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MEDICAL ETHICS
Greek Medicine and the Origins of Ethical Codes
History of Ethics
Ethical Concepts and Principles
Medical Ethics in Non-Western Cultures
GREEK MEDICINE AND THE
ORIGINS OF ETHICAL CODES
The word ethics is derived from the Greek word
ethikos meaning character, manners and morals.
Medical ethics, according to Professor Dunstan,
have been described as the obligation of a moral
nature which govern the practice of medicine.
Associating ethics with culture and medicine
demands further explanation of what is ethics in
the sense of medical practice.
HISTORY OF ETHICS
GREEK MEDICINE AND THE
ORIGINS OF ETHICAL CODES
GREEK MEDICINE AND THE ORIGINS
OF ETHICAL CODES
Ethics has become an important value of all
medical research and treatment and throughout
the generations under the Hippocrates
Principles.
The principle of medical ethics from traditional
approach stated in the Hippocratic Oath as the
standards of professional competence and
conduct which the medical profession expects of
its members, develops towards a more analytical
approach of doctor-patient relationship and with
respect to patients autonomy.
NUREMBERG CODE (1946)
The most dramatic and well-known chapter in the
history of research with human participants opened on
December 9, 1946, when an American military tribunal
opened criminal proceedings against 23 leading
German physicians and administrators for their willing
participation in war crimes and crimes against
humanity.
Among the charges were that German Physicians
conducted medical experiments on thousands of
concentration camp prisoners without their consent.
Most of the participants of these experiments died or
were permanently crippled as a result.
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NUREMBERG CODE (1946)
THALIDOMIDE (1950s)
In the late 1950s, thalidomide was approved as a
sedative in Europe; it was not approved in the United
States by the Food and Drug Administration (FDA).
The drug was prescribed to control sleep and nausea
throughout pregnancy, but it was soon found that
taking this drug during pregnancy caused severe
deformities in the fetus.
Many patients did not know they were taking a drug
that was not approved for use by the FDA, nor did they
give informed consent.
Some 12,000 babies were born with severe deformities
due to thalidomide.
THALIDOMIDE (1950s)
U.S. Senate hearings followed and in 1962 the
so-called "Kefauver Amendments" to the
Food, Drug and Cosmetic Act were passed into
law to ensure drug efficacy and greater drug
safety.
For the first time, drug manufacturers were
required to prove to the FDA the effectiveness
of their products before marketing them.
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NUREMBERG CODE (1946)
As a direct result of the trial, the Nuremberg
Code was established in 1948, stating that the
voluntary consent of the human participant is
absolutely essential," making it clear that
participants should give consent and that the
benefits of research must outweigh the risks.
Although it did not carry the force of law, the
Nuremberg Code was the first international
document which advocated voluntary
participation and informed consent.
THALIDOMIDE (1950s)
DECLARATION OF HELSINKI (1964)
In 1964, the World Medical Association
established recommendations guiding medical
doctors in biomedical research involving human
participants.
The Declaration governs international research
ethics and defines rules for "research combined
with clinical care" and "non-therapeutic
research."
The Declaration of Helsinki was revised in 1975,
1983, 1989 and 1996 and is the basis for Good
Clinical Practices used today.
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DECLARATION OF HELSINKI (1964)
Issues addressed in the Declaration of Helsinki:
Research with humans should be based on the results
from laboratory and animal experimentation
Research protocols should be reviewed by an
independent committee prior to initiation
Informed consent from research participants is
necessary
Research should be conducted by
medically/scientifically qualified individuals
Risks should not exceed benefits
TUSKEGEE SYPHILIS STUDY
(1932 -1972)
NATIONAL RESEARCH ACT (1974)
Due to the publicity from the Tuskegee Syphilis Study,
the National Research Act of 1974 was passed.
The National Research Act created the National
Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research, which was
charged to identify the basic ethical principles that
should underlie the conduct of biomedical and
behavioral research involving human participants and
to develop guidelines which should be followed to
assure that such research is conducted in accordance
with those principles.
