Ethics in Medical PracticeCHAPTER 1

Society as a whole is always guided by ethics, and it is more so in case of health care providers. Ethics in global culture means the disciplined study of morality, a concept that encompasses right and wrong behavior, i.e. what we should or should not do, good and bad character (virtues and vices). The fundamental question that ethics addresses is, What is moral? This question involves two other questions: What should our behavior be and what virtues should be cultivated in our moral lives? For centuries the basis for what morality should be in clinical practice has been the obligation to protect and promote the interest of the patients. This ethical obligation must be made more specific to be used clinically. We can accomplish this goal by examining two perspectives, that of the physician and that of the patient. In the history of medical ethics, the older of these two perspective is that of the physician. Based on scientific knowledge, shared clinical experience, and a careful unbiased evaluation of the patient, the physician can identify those clinical strategies that most likely will serve the health-related interests of the patient and those that will not. The ethical principle of beneficence structures this clinical perspective on the interest of the patient. The two most frequently referred to systematic accounts of what make actions morally right or wrong (or theories of obligation) are: Deontological theories—some principles are intrinsically right regardless of resulting consequences.¹ Consequentalist theories—greatest happiness of greatest number.² Principles of these two theories are same.

The ethical doctor adheres to beneficence. Beneficence-based clinical judgment has got ancient roots. In India in 600 BC, Sushrut³ has laid 4down a set of rules, how the medical profession should behave (Table 1.1).

Hippocratic oath⁴ is an oath traditionally taken by physicians pertaining to the ethical practice of medicine. It is widely believed that the oath was written by Hippocrates, the father of medicine, in the 4th century BC, or by one of his students. Although mostly of historical and traditional value, the oath is considered a rite of passage for practitioners of medicine, although it is not obligatory and no longer taken up by all physicians. Several parts of the oath have been removed or re-shaped over the years in various countries, schools, and societies as the social, religious, and political importance of medicine has changed. Most schools administer some form of oath, but the great majority no longer use the ancient version. The Hippocratic Oath has been updated by the declaration of Geneva as adopted by the third General Assembly of World Medical Association at Geneva, Switzerland, in September 1948 (Table 1.2) and the International Code of Medical Ethics as adopted by the general Assembly of World Medical Association held in London, in october1949. In the United Kingdom, the General Medical Council provides clear modern guidance in the form of its ‘Duties of a Doctor’ and ‘Good Medical Practice’ statements. Since then many modifications have been made over the years; in the 22nd World Medical Assembly Sydney, Australia, August 1968, and the 35th World Medical Assembly Venice, Italy, October 1983 and the last one being WMA General Assembly, Pilanesberg, South Africa, October 2006.5

The medical practitioner ought to keep in mind four cardinal aims:

Preserving life is the most important aim of the doctor. But in certain circumstances, it is a difficult question. The first question is when life 6begins, the second whom to sacrifice in a critical condition, mother or the fetus and the third is about euthanasia.

How can euthanasia be defined, and what are the various terms linked to it? Euthanasia literally means good death (from the Greek, eu = Good, thantos = death). Euthanasia is the intentional killing, by act or omission, of a dependent human being for his or her alleged benefit, the key word being intentional. When the person who is killed has made and expressed a wish to be killed, it is termed voluntary euthanasia, When the person who is killed is not capable of giving permission, it is termed non-voluntary euthanasia. When the person who is killed has made and expressed wish not to be killed, it is termed involuntary euthanasia. When someone provides an individual with the information, guidance and means to take his own life, it is referred to as assisted suicide. When a doctor helps in this, it is physician assisted suicide. Causing a person's death by performing an action is called euthanasia by action. Euthanasia by ommission refers to intentionally causing death by not providing necssary and ordinary care or food and water. Some medical actions that are often labelled passive euthanasia are not a classic form, as the intention is not there. Euthanasia is not only for people who are terminally ill, the proactivists are replacing them as hopelessly ill, desperatly ill, etc.

