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Lecture for 4th year medical
students at the Faculty of Medicine Salman University Kharj on 30th
April 2013 by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH
(Harvard)
Learning Objectives
- Theories of health care ethics
- Principles of health care ethics
Key Words and Terms
UNIT OUTLINE
PURPOSES OF MEDICINE
A. Protection of morality/ddiin
B. Protection of Life Nafs
C. Protection of Progeny, Nasl
D. Protection of the Mind, ‘Aql
E. Protection of Wealth, Al
Mal
PRINCIPLES OF MEDICINE
A. The Principle of Intention, qasd
B. The
Principle of Certainty, Yaqeen
C. The Principle of Injury:
autonomy, beneficence, non-malefacence, justice
D. Principle of Hardship, mashaqqat
E. The Principle of Custom or
Precedent, ‘aadat
INTRODUCTION
Concern with moral issues in medicine increased in the recent past due to new medical technology and increase in moral violations by medical practitioners. In 1976 Beauchamps and Childress wrote authoritatively about ethical theory and ethical principles The following international declarations covered legal medical issues from a European world-view: Declaration of Geneva, International Code of Medical Ethics, Declaration of Tokyo, Declaration of Oslo, and Declaration of Helsinki.
MODERN ETHICS
Modern Ethical analysis can be
normative (what ought to be done), or practical (what most people do), and
non-normative (what is actually going on). Morality has became communal
consensus about what is right and what is wrong making ethics became and
changeable with change of community values.
Beauchamp and Childress listed
eight European ethical theories none of which can on its own explain all
ethical or moral dilemmas. These theories can be listed as the utilitarian
consequence-based theory, the Kantian obligation-based theory, the rights-based
theory based on respect for human rights, the community-based theory, the
relation-based theory, and the case-based theory.
There are 4 basic European ethical
principles according to Beauchamps and Childress (1994) are: autonomy,
beneficence, non malefacence, and justice.
ALTERNATIVE APPROACH TO ETHICS
Consistent and robust ethical
analysis is possible when based on the following purposes and principles. The
five purposes are preservation of morality/ddiin,
life, progeny, intellect, and wealth. Any medical action must fulfill one of
the above purposes if it is to be considered ethical. The basic principles relevant to medical practice are: intention, kasd; certainty, yakin; and harm,
dharar. The 4 ethical
principles enunciated by Beauchamps and Childress are all subsumed under the
principle of harm.
PURPOSES OF MEDICINE
PROTECTION OF LIFE, nafs: The
primary purpose of medicine is to fulfill the second purpose, the preservation
of life. Medicine contributes to the preservation and continuation of life by
making sure that the nutritional functions are well maintained. Medical
knowledge is used in the prevention of disease that impairs human health.
Disease treatment and rehabilitation lead to better quality health.
PROTECTION OF PROGENY, nasl: Medicine
contributes to the fulfillment of this function by making sure that children
are cared for well so that they grow into healthy adults who can bear children.
Treatment of infertility ensures successful child bearing. The care for the
pregnant woman, peri-natal medicine, and pediatric medicine all ensure that
children are born and grow healthy. Intra-partum care, infant and child care
ensure survival of healthy children.
PROTECTION OF THE MIND, ‘aql: Medical
treatment plays a very important role in protection of the mind. Treatment of
physical illnesses removes stress that affects the mental state. Treatment of
neuroses and psychoses restores intellectual and emotional functions. Medical
treatment of alcohol and drug abuse prevents deterioration of the intellect.
PROTECTION OF WEALTH, mal: The
wealth of any community depends on the productive activities of its healthy
citizens. Medicine contributes to wealth generation by prevention of disease,
promotion of health, and treatment of any diseases and their sequelae.
Communities with general poor health are less productive than a healthy vibrant
community. The principles of protection of life and protection of wealth may
conflict in cases of terminal illness. Care for the terminally ill consumes a
lot of resources that could have been used to treat other persons with
treatable conditions. The question may be posed whether the effort to protect
life is worth the cost. The issue of opportunity cost and equitable resource
distribution also arises.
PRINCIPLES OF MEDICINE
THE PRINCIPLE OF INTENTION, qasd: The Principle of intention
comprises several sub principles. The sub principle that each action is judged
by the intention behind it calls upon the physician to consult his inner
conscience and make sure that his actions, seen or not seen, are based on good
intentions. The sub principle that what matters is the intention and not the words
rejects the wrong use of data to justify wrong or immoral actions. The sub
principle that means are judged with the same criteria as the intentions
implies that no useful medical purpose should be achieved by using immoral
methods.
THE PRINCIPLE
OF CERTAINTY, yaqeen: Medical
diagnosis does cannot reach the legal standard of certainty. Treatment
decisions are best on a balance of probabilities. Each diagnosis is treated as
a working diagnosis that is changed and refined as new information emerges.
This provides for stability and a situation of quasi-certainty without which
practical procedures will be taken reluctantly and inefficiently. Existing
assertions should continue in force until there is compelling evidence to
change them. Established medical procedures and protocols are treated as
customs or precedents. What has been accepted as customary over a long time is
not considered harmful unless there is evidence to the contrary. All medical
procedures are considered permissible unless there is evidence to prove their
prohibition.
THE PRINCIPLE OF INJURY, dharar: Medical intervention is
justified on the basic principle is that injury, if it occurs, should be
relieved. An injury should not be relieved by a medical procedure that leads to
an injury of the same magnitude as a side effect. In a situation in which the
proposed medical intervention has side effects, we follow the principle that
prevention of a harm has priority over pursuit of a benefit of equal worth. If
the benefit has far more importance and worth than the harm, then the pursuit
of the benefit has priority. Physicians sometimes are confronted with medical
interventions that are double edged; they have both prohibited and permitted
effects. The guidance of the Law is that the prohibited has priority of
recognition over the permitted if the two occur together and a choice has to be
made. If confronted with 2 medical situations both of which are harmful and
there is no way but to choose one of them, the lesser harm is committed. A
lesser harm is committed in order to prevent a bigger harm. In the same way
medical interventions that in the public interest have priority over
consideration of the individual interest. The individual may have to sustain a
harm in order to protect public interest. In the course of combating communicable
diseases, the state cannot infringe the rights of the public unless there is a
public benefit to be achieved. In many situations, the line between benefit and
injury is so fine that salat al
istikharat is needed to reach a solution since no empirical methods can be
used.
PRINCIPLE OF HARDSHIP, mashaqqat:
Medical interventions that would otherwise be prohibited actions are
permitted under the principle of hardship if there is a necessity. Necessity
legalizes the prohibited. In the medical setting a hardship is defined as any
condition that will seriously impair physical and mental health if not relieved
promptly. Hardship mitigates easing of the sharia rules and obligations.
Committing the otherwise prohibited action should not extend beyond the limits
needed to preserve the Purpose of the Law that is the basis for the
legalization. Necessity however does not permanently abrogate the patient’s
rights that must be restored or recompensed in due course; necessity only
legalizes temporary violation of rights. The temporary legalization of
prohibited medical action ends with the end of the necessity that justified it
in the first place. This can be stated in al alternative way if the obstacle
ends, enforcement of the prohibited resumes/ It is illegal to get out of a
difficulty by delegating to someone else to undertake a harmful act.
THE PRINCIPLE OF CUSTOM or
PRECEDENT, ‘aadat: The standard of
medical care is defined by custom. The basic principle is that custom or
precedent has legal force. What is considered customary is what is uniform,
widespread, and predominant and not rare. The customary must also be old and
not a recent phenomenon to give chance for a medical consensus to be formed.