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TUSKEGEE SYPHILIS STUDY
(1932 -1972)
During a research project conducted by the U.S.
Public Health Service, 600 low-income African-
American males, 400 of whom were infected with
syphilis, were monitored for 40 years.
Free medical examinations were given; however,
participants were not told about their disease.
Even though a proven cure (penicillin) became
available in the 1950s, the study continued until
1972 with participants being denied treatment.
TUSKEGEE SYPHILIS STUDY
(1932 -1972)
In some cases, when participants were diagnosed as
having syphilis by other physicians, researchers
intervened to prevent treatment.
Many participants died of syphilis during the study.
The study was stopped in 1973 by the U.S. Department
of Health, Education, and Welfare only after its
existence was publicized and it became a political
embarrassment.
In 1997, under mounting pressure, President Clinton
apologised to the study participants and their families.
BELMONT REPORT (1979)
Carrying out its charge, the National Commission
for the Protection of Human Subjects of
Biomedical and Behavioral Research prepared the
Belmont Report in 1979.
The Belmont Report attempts to summarize the
basic ethical principals identified by the
Commission in the course of its deliberations.
The Report is a statement of basic ethical
principles and guidelines that should assist in
resolving the ethical problems that surround the
conduct of research with human participants.
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ETHICAL CONCEPTS AND
PRINCIPLES
ETHICAL CONCEPTS AND
PRINCIPLES
In Malaysia, there seems to be a guideline for
medical ethics but it is unclear and inconclusive.
The Malaysian Medical Association only refers
medical ethics as a civil code of behaviour
considered correct by members of the profession
for the good of both the patient and profession.
This Code of Medical Ethics generally sets
guidelines for the proper conduct of the doctor
practising in Malaysia, however, is not, and
cannot be exhaustive.
ETHICAL CONCEPTS AND
PRINCIPLES
Autonomy
Autonomy is crucial in medical ethics and regarded as
the primary medical principle.
This principle insists that a person should have control
over their own bodies and should make their own
decisions as to undergoing medical treatment.
In exercising the right of autonomy, the only person
who can solely make a decision for himself is the
person who has been granted the right and not
others, despite the fact that others may offer
assistance and advice in making such decision.
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ETHICAL CONCEPTS AND
PRINCIPLES
In the UK, the British Medical Association
(BMA) defines medical ethics as the
application of ethical reasoning to medical
decision making.
The definition then continues to include
critical reflection about norms or values, good
or bad, right or wrong, and what ought or
ought not to be done in the context of medical
practice.
ETHICAL CONCEPTS AND
PRINCIPLES
There are four main ethical principles that
become the most familiar litany recited in
ethics: autonomy, beneficence, non-
maleficence, and justice.
In Malaysia, these four main principles of
medical ethics have been incorporated and
recognised in the notions of the Malaysian
Code of Medical Ethics.
ETHICAL CONCEPTS AND
PRINCIPLES
The basis for autonomy differs from one culture to
another, from West to East.
The idea of autonomy differs from one patient to
another depending on their prior values and cultural,
personal and social relationships.
Since Asian families decisions are crucial in the health
decision-making process, some Asian patients prefer
their families to make the decision for them.
A similar situation can also be found in Malaysia,
whereby spouses or family members may influence
the decision made by a patient.
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ETHICAL CONCEPTS AND
PRINCIPLES
Justice
Justice is defined as fair, equitable and appropriate
treatment in the light of what is due or owed to a
person.
Most societies invoke the material principle of justice
in dealing with public policies, relying on different
principles in various situations and contexts.
Due to the imbalance between supply and demand,
and funding to meet the demand, people will face a
problem of justice, as to whom is selected as
deserving of subsidized treatment, and a problem of
policy, as to who may decide on this access to
treatment.
ETHICAL CONCEPTS AND
PRINCIPLES
Beneficence
Beneficence literally refers to an action done to
benefit others.
There is a situation when beneficence may conflict
with respect for autonomy, particularly where the
doctors decision to do good in the best interest of
patient may be contrary to the patients wish.