Hinduism advocates the doctrine of rebirth and reincarnation. Religious scriptures use the metaphor of the immortal soul changing bodies the way human beings change their garments. With this background, perceptions are different in India about euthanasia. Both voluntary and involuntary euthanasia has been indirectly prevalent and rampant in India for centuries. Saints and sages used to take up Samadhi;Sati, where a wife jumps into the funeral pyre of her husband (Forced Euthanasia) and Prayoaveshan, voluntary cessation of nutrition which has religious sanctity. Currently under Indian Law, all forms of euthanasia are illegal and outlawed.^{6, 7}

The real aim of the physician is to effect the cure of the illness. When a cure is not possible, the object should be to lessen suffering. A doctor must also aim to bring comfort to a patient. In the process of effecting a cure or relieving pain, a practitioner on account of the faith he inspires in his patient may by sympathetic care and by explaining the illness or disease bring solace to his patients. A doctor deals with human beings. His attitude, his way of handling a patient, his understanding of and his approach to human suffering all have a bearing on his ability to inspire confidence in the patient. He ought not to lose his temper and indulge in strong language. The professional man should first and foremost be a gentleman. In course of his practice the practitioner will come acroos many trying circumstances which call for self-control, hence the demeanour of the practitioner towards a patient must be cautious, sympathetic, friendly and helpful.

Prevention of disease also is the aim of the doctor. The oft repeated quote “prevention is better than cure” still holds good. The present day physician is in a more enviable position than his forefathers as modern drugs have made it possible for the physician to prevent many diseases.

The fourth aim of the doctor is to help in the advancement of medical knowledge. If he has discovered something, however small, he should attempt to desseminate his knowledge, the best way is to publish it in medical journal. He must update his knowledge by attending CMEs and reading recent journals.

The physician may choose whom he will treat and lay down terms of his service, but once he accepts the charge, it is his responsibility to exercise due care and diligence in the diagnosis and treatment using the best means and information avialable to him. He cannot give up the patient without his/her consent except for valid reasons such as that remedies other than prescribed by him are being used, his remedies and instructions are being ignored, he is convinced that the complaint of the patient is not genuine, the doctor himself for reasons of his own health is unable to attend the patient, etc.8

There are occasions when a practitioner must advise his patient to consult another doctor as no medical practitioner can claim to be a specialist in every branch of medicine. The right of the patient to ask for a second opinion should as far as possible be respected. The family physician must suggest the name of the consultant, but in the event of a difference between him and the relatives, the choice of the relatives must prevail. Guidance regarding when to refer and the consultation is given in the principles of Medical ethics of the Indian Medical Association, the British Medical Association.⁸

It is an elementary rule of ethics that a doctor must not entice away patients from his colleagues and that he ought to behave towards them as he would have them behave towards him. The duties of doctors towards each other is described in detail in the International Code of Ethics.

A practitioner's fee should be commensurate with the services rendered and the patient's ability to pay for his services, he expects to be reasonably compensated. What would be reasonable would depend upon the practitioners capability, training and experience and the current practice among his colleagues. Dichotomy or splitting of fees is unethical.

A medical practitioner is under obligation to his patient to preserve his secrets, but in a court of law even without the patient's consent, he is bound to answer questions relevant to the case under subpoena. Ethics on which medical opinion is divided are disclosure of veneral disease 9and HIV infection to the other partner. Some say secrecy must be maintained at any cost, their argument being, the basis of the science of medicine is the intimate relationship between the patient and the doctor.

A written consent must be taken from the patient when experimentation is done on him or her. It would be unethical to do something mainly by way of experimentation, i.e. what is done is not strictly related to the cure of the patient. As soon as ill effect is noted, the experimentation must be stopped and the doctor should make efforts to see the ill effects be remedied. The case for and against experimentation on human beings is often discussed and argued.

A practitioner cannot name a private nursing home, dispensary or hospital on his own name. The advertisement should only contain the name, address, approach and facilities avilable and the type of patient the nursing home entertains. If assistants are there for help, the ultimate responsibility rests on the practitioner.

Drugs should be used only as therapeutic agents. A doctor prescribing narcotics ought to be extra-cautious and must not help the patient to induldge in them. A drug is not to be used because it is new when older ones are equally effective. The cost of the drug must be considered. The prescription should not be written in secret formulae.

