must have the highest regard for human life and should do all in their powers to foster and preserve it, not denigrate or take it.
- They must conduct their personal lives in a decent, responsible and respectable manner and in a way that does not bring reproach and opprobrium to the profession of medicine
- They must maintain absolute confidentiality of information obtained on a patient even after the death of the patient.
So important are the behaviour and conduct by which a doctor is expected to live and practice that in every society they are clearly written out and handed over to every doctor at the time of his registration by the medical practice regulatory body in that country. The rules are spelt out in this manner in order to enable the general public and the regulatory body to hold the doctor to account once he infringes the laid down regulations. In Nigeria, the Medical and Dental Council has listed these rules in a document called Rules of Professional Conduct For Medical and Dental Practitioners. It is in the best interest of every practicing doctor in the country to be conversant with the content of this document. It contains information on the duties of a doctor as well guidelines on how he should relate to his patient, his colleagues and the general public.
Ethical Committees are usually formed in medical and health institutions, such as medical schools in universities and hospitals, to encourage ethical practices in the operations of those institutions. Members of such committees, who are expected to be independent minded, assume legal and ethical obligations to ensure the health, safety and welfare of humans used for research purposes. Usually the committees devise a risk-benefit ratio to determine whether or not the benefit of the research outweighs the risk to the subjects. Many reputable journals will not accept to publish scientific findings emanating from a health or medical institution unless there is clear evidence that the research that led to those findings, had been scrutinized and approved by a duly constituted Ethical Committee. The University of Port Harcourt Teaching Hospital has a vibrant Ethical Committee which is currently chaired by Professor Anthony Okpani of the hospital’s Department of Obstetrics and Gynaecology..
OTHER CODES AND DECLARATIONS OF ETHICAL PRACTICE
Aside from those to which reference has already been made in this paper, there are a number of other Codes and Declarations which were also promulgated at various times to regulate human behaviour and actions especially during warfare and while carrying out research on human subjects .Let us briefly touch on them.
THE NUREMBERG CODE
Following the unmitigated savagery that occurred during the second world war, it became necessary to set up 12 war crime trials at the end of the war. Of the many perpetrators of the hideous crimes, especially those that took place at Nuremberg during the war, were 20 doctors who were tried under the “Doctors Trial” US Military Court action. Their plea was that there were no laws preventing experimentation with human subjects at the time of their action and that their experiments varied little from pre war procedures. After the trials, the need to fill such a void gave rise, in 1947, to the formulation of The Nuremberg Code – which consists of ten clauses of ethical guidelines which are obligatory and regulate the conduct of experiments involving human subjects.
THE DECLARATION OF HELSINKI
Like the Nuremberg Code, this is another cornerstone document on human research, having been developed by the World Medical Association. Combining features of the Nuremberg Code and the Declaration of Geneva, the Declaration of Helsinki lists the duties of a physician and although lacking the force of law in international jurisprudence, the document has had profound influence on the formulation of national and international laws on medical ethics as it was developed by members of the medical profession.
No one watching the recent trial of Dr. Conrad Murray in a court of law in far away Los Angeles, USA, who is standing trial on a charge of gross professional negligence leading to the death of the pop idol Michael Jackson, who was a patient of his, would under rate the backlash and agony that a doctor suffers when faced with issues that border on the violation of his professional ethics. Ranging from death sentences, imprisonment for various terms and having their names struck-off Registers of Medical Practitioners, temporarily or permanently, doctors have suffered all manner of public disgrace and humiliation for violating the ethical provisions of their profession. The horrendous nature of some of the actions reportedly carried out by doctors, especially in Nazi Germany during the World War 2 and by the Japanese, is so shocking as to be almost unprintable. They include vivisection, gonadal irradiation and exposure to mustard gas, burning with phosphorus and incendiary bombs, as well as direct administration of poisons.
