Medical Ethics

Professor ( Dr ) Monem AlshokDepartment of Medicine College of Medicine,

Babylon University

It is now generally agreed that medical Ethics should be an integral part of medical education throughout undergraduates ,

postgraduates Medical Education . It had been recognized that good doctor – patient relationships were required to

achieve the goals of medicine . Although there is disagreement & different opinions among experts about what aspects of Medical Ethics but the wide agreement has nevertheless emerged in recent years is that we should teach medical Ethics

especially for medical students & residents.

Why We Teach Medical Ethics?

Contribution to the care of patients. Improve quality of patient care in

term of both the process & outcome of care.

Improve Ethics of Decision _ Making .

Improve Skills of Ethical Analysis.

Who should Teach Clinical Medical Ethics?

1 .Should be taught by those who did it well and who has the capacity to

motivate students and residents to improve the quality of both :

patient outcomes and their patient – physician interactions

2.Physician Teachers are especially desirable , having their teachers' modeling of ethical behavior &

professional conduct.

What Should Be Taught?

The teaching of clinical medical Ethics should include 3 dimensions :

1.Cognitive Knowledge 2.Behavioral Skills

3 .Character development.

How and When should Clinical Medical Ethics be taught?

6 principles ( the 6 C 's ) had been emphasized by one of the university.

)1( Clinically – based. )2( Case – based.

)3( Continuously reinforced in class .( 4 year medical students and whenever possible , ethics teaching should be linked with students other learning objectives ( e.g.) an ideal time to teach about brain death & vegetative state is during a basic science course on neuroanatomy &

neurophysiology. )4( Coordinated with clinical clerkships.

)5( Clean ( Simple ) , e.g. informed consent , teach how you make ? in simple way

)6 ( Clinician as instructors . also as role models for students.

Methods:

The course consist of series of lectures: Introductory lecture. *

* General Medical Ethics with concentration on the 4 principle or fundamentals of Ethics ( Beneficence , Non malfecience ,Autonomy & justice )

* Patient – doctor relationships , Doctor relation to his colloquiesand relation to society

* Ethics in Specialized medical disciplines * Ethics in researches & in recent advances of

medical technology , in Organ transplantation ,Assisted life

prolongation & End of life issues ,Euthanasea ,Quality of life issues ,Stem cell research , Surrogacy & few other Ethical dilemmas

EthicsEthics

Is defined as a ‘code of conduct,’ a moral Is defined as a ‘code of conduct,’ a moral way of dealing with day to day matters in way of dealing with day to day matters in life( as in death)life( as in death)

Is a way of observing norms, values, Is a way of observing norms, values, principles which are accepted as standard, principles which are accepted as standard, good , honest , fair and equitablegood , honest , fair and equitable..

It implies that one may not do to another It implies that one may not do to another person, what one may not want done to person, what one may not want done to himselfhimself..

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ETHICS THROUGH THE ETHICS THROUGH THE AGESAGES

Ethics is derived from the Greek word Ethics is derived from the Greek word ‘ Ethos‘ Ethos.’.’

It is a branch of PhilosophyIt is a branch of Philosophy , ,

akin toakin to : :

LogicLogic

MetaphysicsMetaphysics

Politics andPolitics and

AestheticsAesthetics . .

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MEDICAL ETHICSMEDICAL ETHICS

Is a branch of moral philosophyIs a branch of moral philosophy..

Is the application of normative ethical Is the application of normative ethical principles in medicineprinciples in medicine..

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ETHICS THROUGH THE ETHICS THROUGH THE AGESAGES

Moral PathwaysMoral Pathways

A. SecularA. Secular. .

B. ReligiousB. Religious..

Codes of MoralityCodes of Morality

Hammurabi’s Code of Conduct : 1792BCHammurabi’s Code of Conduct : 1792BC

Hippocrates 460 BC -399 BCHippocrates 460 BC -399 BC

World Medical Council -Helsinki World Medical Council -Helsinki declaration 1964---- last updated in 2008declaration 1964---- last updated in 2008

Muslim Physician’s Oath 1980sMuslim Physician’s Oath 1980s

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Dua e M ADua e M A

Characters of a physicianCharacters of a physician::

Honest Humility, modesty, taqwaHonest Humility, modesty, taqwa

Matching knowledge skills and Matching knowledge skills and attitudeattitude..

Serve with Birr wal EhsaanServe with Birr wal Ehsaan

Polite, rage control, patient listener, Polite, rage control, patient listener, effective communicatoreffective communicator..

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ETHICAL THEORIESETHICAL THEORIES

DEONTOLOGYDEONTOLOGY (Kant) (Kant)

Focuses on ‘Duties and Focuses on ‘Duties and ObligationsObligations. ’. ’

The means as well as the ends should The means as well as the ends should both be goodboth be good.’.’

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VIRTUE THORIESVIRTUE THORIES

Focus upon the ‘QUALITIES of a Focus upon the ‘QUALITIES of a CHARACTERCHARACTER.’.’