A practitioner should avoid soliciting practice either personally or by advertisements in newspaper, by playcards or by distribution of circulars, cards or handbills, by giving as commission percentage of fees received or employing or sanctioning employment of agents or canvasses for the purpose of procuring patients. The scale of fees can be put in the chamber of the practitioner, not outside.

What is psychologically advisable in a particular situation is ethically also correct. Not disclosing certain items to the patient can best be judged only from what effect the disclosure would have on the patient. In modern days when the information on diseases is just a key away, whether to divulge all information should be kept in mind. How much should be told to the patient depends on the patient's intelligence, his ability to appreciate what is told to him, his education and his nervous and psychological attitude in the matter. If the doctor decides not to tell a patient regarding a fatal disease from which the patient is suffering, he should nevertheless freely and frankly inform the patient's relatives about the disease. This helps to safeguard the patient's interests, he can make a will, arrange his affairs, etc.

Ethical issues have become important and the recent press headlines about euthanasia, destruction of frozen embryo, refusal to fund marrow transplant, controversy on stem cell research and genetic research, organ donation and transplantation etc prove that. There are advances in medical technology and each new technology brings its own ethical issues. Society as a whole is now better informed. Doctors are involved in management, and there is the big question of public funding.11

The four Principle approach, other wise known as Principlism was formulated as a basis for working out practical solutions for problems in medical ethics. They are beneficence, non-maleficence, autonomy, Justice. Later on Truth telling, Confidentiality and Preservation of life were added to the principles.

Beneficence is to act in the best interests of the patient, and to balance benefits against risks. In medicine, the ethical principle of beneficence requires the physician to act in a way that is reliably expected to produce the greater balance of clinical benefits over harms for the patient.⁹ Putting this ethical principle into clinical practice requires making it specific to clinical practice.¹⁰ It makes an important claim to interpret reliably the health-related interest of the patient from the perspective of medicine. This perspective is provided by accumulated scientific research, clinical experience and reasoned response to uncertainty. This perspective should not be understood to be the function of an individual physician's clinical perspective and therefore should not be based merely on the clinical impression or intuition of an individual physician. Beneficence-based clinical judgment should be the function of a rigorous clinical perspective that appeals to the best available evidence and its clinical application to a particular case. It identifies the benefits that can be achieved for the patient in clinical practice based on the competencies of medicine. The benefits that medicine is competent to seek for patients are the prevention and management of disease, injury, handicap, and unnecessary pain and suffering and the prevention of premature or unnecessary death.

Autonomy means to respect the right of the individual. Capacity to think, decide, and take action about her own life in the context of respect for everyone else involved is autonomy. If there is mental incompetence, there is no autonomy. Respect for autonomy enters the clinical practice by the informed consent process. This process usually understood to have three elements, disclosure by the physician to the patient of adequate information about the patient's condition and its management, understanding of that information by the patient and a voluntary decision by the patient to authorize or refuse treatment. Beacause each patient's perspective on her interest is a function of her values and beliefs, it is impossible to specify the benefits and harms of autonomy-based clinical judgement in advance. There is always a debate about autonomy and paternalism. When the patient is autonomous, if paternalism creeps in, any procedure may be questionable.12

It means that the physician should prevent causing harm and is best understood as expressing the limits of beneficence. This is commonly known as ‘Primum non nocere’ or first do no harm. Then, seek to prevent it. But there is always an inherent risk of paternalism in beneficence-based clinical judgment. If it is mistakenly considered to be the sole source of moral responsibility and therefore moral authority in medical care, it invites the physician to conclude that beneficence-based judgments can be imposed on the patient in violation of her autonomy. Paternalism should always to be avoided in medical practice.

Justice signifies, to treat patients fairly and without unfair discrimination, there should be fairness in the distribution of benefits and risks. It raises many questions like how to care for scarce health care resources and how to distribute them. Medical needs, and medical benefits should be properly weighed. Discrimination against underprivileged should be avoided.

