Sunday, August 10, 2008

Medical Ethics - what every patient needs to know !

The recent debate about whether couples should be allowed to abort a fetus who has a birth defect after the 20 week legal limit has been featured exhaustively in the Indian press. This is one of those topics which generates more heat than light ; and since it provokes strong emotions, we often lose sight of logic while looking at these controversial issues. Doctors and philosophers have evolved systems to deal with such sticky issues – and this is the domain of medical ethics.

What is medical ethics, and how does it apply to you ? Doctors have always been responsible professionals and they deal with life and death on a daily basis. We realize that every patient is different ; many areas are highly controversial; and that there are no easy answers for many medical problems. These include: when does life begin ? should abortions be allowed ? till what age is it permissible to abort a fetus ? is cloing ethical ? should we permit euthanasia ( mercy-killing) ? when is it allright to remove life-support from a patient ? These are complex areas because they deal with medicine, religion , morality and law.

The medical profession has always abided by a code of ethics. This was first formalized by Hippocrates over 2000 years ago as the Hippocratic oath. Modern updated versions include the Indian Medical Council’s Ethical Code for doctors.

The three pillars of medical ethics are:

  • Autonomy ( independence). We respect the patient’s autonomy, and empower him to decide . The patient should have the final say, and has the right to refuse or choose their treatment.
  • Beneficence. The doctor should act in the best interest of the patient. This is the hallmark of any professional.
  • Non-maleficence. "First, do no harm" (primum non nocere). The action should not harm anyone.

These pillars do not always give pat answers as to how to handle a particular situation, but do provide a useful framework for understanding and resolving ethical dilemmas. Sometimes, no good solution to a dilemma exists, and occasionally, the values of the patient or doctor conflict with the values of society.

How can we apply these principles to a particular case ? For example, should abortions be allowed after 20 weeks when the fetus has a severe birth defect ? Is it permissible to kill the fetus because the parents want to ? Some actions can create a positive outcome while also potentially doing harm. How do we balance these ?

The principle of non-maleficence states that no one should be harmed. Allowing the abortion will harm the fetus because it will take away its life. This brings us to the thorny issue of when the fetus can be considered to be a independent human being . Normally, the answer would be only after birth – but is it fair to use different standards because the baby has not yet been born ? Many religions ( and pro-lifers) would condemn all abortions, no matter what the age of the fetus, because they think it is reprehensible to take away life when we do not have the power to create it. They feel this is like playing God – and if we are willing to kill a fetus at 20 weeks, then what’s to stop us from killing it at 28 weeks ? or at birth ? On the other hand, is it fair to burden the parents with the responsibility of bringing up a child with a birth defect, when they don’t want to do so ? We need to realize that the 20 week limit is arbitrary – and just because it is laid down in a law does not give it a special status ! The fact that different countries have different limits (even though humans are the same all over the world) just underlines this arbitrariness !

Unfortunately, laws are rigid, because they are in black and white. The problem with this is that they cannot keep up with changing medical technology. Thus, while a law passed in 1971 was a great law at that time, it may no longer be good in 2008. However, amending a law is a challenging and expensive options. In order to prevent such problems, all laws which deal with health and medical issues should have some flexibility built into them, to provide them with a human face. For example, they could have a clause which allows an empowered committee of doctors, officials and judges, to consider individual cases who have special needs. Until this happens, the law will continue causing a lot of private pain, because it is blind.

There are no easy answers – and only King Solomon could resolve disputes like this without offending someone. Each individual will look at this issue with a different lens. Personally, I find that the principle of autonomy is very useful in resolving such cases.

The principle of autonomy recognizes the rights of individuals to self determination. This is rooted in our democratic society’s respect for citizens’ ability to make informed decisions about personal matters. If the goal of family planning is to ensure that every child is a wanted child, then is it fair for Society to force couples to have a child they don’t want ? Who is this good for ? It seems to harm everyone involved – the parents, because they don’t want the child; the child, because it is unwanted; and society as well, because it is then burdened with an unloved child.

I think how we look at this depends to a large extent on our world view. Most judges spend all their time resolving disputes between individuals and giving judgments. They naturally take the view that individuals cannot resolve matters for themselves or make sensible decisions. ( If they could, then they would never need to come to the Court for justice !) Because they are used to dispensing justice, they are very comfortable deciding and interpreting for others. Doctors, on the other hand, are much more likely to be empathetic, because they are in a “helping profession” and are more tuned to helping patients attain their own goals. They will often follow the Golden Rule - treat others the way you would like to be treated yourself !

Life was much simpler in the past. Society allowed doctors the freedom to help patients make these decisions on medical matters of life and death ; and trusted that doctors would fulfill the trust placed in them because of their professional code of ethics. Patients who had a problem would go their personal doctor, who would use his judgment in crafting a solution suited to their personal circumstances.

Unfortunately, today the medical profession in India is in crisis and society no longer holds the medical profession in the high esteem it used to in the past. Doctors are no longer felt to be trustworthy – and their ability to make decisions in their patients’ best interests has been progressively curtailed. These decisions are now made by bureaucrats and judges , who often may not feel the individual pain of the patient, as they do not see patients one-on-one. This lack of empathy means that most decisions are made using only facts, figures and logic – as a result of which they are often cruel to individuals. This is hardly surprising, because decisions made by a system are designed to be heartless – and this is the price we have all agreed to pay.

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