Virtuous people act virtuouslyVirtuous people act virtuously. .

Simply knowing the rules of Simply knowing the rules of goodness is not enough. One must goodness is not enough. One must practice them toopractice them too..

Aristotle defined it as ‘an attribute Aristotle defined it as ‘an attribute in people who are virtuous by in people who are virtuous by nature and act accordinglynature and act accordingly.’.’

PRINCIPLESPRINCIPLES

AUTONOMY AUTONOMY TakrimTakrim

BENEFICENCE BirrBENEFICENCE Birr

NONMALIFICENCENONMALIFICENCE

JUSTICE AdlJUSTICE Adl18

Adl o EhsaanAdl o Ehsaan

AdlAdl is expected of every just person to is expected of every just person to dispense in day to day lifedispense in day to day life . .

EhsaanEhsaan is a virtue many steps higher is a virtue many steps higher than than Adl.Adl. It is a combination of It is a combination of Altruism, Self denial and SacrificeAltruism, Self denial and Sacrifice..

Fazl Fazl is only attributable to Allah STis only attributable to Allah ST..

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JUSTICEJUSTICE

DistributiveDistributive Fair , equitable, and appropriate Fair , equitable, and appropriate

distribution of services and distribution of services and resourcesresources..

RetributiveRetributive Punishment matched with crimePunishment matched with crime..

Some ethical questionsSome ethical questions

ExploitationExploitation.. استغالل استغاللblatanblatan صارخصارخviolationviolation..انتهاكانتهاك

Abuse of authorityAbuse of authority

InjusticeInjusticeTyrannyTyranny طغيان طغيان استبداد استبداد

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Ali’s (as) mandate On Justice

‘ ‘ Orderly placement of your matters Orderly placement of your matters is justiceis justice ’ ’

And Justice requiresAnd Justice requires: :

Depth of understandingDepth of understanding

Profoundness of knowledgeProfoundness of knowledge

Fairness of judgementFairness of judgement

Clarity of mindClarity of mind..

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ResearchResearch

Violation of fundamental principle of Violation of fundamental principle of medical ethics in the name of medical ethics in the name of research and benefit to mankindresearch and benefit to mankind..

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Principles of Justice in Principles of Justice in RESEARCHRESEARCH

The risks and benefits on the same partyThe risks and benefits on the same party..

One party bears the risks while the other One party bears the risks while the other party gains the benefitsparty gains the benefits..

Both parties may bear the risks, while Both parties may bear the risks, while another party (stake holder) gains the another party (stake holder) gains the benefitsbenefits. .

Both parties gain the benefits while another Both parties gain the benefits while another party bears the costsparty bears the costs..

Assisted life Assisted life ProlongationProlongation

Assisted Life ProlongationAssisted Life Prolongation . .

Euthanasia. Assisted death issuesEuthanasia. Assisted death issues..

Brain Death/ Somatic DeathBrain Death/ Somatic Death..

Delaying death for organ harvestingDelaying death for organ harvesting. . 25

ETHICAL DILEMMASETHICAL DILEMMAS

Organ trade and theftOrgan trade and theft..

Presumed Consent. . ‘To Opt OutPresumed Consent. . ‘To Opt Out. ’. ’

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STEM CELL RESEARCHSTEM CELL RESEARCH

The employment of embryos to The employment of embryos to harvest the Stem Cellsharvest the Stem Cells..

Are embryos aliveAre embryos alive ? ?

When does life beginWhen does life begin??

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What is a Stem cellWhat is a Stem cell..

They are pluripotent,totipotent cells They are pluripotent,totipotent cells with the inherent capacity to any of with the inherent capacity to any of the three germinal layers and thus the three germinal layers and thus the bodily organs. They are produced the bodily organs. They are produced by TROPHOCYTES in early by TROPHOCYTES in early embryological stages (5-14 days)embryological stages (5-14 days)..

Human Genome Project was launched Human Genome Project was launched in 1998in 1998..

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What can stem cell doWhat can stem cell do

Potentially any cell, tissue or an organ Potentially any cell, tissue or an organ can be grown in vitro as well as in can be grown in vitro as well as in vivovivo

Anything from diabetes to cardiac Anything from diabetes to cardiac conditions to deaf ears , blind eyes or conditions to deaf ears , blind eyes or paraplegic patients may be curable in paraplegic patients may be curable in future yearsfuture years..

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sourcessources

EmbryosEmbryos

Umblical cordsUmblical cords

Recently adult skins, bone marrow Recently adult skins, bone marrow etcetc..

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SURROGACYSURROGACY

The dilemma of SurrogacyThe dilemma of Surrogacy . .

Is it Justified in certain special Is it Justified in certain special circumstancescircumstances?.?.

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Common practiceCommon practice

Ovum donation is acceptable but the Ovum donation is acceptable but the sperm donation has not gained sperm donation has not gained popularitypopularity..

