EthicsPATIENT INTERACTION

Ethos

Some pockets of knowledge have commonplace and simple labels, like ‘ethics in medicine’. So simple that much about them is taken for granted. Too many people resign themselves to an uncomfortable number of assumptions and make do with superficial knowledge. Biomedical ethics may be (rightly) classified under ‘doctor knowledge’, but it is not out of place for as many as can to seek a deeper understanding of the term, given how its application directly affects life. Nevertheless, the intent here is not a treatise on ethics in medicine—far more enlightened people than I have seen to that throughout history. It is rather the first course of sorts, to whet the appetite for a purposeful and deeper probe into the ethos of the physician’s trade.

Perhaps the most widely known precursor to a structured form of western medical ethics is the Hippocratic Oath. In the time of the Ostrogoths, an East Germanic people in the 5th century, the earliest known code of medical ethics was formulated. According to the works of Cassiodorus, a Roman scholar who served the Ostrogothic king then, the Formula Comitis Archiatrorum (the said code) highlighted a need for physicians to be more knowledgeable; and established the practice of consulting other doctors. Historians thus place the writing of the Oath between the fifth and third centuries BC in Ionic Greek. There have been various modifications of the original text over the years but the Oath still upholds principles of a superlative significance, including those of confidentiality and non-maleficence. More than mere symbolism, the swearing of the Oath is a prerequisite for graduating from medical school in many countries today. In the years to follow, scholars of Jewish, Islamic and Catholic origin would make their contributions to the field.

The Practical Ethics of the Physician, based on the works of Hippocrates and Galen, was written by a 9th-century Arab physician, Ishaq bin Ali al-Ruhawi. Covering a wide array of ethical topics, from the conduct of a physician with his patient to public attitude towards the medical profession, his book is considered by some to be the first documentation of medical ethics.

Moses Ben Maimon, commonly known as Maimonides, lived between the 12th and 13th centuries. He was a most influential rabbi, physician and philosopher with about ten known published medical works. Perhaps his combined expertise in theology, philosophy and medicine place his works on a pedestal. A 2004 entry in the Canadian Journal of Surgery alludes to his methods of cooling and organ retrieval after death.

Equally note-worthy of medieval times is the Italian Dominican friar, Saint Thomas Aquinas. A foremost scholastic philosopher, theologian and jurist, he wrote on almost all aspects of western philosophy, including ethics. The first appearance of the Principle of Double Effect is found in what is considered his greatest work: the Summa Theologiae. This principle addresses whether or not one should act when an otherwise legitimate action may also cause an effect one would otherwise be obliged to avoid-relieving a terminally-ill patient’s pain with a drug that might cause sedation or a slightly shortened life, for example. In his book, Double-Effect Reasoning: Doing Good and Avoiding Evil, T.A. Cavanaugh lists this set of criteria according to Thomas Aquinas. He stated that an action is justified, even when its good effects are inseparable from its foreseen injurious effects if these are true:
  • The nature of the act is itself good, or at least morally neutral;
  • The agent intends the good effect and does not intend the bad effect either as a means to the good or as an end in itself;
  • The good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect, and the agent exercises due diligence to minimize the harm.
An interesting application of this principle is in the case of a pregnant mother whose life is threatened by the child she bears. Thus, although any intervention taken to save the mother’s life may end that of the child, such an intervention may rightly be pursued, very much in line with the aforementioned criteria. In the act of saving the mother’s life, the death of her child is not intended; and the circumstances are grave enough that if nothing is done, both the mother and child very likely become casualties.

In modern times, the first modern code of ethics, in which the expressions ‘medical ethics’ and ‘medical jurisprudence’ were coined, was drawn up by Thomas Percival, an English physician, in 1794. Within the next two hundred years, the United Kingdom’s Parliament would pass the Apothecaries Act; and the American Medical Association would adopt its first code of ethics, beginning an intentional regulation of the medical profession in both countries. More recent times have witnessed an increased number of institutional Review Boards, hospital ethics committees, clinical ethicists and the inclusion of biomedical ethics in the curricula of many medical schools. The World Medical Association developed the Declaration of Helsinki in 1964. It is a highly respected document that has seen seven revisions and served as a guide for the medical community on human research ethics. Succinctly put by a Brazilian forum in 2000, “even though the Declaration of Helsinki is the responsibility of the World Medical Association, the document should be considered the property of all humanity”.

I greatly fear that I may have been more scholarly than intended but, if nothing else, keep in mind the spirit of the words written thus far. We will always blaze the right trail if we do not shy away from knowing the origin of what presently exists; if we submit to the brilliance and learn from the inane silliness of those who have gone before us; if we let right reason guide how our knowledge of this history dictates our thoughts and actions presently.

Bibliography
  1. Nemec, Jaroslav. Highlights in Medicolegal Relations. National Library of Medicine.
  2. Levey, Martin (1967). “Medical Ethics of Medieval Islam with Special Reference to Al-Ruhawi’s ‘Practical Ethics of the Physician’”. Transaction of the American Philosophical Society. New Series. American Philosophical Society. 57 (3): 1–100.
  3. Vivian McAlister, Maimonides’s cooling period and organ retrieval (Canadian Journal of Surgery 2004; 47: 8–9)
  4. Summa Theologiae, IIa-IIae Q. 64, art. 7.
  5. T.A. Cavanaugh, Double-Effect Reasoning: Doing Good and Avoiding Evil, p.36, Oxford: Clarendon Press
  6. Codes of Ethics: Some History, Center for the Study of Ethics in the Professions at IIT.
  7. Human, Delon; Fluss, Sev S. (July 24, 2001). “The World Medical Association’s Declaration of Helsinki: Historical and contemporary perspectives. 5th draft”.
This article was written by Obinna Amaji, a 400-level medical student at the University of Ibadan.

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