Confidentiality is the basis of trust between doctor and patient.^{12, 13} By acting against this principle one destroys the patient's trust. Breaches of confidentiality can lead to breakdown of the patient-doctor relationship, lack of confidence and trust in other doctors, failure by patient to seek future medical treatment as a result of which their health may suffer, and can lead to disciplinary action against the doctor and civil action for 13compensation., But there is clash, i.e. when confidentiality would harm others. The points against confidentiality are lay patients unable to cope with data, opinions (not facts) cause anxiety, and accuracy improves by sharing information. The supporters of confidentiality claim that, data belongs to the patient and should not be shared with others.

In obstetrics and gynecology, ethical issues have arisen out of social concerns about abortion, fetal research, medically assisted procreation, genetic engineering and conflict of interest between the pregnant woman and the fetus she carries. Now it has become virtually impossible to practice any branch of medicine without refering to ethical matters. If the patient refuses to accept the alertnatives supplied in beneficence-based clinical judgement, the physician is ethically and in most part of the world legally obligated to engage in what is known as informed refusal. The matter of informed refusal is very clear. The risks and benefits are explained to the patient in detail and they should be thoroughly documented in the notes of the patient.

Beneficence-based and autonomy-based clinical judgements in gynecological practice are usually in harmony, like management of ruptured ectopic pregnancy. Sometimes, they may come into conflicts. In such a situation, one should not override the other. Their differences must be negotiated in clinical judgement and practice to determine which management strategies protect and promote the patients interests. In the techniqual language of ethics, it is medical ethical principles as prima facie or potentially overridable in nature.¹⁴

There are obvious beneficence-based and autonomy-based obligation to the pregnant patient. While the physician's perspective on the pregnant 14woman's interest provides the basis of beneficence-based obligations, her own perspective on those interests provides the basis for autonomy-based obligations. Because of an insufficiently devoloped central nervous system, the fetus cannot meaningfully be said to possess values and beliefs. Thus, there is no basis for saying that the fetus has a perspective on its interest. Therefore, there is no autonomy-based obligation to the fetus. The physician, however, has a perspective on the fetus's health-related interests and can have beneficence-based obligations to the fetus, but only when the fetus is a patient. But there are conflicts among ethical obligations, and they can be divided into four groups:

It involves many issues like donor insemination, IVF, egg sharing, freezing and storing of embryos, embryo research and surrogacy. When Louise Joy Brown was born in 1978, the whole world was up in arms against it. Now IVF is commonplace. Still many ethical issues are involved in IVF. First there is a big question whether the in vitro embryo is a patient or not. It is appropriate to think that it is a pre-viable fetus and only the woman can give it the status of a patient. Hence, preimplantation diagnostic counseling is non-directive and counseling about how many embryos to be transferred should be evidence-based. Donor insemination raises the issue whether the child should be told about his genetic father or not. Egg sharing is also surrounded by many ethical issues. Ethics changes from time to time keeping pace with the changing social values, the surrogacy issue being an example. It was considered unethical few years back, now in a recent issue of India Today, a lengthy article has appeared supporting surrogacy with the name of a center, the photos of the physician and a number of happy surrogate mothers. One surrogate mother proudly claimed that, she had given her womb for rent three times to tide over her husband's financial crisis! To discuss all the ethical aspects of IVF is beyond the scope of this chapter. The reader is advised to consult a specific chapter devoted to this topic alone in the book.

There are many issues involved like competence and referal, disclosure, confidentiality and routine screening. The foremost issue is that the sonologist must be competent enough to give a definitive opinion. Now routine screening is adopted at 18–20 weeks, but prior to screening the prenatal informed consent for sonogram(PICS) must be taken. This includes informed consent about the disclosure. Strict confidentiality must be maintained.¹⁵

The process of genetic research raises difficult challenges particularly in the area of consent, community involvement and commercialisation. However, it must be recognised that many of these issues are not unique to genetics but rather represent variations and new twists on problems that arise in other types of research. Results of genetic research should be provided to subjects only if the tests have sufficient clinical validity. Results should never be disclosed to relatives, except in case of pedigree research. Policies regarding disclosure of test results should be included in the informed consent process. The genomic era poses challenges for 16the international community and research enterprises. Council for International Orgnisation of Medical Sciences (CIOMS) guideline should adress the ethical issues of genetics. The five ethical principles are required to guide the scope and practice of biomedical research, the goal being to care and protect greatest sources of human suffering and premature death and to relieve pain and suffering caused by the disorder.^16–18