Here in Nigeria, according to the records at the office of the Registrar of the Medical and Dental Council, between 2001 and 2011, 117 complaints of wrong doing by doctors – alleged professional negligence, infamous conduct, self advertisement, professional malpractice have been reported to the Council by aggrieved persons and organizations. Of these, the Council found as follows after due investigations:
- In 59 cases, not guilty
- In 56 cases, guilty
- In 2 cases, for judicial review in court.
The doctors that were found guilty received various forms of punishment ranging from reprimand, to having their names struck-off the Register of Medical Practitioners in the country. Some were referred further for prosecution.
ETHICAL DILEMMAS IN MEDICINE
Ethical dilemmas occur when practical realities on possible options appear to be in conflict with clearly stated ethical codes of conduct. A doctor may come across many such instances in his carrier.
Let me illustrate with one or two examples. All the ethical codes of conduct enjoin a doctor to “maintain the utmost respect for human life from the time of conception” and to neither kill, administer a noxious agent to a patient nor to take a life. What then does a doctor do that is faced with the case of a 16 year old school girl who had been raped by an unknown assailant during a burglary attack at her home and put in the family way, demanding for the termination of her pregnancy? Or how does a doctor handle the case of a wife who is perfectly healthy but with an azoospermic husband when the couple is desperately looking for a child? Many cases such as these may come the way of the doctor who will have to work his way through them all. Or even more grave than these, is it ethical for a doctor to abandon his patients and go on strike?
Permit me to commence my conclusion with a short excerpt from an exhortation I made to some graduating doctors in September, 2001, in my capacity then, as Vice –Chancellor of the University of Port Harcourt. “Let me then leave you with two issues: “ethics” and “continuing medical education”. To practice medicine is a wonderful privilege but one which must not be abused. To whom much is given, much is expected. You must register and familiarize yourselves with the Medical and Dental Council of Nigeria’s definition of “malpractice” and other issues on medical ethics. Above all, you must show sympathy, consideration and understanding to your patients at all times and do unto them as you would wish it done unto you –”
These statements were as true then as they remain true today. They address the issue of the moral content of our practice as doctors and they do not derive from any religious dogmas – Hinduism, Islamism, Christianity or indeed, any other faith for that matter. But then, while all this may be true, it is really difficult to separate ethics from religion as no true believer of any faith, be he a doctor or otherwise, would carry out the atrocities that had been described in the earlier sections of this paper, strictly on account of his religious beliefs. For without doubt, the great religions of the world, all ascribe to the common good – the equality of all before God and the sanctity of human life, which should be respected and preserved..
Love thy neighbour as thyself and Do unto others as thou would have them do unto you are two seminal injunctions in the Holy Bible to all Christians, which, to my mind, sum up the entire portfolio of all ethics, including medical ethics. When one loves one’s neighbor as one’s self and does to others as one would have them do to one, one would do no harm to others – prImium, non nocere – first, do no harm: the cornerstone of medical ethics. In such a circumstance, one would not discriminate on account of race, or administer a noxious drug to kill a patient or fail to attend to a patient because of insolvency. Although these injunctions are taken from the Holy Bible, there is no doubt that their corollaries and counterparts exist in the Holy Koran and the other major religious books of the world.
My submission therefore to this distinguished audience of young, talented and articulate men and women with fertile, receptive and impressionable minds, is that ethical promulgations, be they in Medicine, Law or Divinity – the three original professions, are inspirational statements, which serve as pointers to centrality of Love in the affairs of men. They bring us closer to the quintessential nature of God, even as they serve as the entity by which the Almighty God does no harm to us despite our sinful nature.
Seen in this light, Ethics in Medicine fails to become a set of decrees, dictates or even rules by which we, as doctors, are compelled to live, with all the fear of deregistration and incarceration in prison, and from which we should be absolved, freed and unchained, on retirement from active medical practice, as is being advocated by some in the profession. Ethics in Medicine then becomes a way of Life.
ETHICS IN MEDICINE, A LECTURE DELIVERED AT THE PUMSA/PUMGRAD RE-UNION WEEK BY NIMI D BRIGGS on NOVEMBER, 2011