Many clinics have moved to Many clinics have moved to anonymous donation……. Which can anonymous donation……. Which can raise the fear of incestraise the fear of incest..

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Physicians shouldPhysicians should

Protect the human rights ( Autonomy)Protect the human rights ( Autonomy)

Serve only for patient’s benefit Serve only for patient’s benefit (Beneficence)(Beneficence)

Observe JusticeObserve Justice . .

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Data collectionData collection : :

9090 Fourth year medical students, Fourth year medical students, and from 50 6th year students and from 50 6th year students

interrogated about the courseinterrogated about the course . .

The study carried during the The study carried during the academic year 2006 – 2007academic year 2006 – 2007. .

Students Should know Students Should know the 4 principlesthe 4 principles: :

Respect the human rights ( Autonomy). Respect the human rights ( Autonomy). Al TakrimAl Takrim..

& &Serve for patient’s benefit Serve for patient’s benefit (Beneficence)and (Beneficence)and (Non Maleficence) (Non Maleficence) Al Birr, and Al IhsanAl Birr, and Al Ihsan

Act with Justice. Act with Justice. Al_AdlAl_Adl

Sources of Med Ethics : Religion , Conscience Sources of Med Ethics : Religion , Conscience and consuetude ( Tradition & Habit )and consuetude ( Tradition & Habit )

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Islamic moral codeIslamic moral code also also mentionedmentioned

The moral code of Islam isThe moral code of Islam is : : AmrAmr Bil Bil MaroofMaroof wa wa nahi Analnahi Anal – –Munkar, Munkar,

(31:17(31:17 ) ) ie Bid good , forbid evilie Bid good , forbid evil..

If you don’t do good don’t do harmIf you don’t do good don’t do harmIt was also the mission statement of Imam It was also the mission statement of Imam Hussain a.s in KarbalaHussain a.s in Karbala..

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Islamic Sources also Islamic Sources also mentionedmentioned

Noble Quran is the final divine testament on Noble Quran is the final divine testament on ethicsethics..

Hadit e Nabvi…Hadit e Nabvi…B’aasat latmam makram al B’aasat latmam makram al akhlaq’akhlaq’ ‘i.e I am sent to accomplish morality ‘i.e I am sent to accomplish morality..

Imam Ali is a role model of Prophet’s teachingsImam Ali is a role model of Prophet’s teachings . .

Nahaj al Balagha is a roadmap on ethicsNahaj al Balagha is a roadmap on ethics

Imam Imam Zain Al Abedin Sajjad Zain Al Abedin Sajjad a.s gave us the a.s gave us the monumental Sahifa- e Kamila containing monumental Sahifa- e Kamila containing Dua-e Makaram Al AkakhlaqDua-e Makaram Al Akakhlaq.’.’

Results :85% of the students thought the

course is theoretically & practically useful.

About 75% of the students mention the course is relevant to their medical

training & to their future career. 80% consider that the issues of

patient – Dr relationships & Dr – Dr relationships an important teaching

subject. Few of the 6th year student were

unable to recall the 4 principles. 10% mention the method of problem

solving approach & be simple way & the language better in Arabic.

The students are an important materials in the evaluation of the medical education.

They have to be involved in planning for development of medical curriculum also

during assessment of this medical curriculum , that is why we consider their

overviews & opinions Finally we hope in future we can introduce

the programmed that involve engagement of the students in project work , small groups

workshops & seminars ; and also every attempts will be made to encourage other

faculty staffs from various medical disciplines to share in our course &

participate in the education of clinical medical Ethics .

Some example of Case teaching approach:

Q1.An elderly woman is admitted to the hospital after suffering from stroke . She is not conscious & must be fed through NGT . She does not have a living will or a health care proxy . However , her son insists to hospital that he

wants the tube removed so his mother can die . ?Q2 .What is Islamic position on fetal tissue & stem cell

transplant ? Iran has taken a very pragmatic approach and taken a lead

in the Islamic world to allow stem cell research , even eugenics and animal cloning. (Mansur Senaie ,2006)

Q3 . Is abortion allowed for pregnancy happed by rape or in unmarried virgin girl ?

الخير في قراءة االL في تدبرالخير في قراءة االL في تدبروالفي عبادة االL بتفكروالفي عبادة االL بتفكروال في علم االL بحلم وال في علم االL بحلم

امام المتقين علي ( ع )امام المتقين علي ( ع )ألسالم عليك يا ابو ألحسنين ألسالم عليك يا ابو ألحسنين

ورحمته وبركاتهورحمته وبركاتهألسالم عليك ياامامي علي ابن ألسالم عليك ياامامي علي ابن

موسى الرضا ( ع ) موسى الرضا ( ع )

ALSALAM ALAIKOM WA ALSALAM ALAIKOM WA RAHMATAHU WA RAHMATAHU WA BARAKATUHBARAKATUH

WA MA ALAINA WA MA ALAINA ILLALABALAGAH AL MUBEEN ILLALABALAGAH AL MUBEEN YA SEENYA SEEN

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