Sometimes teenaged girls request for oral contraception. They are already in an active sexual relationship. They do not want that their parents should know about them taking contraceptives. What ethical consideration must guide the the physician in such a situation? Lord Fraser's recommendation is quite ethical and they are as follows:¹⁹

Teaching biomedical ethics in residency training is a must. How to do, what to include is the duty of the faculty head and members of the faculty. The teaching should be built on ‘the five Cs’, i.e. clinically based teaching, cases as the teaching focus, continuous teaching through out the medical curriculum, co-ordinating ethics teaching with the trainee's other objectives and clinician's active participation both as co-instructors and role models for students. In our opinion, this should be taught to the students during the grand round, and in each case the ethical conflicts can be discussed in detail. As now most of the institurtions are having an ethical committee, it is easy to introduce the residents to biomedical ethics.²⁰

This involves many ethical issues and the first and foremost is, it is destroying a life by destroying the fertilised embryo. This raises the fundamental question of when life starts. Does human life begin at gastrulation (the next step after the blastula), at neurulation (formation of a primitive streak, the first signs of nervous system development), at quickening (the first signs of movement), or at the moment of sentience 17(consciousness)? When can an embryo first feel pain or first suffer? Indeed these are difficult questions. Somehow it seems inherently obvious that a wriggling fetus deserves more protection than a 100-cell embryo. Yet, the mere fact that an embryo has some capacity for development into a human being seems to endow it with a degree of moral respect not given simply to the pluripotent cells derived from it. The goal then should be to minimize the exploitation of human embryos at any stage of development. Beyond these considerations lie other, somewhat more concrete, ethical concerns. For example, due to the currently inefficient nature of the cloning process, the enormous number of anticipated technical hurdles, and the potential success of the method, an increased demand for oocytes will arise, raising issues of the exploitation of women across the world who will be paid or even coerced to donate eggs through procedures whose safety may be highly variable. Moreover, as the private sector weighs in, will therapeutic cloning be done with the best interests of embryo and patient alike, or will profit motives create a cost-benefit approach to cloning? Clearly these issues are on the horizon and they draw nearer as the potential for tissue regeneration increases through ES cell research. Hence, scientists must accept responsibility for therapeutic cloning. Fortunately, there is hope that research itself can find a way out of this dilemma. Straightforward issues of safety can be tackled by public funding into the risks involved in therapeutic cloning. Issues of female exploitation may be overcome by using animal eggs and to re-program adult human cells. Even more promising is the possibility of adult stem cell research.^{21, 22}

What is the relationship between law and ethics? Are they same? Ethics is involved with moral judgement, and the law, however, concerns public policy. At one level it defines what one can/cannot or must/must not do to avoid risk of legal penalty. For example, practitioners must at all times comply with the law in case of induced abortion. Ethics encompasses much more than law. Ethics can help to determine what is ‘right’, in the sense that it is ‘good’. The intention of law is to define what is ‘right’, in the sense that it is or is not permitted. It can be safely concluded that not only is ‘determining that some thing is unethical, neither a necessary nor a sufficient reason to make it illegal’, but also determining that some thing is lawful does not necessarily make it ethical. In many occasions the law assists clinical decision-making by setting parameters which helps both the patient and the physician.18

Ethics has now pervaded everyday life of the medical practitioner in a big way and in each and every step, he is beset with ethics. The physicians are taking ethical decisions every day since he or she qualifies, perhaps without knowing it. There is seldom an absolutely right or wrong decision. One is often trying to balance the greater good or lesser evil. Medical practice deals directly with humans, and interventions by medical professionals are often a matter of life and death. Medical knowledge and technology put practitioners in a position from where they can wield exceptional influence. Practitioners must balance this power with ethical conduct. Although some decisions must be reached quickly, the process of decision making should be no less rigorous. They are obliged to follow and respect the code of ethics which they vow to uphold when they graduate.