It is the duty of the doctor to balance these
obligations against her or his beneficence-based and
autonomy-based obligations to the pregnant woman.
ETHICAL CONCEPTS AND
PRINCIPLES
Applying the principle to the scope of medical
treatment, Brazier discusses the dilemma that
confronts the medical authorities and families
with regard to conjoined twins, knowing the fact
that one would die in a separation surgery.
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ETHICAL CONCEPTS AND
PRINCIPLES
Indeed, in the UK, it was a political decision to
create the National Health Service (NHS) based on
the ideal of equal access to treatment for all
citizens in need.
In Malaysia, the concept of justice in medical
practices relates to policies such as equal
opportunities, issues of right and wrong and the
allocation of limited resources.
ETHICAL CONCEPTS AND
PRINCIPLES
Non-Maleficence
The do no harm principle implies action in not
inflicting harm on others and relates to the
principle of respect for persons.
The importance of this principle is that it urges
against harming one patient to help another.
ETHICAL CONCEPTS AND
PRINCIPLES
For example, five years ago, doctors in Manchester
had to decide the fate of the Siamese twins; Jodie and
Mary.
By doing nothing both babies would have eventually
died.
However an operation would mean that one baby
would have to die in order for the other baby to live.
Separating Mary, would and did cause her death.
Nonetheless, doing no harm to Mary would kill Jodie
who had the potential to survive.
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ETHICAL CONCEPTS AND
PRINCIPLES
This led the doctors to bring an action before the ISSUE: Medical Futility
Court to get judicial consent to carry out the
operation, as the parents refused to give consent
on the basis of religious grounds. The Court of
Appeal ruled to sanction sacrificing Marys life in
order to save Jodie.
ETHICAL CONCEPTS AND
PRINCIPLES
Some ethicists claim medical futility is an ancient
concept and inadequate for modern ethical
deliberations.
In Hippocratess time, medical knowledge was
limited and disease processes frequently
overpowered patients.
Modern medical knowledge and progressive
technologies have dramatically altered our ability
to sustain life.
MEDICAL ETHICS IN NON
WESTERN CULTURE
Medical ethics in Islam Chinese medical ethics
The problems raised are pertinent predominantly to
Muslims, or derive directly from the commandments
of Islamic law
When Islamic law and the State law on certain
medical ethics are contradictory the fatwa is issued to
mediate.
Islamic medical ethics are often inseparable from
social and political issues
Abortion from 120 days onwards is illegal
A foetus has a legal identity though incomplete
A foetus acquires four rights; inheritance, lineage, wills and
trust
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ETHICAL CONCEPTS AND
PRINCIPLES
Medical futility is defined as a clinical action
serving no useful purpose in attaining a specified
goal for a given patient.
Hippocrates clearly stated that physicians should
refuse to treat those who are overmastered by
their disease, realizing that in such cases medicine
is powerless.
Websters dictionary defines futile as serving no
useful purpose, completely ineffective.
MEDICAL ETHICS IN NON
WESTERN COUNTRIES
MEDICAL ETHICS IN NON
WESTERN CULTURE
Chinese medical ethics are closely integrated with
ancient Confusion and Buddhist teaching but
there are no definite religious texts as there are in
Hindu and Muslim thought.
In the Ming Dynasty, many physicians discussed
and wrote about questions of medical ethics,
including Hsu Chun-fu who in 1556, compiled a
section on medical ethics headed The Medical
Way.
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MEDICAL ETHICS IN NON
WESTERN CULTURE
An Orthodox Manual of Surgery stated ten
commandments and ten requirements for
physicians which form the most comprehensive
statement on medical ethics in China.
It included the duties of a physician to the patient
and the importance of advancement of medical
knowledge as well as the rules for social
intercourse.
THE END
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MEDICAL ETHICS IN NON
WESTERN CULTURE
Japanese medical ethics
Traditional Japanese medical ethics derive from
Buddhist thought and indigenous Shinto tradition.
One example of a Japanese code of medical ethics
comes from Ri-shu school of medical practice.
The physician is obliged to protect against
disclosing any secrets he learns during his medical
education.