Thesis Paper on the Formulation of Modern, Global Medical Ethics

Gerald Neitzke, Brigitte Lohff
Department of history, ethics and theory of medicine,
Hannover Medical School, Germany (Director: Prof. Dr. B. Lohff)

and

Andreas Schapowal
The Davos Doctors´ Association, Switzerland

PREAMBLE

Responsible medical conduct requires the recognition of an ethical basis. This is the case in all cultures and religions, and also for physicians who do not feel affiliated with any particular religion. Medical ethics should consider traditional values such as sympathy, charity, compassion, tolerance and equity and should respect the General Declaration of Human Rights of the United Nations and the Ethical Guidelines of the World Medical Association, such as the Declaration of Geneva and the Declaration of Helsinki.

Unanswered questions: Are global medical ethics, to which representatives of all world religions could agree, conceivable? Where does the physician who is not of a particular religious persuasion find the foundation for responsible conduct?

THESES

Thesis I: The health of the individual is the most valuable asset in the medical profession. The autonomy and dignity of the individual must always be preserved.

Comment: It therefore follows that the interests of society must indeed be considered, but may not be placed above those of the individual. Every person decides for himself/herself on the necessity, the time, and the extent of medical assistance. Medicine is merely an offer to the individual in his/her attempt to maintain or restore health. Preserving patient autonomy at the same time means establishing the patient's ability to make a decision through appropriate information and respecting the patient's decision. The individual's dignity is respected by acknowledging his/her autonomy. If the patient is unable to make a decision, e.g. the autonomous will of the patient is not discernible because of his/her illness, the patient's presumed will and interest must serve as the basis for a decision.

Unanswered questions: Are the individuals themselves solely responsible for maintaining their health? Can the offer of medical care be made dependent upon certain obligations for maintaining health (proper nutrition, avoidance of alcohol, cigarettes or other drugs, risk- laden recreational activities...)? Are sanctions permissible on the part of the solidaristic community with respect to certain individual behavior? Can the offer of medical assistance set limits on individual freedom? What limits are set for an autonomous decision, e.g. through social context (the patient's consideration of the interests of relatives or of society, respect of cultural values...)? How can the incapacity to decide be recognized with certainty?

Thesis II: "Life" and "death" are terms that should not and cannot be defined by physicians alone. For this purpose, a social discussion is necessary that is as comprehensive and open as possible.

Comment: Not so much are the definitions concealed behind the terms "life" and "death," but rather the experiences, concepts, views, and convictions that every person acquires for himself/herself. A large number of medicoethical problems arises, however, through the various answers to the questions of the beginning of life (e.g. upon fertilization, implantation, development of the embryonic nervous system, birth, development of individual self- awareness...) and the end of life (e.g. upon apallic syndrome, brain death, heart death, social death...). Is there common ground worldwide for the concepts of life and death that could serve as a basis for global medical ethics? A definition that is not in accord with the feelings, values, and religious attitudes of the patients, relatives, physicians, and care givers cannot, in our opinion, serve as a foundation.

Unanswered questions: What concrete criteria for determining "life" and "death" can be brought forward by the world religions and the different forms of medicine? What influence does the belief in life after death or reincarnation have on ethical considerations? What influence does the idea have of to whom a person feels accountable (to himself/herself or to a transcendent power, e.g. God)?

Thesis III: According to the consensus to the terms "life" and "death," rights must be clearly laid down for people in all phases of life.

Comment: Even after clarification of the terms "life" and "death," the question remains as to what kind of protection a person should be entitled in different phases of his/her life: May we treat embryos differently than we treat adults? Is it permissible to weigh between the interests of people in different phases of life? We disapprove of every unequal legal or medical treatment selected on the basis of sex, religion or philosophy of life, race, nationality, social circumstances or on the basis of existing or expected illness.

Unanswered questions: What concrete rules can be found pertaining to medicoethical problems such as euthanasia, abortion, persons in a coma/persistent vegetative state? May financial considerations (costs of intensive therapy, health expenses in old age, etc.) play a role in making a decision on life-prolonging measures? What role can physicians play in the creation and conversion of concepts for population planning? How can medical measures for population policy on the one hand and for individual family planning on the other be justified and be brought into agreement with each other (contraception, sterilization, abortion versus in vitro fertilization, intrauterine therapy, surrogate motherhood)? How can the danger of discrimination through predictive procedures such as prenatal diagnostics, gene tests, genetic examinations for insurance companies or employers be averted with certainty? Can these techniques be used at all without manipulations of the genetic make-up or aimed preference of certain hereditary factors being the inevitable result?

Thesis IV: Social commitment is a component of the medical profession.

Comment: May the purposes of medicine be limited to the making of an individual diagnosis and the treatment of the respective illness? The WHO defines health as the "condition of complete physical, mental and social well-being and not merely the absence of disease or infirmity". If it is the goal of physicians to maintain or restore this form of health in as many people as possible, then social commitment is an integral component of medical conduct. Social responsibility ranges from such goals as commitment to a fair health system in one's own country to the involvement in the improvement of working conditions, to questions of global distribution of health resources and the commitment for a healthy environment (suitable for life). That there are overlaps with other disciplines (social sciences, politics, natural sciences, etc.) in terms of content is not obstructive, but they are understood rather as an appeal to bring forward medical standpoints in an interdisciplinary discourse.

