World Health • 49th Year, No.5, September-Dctober 1996 29
Bioethics and medical pract1ce •
Julio Monti Momberg & Roberto Mancini Rueda
The relationship between doctor and patient is moving from paternalism Ia partnership.
I
n the last few years, we have witnessed a drastic evolution in ethical thought in relation to medicine. It has shifted from pater- nalism and rigid moral principles that would defend the practice of medi- cine at all costs, to the recent empha- sis on personal autonomy as an inalienable right of the patient. This is a clear reflection of the cultural, political, economic and social change which has taken place in our time, and which medicine - and conse- quently bioethics-cannot ignore.When this evolution in thinking is considered in the light of the revolu- tionary advances in science and
technology, as well as people's increased knowledge about their own health problems and the means to solve them, it is easy to understand the conflicts faced by doctors. Some, who may not have had the training needed to adjust to such changes, may try to maintain the traditional attitude of treating the patient's illness alone with the help of God and the tools of their medical art.
As doctors working in PAHO's Regional Programme on Bioethics for Latin America and the Caribbean, we believe that this crisis in medicine does not mean chaos, but rather a watershed which may lead to either a
The solid principles of ethics and social well-being that hove always formed port of health core will be the pillars that continue to support the future development of medical core and the health of society, even in the whirlwind of change in which we live.
better or a worse situation. And as persons responsible for the propaga- tion of bioethics, we feel it is our duty to provoke some profound reflection among people working in the field of health, including those who may still have hardly begun to consider the ethical implications of these changes.
New images of medicine
Throughout our professional lives we have been participants-frequently without realizing it- in the enormous progress made by science and tech- nology in medicine. The image of the noble medical doctor at the pa- tient's bedside, using only his senses, knowledge, experience and a simple stethoscope, has been transformed by the availability of complex equip- ment which can analyse and image bodily malfunctions with a high degree of precision. The traditional deathbed scene has given way to intensive care units, full of devices that measure and control the smallest vital sign and make it possible to maintain life, often by artificial means, almost indefinitely.
30
Intensive care units hove replaced the charitable image of the medical doctor at the patient's bedside.
These advances-more accurate diagnosis, and more opportune and adequate treatment- have caused a spectacular increase in the life ex- pectancy of the population in the last 20 years. Yet while they offer great promise and have many advantages, these advances also imply consider- able risks for humanity.
When we see life being pro- longed- a postponement of the inevitable- by means of numerous tubes connected to the patient or by the use of extremely costly drugs, or when we realize how genetic manip- ulation may become a method of practising "anti-natural selection" on our descendants, we cannot avoid questions about how to define the boundaries that separate the neces- sary from the excessive.
In addition, the enormous changes that human society has experienced in every area, especially in relation to personal freedom, human rights and the search for equity, have affected the practice of medicine and the ethical norms that control it. Medical doctors and philosophers have added the con- cepts of autonomy and justice to the traditional Hippocratic principles of beneficence and non-maleficence.
The doctor-patient relationship has undergone a metamorphosis. The sick acquire rights and the physi- cian's aura of authority is lost.
Today patient and doctor must agree on therapy together, rather than treatment just being taken on trust.
Financial con cer n s
This is not the only area in which medical doctors have lost their al- most godlike place in the social hierarchy, as well as their indepen- dence of action and decision- making. The old idea of medicine as an altruistic profession often seems rather unrealistic today. This is largely because the mediation of financial concerns in the private sector and the institutionalization of treatment in both the public and private sectors have taken so much control over professional practice, and tend to dictate what the doctor's role should be.
World Health • 49th Year, No.5, September-october 1996
Economic realities and resources have had an increasing impact on health care, bringing considerations into play that have little or nothing to do with scientific knowledge and the skills needed for treating the sick.
Health professionals have been told to take economic factors into consid- eration, and have been obliged to add terms such as cost-effectiveness to their vocabulary, which have nothing to do with health itself. All this faces the medical doctor with the dilemma of being on the one hand a defender of the patients' interests and on the other a defender of institutional interests, and these often conflict.
Given this description of the new dynamic of our times, many ques- tions arise: What should be done?
What is best? How do we know what is right or wrong? Such ques- tions present a special challenge for medical doctors and for ethicists, because of their knowledge and because of the way their role is viewed by society. They must re- spond to these questions with a great sense of responsibility, even when they involve a serious conflict of interests.
Medical doctors must be highly competent professionals in their knowledge, abilities and skills, but they must also have a strong commit- ment to the principles of bioethics.
The solemn nature of medical deci-
Never before hove people in general hod a greater knowledge about their own health.
World Health • 49th Year, No.5, September-october 1996 31
Radiologists undergoing training. The new generation of medical students and physrcrans are hrghly aware of the ethrcalrmphcatrons of their profession.
Emergency at a hospital in the United States. More than competence and kindness is required from today's health professionals; they also have to think about cost-effectiveness and ethics.
sions is self-evident: they involve nothing less than the most precious possession of a human being: his or her own life.
Physicians have always had an almost intuitive respect for ethics because it is inherent in their voca- tion. But with the new conflicts that arise from change today, personal attitudes or intuition are not enough.
Bioethical reflection has become a necessary part of medical decision- making. In our activities in the Regional Programme on Bioethics, we are aware that a new generation of physicians and medical students want to acquire the practical and philosophical knowledge needed for understanding ethical issues in health work. They know that this will help them to make decisions that respect the values and rights of their patients.
These young people observe that the medical profession, for which society sets such high standards, is losing its traditional observance of human values and respect for per-
In the next issue
Whether caused by uncontrollable natural phenomena or by humans themselves, emergencies can challenge health services anywhere at any time.
A great deal is known today about how to avoid them or to minimize the damage that they do. The November- December issue of World Health, which is devoted to emergencies and how national and international organizations prepare for them and respond to them, seeks to share some of this valuable knowledge. •
sons, as a result of the trend toward the commercialization of medicine.
Many young doctors are reflecting deeply on this, and are turning to bio- ethics in their search for answers. It is necessary to respect and encourage this process.
We may conclude, on a renewed note of hope, that medical care and the health of society must not be left to chance. The solid principles of ethics and social well-being that have always formed part of health care will be the pillars that continue to support their development in the future, even in the whirlwind of change in which we live. •
Dr julio Monti Momberg and Dr Roberto Mancini Rueda are with the Regional Programme on Bioethics for Latin America and the Caribbean, Pan American Health Organization/World Health Organization, Paul Harris 460, Las Condes, Santiago, Chile.
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