Unanswered questions: Is the WHO's definition of "health" in fact a realizable goal or one always to be strived for but never attainable? To what degree is sociopolitical commitment compatible with the mission of patient care? What specific possibilities of influencing social interests do physicians have?

Thesis V: Besides therapy, fields of prevention/prophylaxis and palliative care should find increased attention as the purposes of medicine.

Comment: Western medicine, through its historically evolved scientific understanding, is predominantly orientated towards therapy in the sense of "the defeat of illness." Moral problems result particularly from the inability to accept and accompany the process of dying. The whole personality of the physician and his/her empathy for the wishes and needs of the suffering and dying are required here. On the other hand, it must likewise be more and more the task of physicians to become active before an illness appears in the sense of health maintenance. To this end, more knowledge in the field of prevention and prophylaxis must be gained and converted into practical abilities.

Unanswered questions: In what way do the tasks of fighting affliction and accompanying those who suffer complement each other? Can the phenomenon "suffering" thus be accepted as an existential component of human life - to such a degree that one can escape forced therapeutic action without becoming a slave to therapeutic nihilism? What form of ecological commitment is included in the concept of prevention (reduction of traffic, air pollution, "electrosmog", global climatic changes, harmful substances in the air, soil, water, food...)? How can preventive/prophylactic measures be effectively realized without endangering the individual's autonomy (see Thesis I)?

Thesis VI: Medicine is a changing discipline. For medical progress to occur, scientific diversity and openness are necessary prerequisites. Biomedical research is subject to generally accepted fundamental principles and must guarantee that the participating individuals have given their consent.

Comment: Since diseases and thus the demands on medicine change with social conditions, medical research is essential. Diagnostic and therapeutic possibilities must be changed or newly developed in such a way that scientifically qualifiable progress in medicine is the result as opposed to chance development. Modern understanding of science must be open to other methods and research topics in the sense of pluralism. Research programs must be made socially lucid. The goals of research may not be worked out by medicine alone, but must rather be developed with and attuned to other social groups, i.e. with the potential patients. Medical research with humans is permissible only after individual informed consent has been given. Research with patients unable to give consent must be advantageous to the patients themselves or to persons with diseases of the same kind. The observed increase of falsification and deceit in scientific publications is scientifically and morally reprehensible.

Unanswered questions: How can knowledge gained through reductionist procedures (e.g. Western medicine) be applied to holistic phenomena such as the condition of an ill person? What influence do reductionist therapy concepts have on holistic phenomena such as the powers of self-healing, salutogenesis, etc.? How can holistic, experience-based medical knowledge (therapy forms of non-Western medicine such as Ayurveda, classical Chinese medicine, Tibetan medicine...; complementary Western courses of treatment such as phytotherapy, homeopathy...) qualify with scientific methods? How is the proof of therapeutic efficacy, i.e. the proof of causation of the mode of therapy for a cure, to be recorded? Should the strict scientific research criteria that are binding for new drugs be applicable to new surgical techniques as well? Does the flood of new medical findings arising from research endanger responsible medical conduct? How can the continuing education of physicians be guaranteed? How can new techniques be developed and brought into diagnosis or therapy without being forced by the pursuit of profit?

Thesis VII: The quality of medical treatment and the contact with the ill is dependent upon the manner in which physicians treat themselves.

Comment: A health system that endangers the health of the physicians and care givers employed within it functions ineffectively and counterproductively. A prerequisite of understanding the suffering of the ill is the ability to empathize with oneself. Dealing with one's own physical, mental, and emotional needs should be a model for patients. Only this way it is possible to influence the circumstances of the ill. It is medicine's duty to establish decent working conditions so that therapy can be offered adequate to the dignity of the ill. Cooperativeness among physicians is a self-evident component of such good working conditions and may not be negatively influenced by economical considerations. "Burn-out" phenomena which have already occurred must be researched and problem-solving strategies developed.

Unanswered questions: To what degree are hierarchical structures within the health care system, which are contrary to the understanding of health care as a system of interdependent individual components, of disadvantage with respect to humaneness and efficiency? What concrete measures for reforming the health care system are needed worldwide in order to establish a health system suitable for all parties concerned? To what extent are the processes of supervision in therapeutic teams (e.g. Balint groups) a necessary requirement for one's own therapeutic work?

Thesis VIII: Physicians have an obligation to global medical ethics with respect to their conscience, their profession, and their patients.

Comment: One's own conscience is the highest authority for individual decisions in medicine. Yet, the code still to be developed must include the possibility of imposing sanctions. Therefore, it is necessary to incorporate the code of global medical ethics into the rules for physicians in their individual countries. Professional and penal measures thereby serve as a corrective of the individual conscience and as guarantees for keeping the medical code.

Unanswered questions: How can a social climate be created - in spite of possible legal sanctions - in which therapeutic errors can be admitted in order to be able to learn from them in an open discourse? How can entrepreneurial, financial, and social pressures be kept away from the question of conscience?