HISTORICAL VIEWS OF THE LIMITS OF MEDICINE "Doctor, I have an ear ache." 2000 B.C. - "Here, eat this root." 1000 B.C. - "That root is heathen, say this prayer." 1850 A.D. - "That prayer is superstition, drink this potion." 1920 A.D. - "That potion is snake oil, swallow this pill." 1975 A.D. - "That pill is ineffective, take this antibiotic." 2006 A.D. - "That antibiotic is artificial. Here, eat this root!" MEDICAL HISTORY The Ancient Egypt 2600 BC The Egyptian Imhotep described the diagnosis and treatment of 200 diseases. It is suggested that he was the first one who enreached the mummification about evisceration. 1550 BC The important source of information is the Ebers papyrus. There is written about 878 medicinal drugs and different kinds of tumors, infestations, dysentery, cranial injury or bone fractures. Examples of remedies in the Ebers Papyrus Include: Cancer - recounting a "tumor against the god Xenus", it recommends "do nothing there against„. Death - half an onion and the froth of beer was considered "a delightful remedy against death. Ancient Greece First doctors question about ethical limits of medicine. The father of Medicine was Apollo. The most famous work were written by Hippocrates in the third century BC. Hippocrates quote: Wherever the art of Medicine is loved, there is also a love of Humanity. HIPPOCRATES Doctor has a duty to heal the sick but he also refuse those who are completely overcome by disease. If someone is overcomes by illness then medicine is powerless. Knowing the limits of medicine is part of the skill of the doctor Doctor who thinks he can heal someone who is beyond the limit of medical care is actually making an error known as „hubris“. Who is the „hubris“? A doctor who thinks he can heal someone who is beyond the limit of medical care. HIPPOCRATES The real doctor should be reliable, discreet, moderate, respectable and hard-working. Diagnosis had to be based only on careful observation or testing of disease symptom. During the treatment the doctor was obliged to write careful medical report. He emphasized that a cause of disease is inappropriate food, inadequate hygiene, unfavourable climate and risks connected with certain professions. Surgery should be used only if it mean effective treatment. RULES OF HIPPOCRATIC MEDICINE To understand the body to be subject to different forces or humours. In a healthy person there is balance between them. If person has an extreme imbalance of these forces it must be due to the nature of the person A doctor can be of no help. (except perhaps in helping the person die as painless as possible). HIPPOCRATIC OATH The doctors were obligated to follow the Hippocratic oath (it is Code of Ethics of medical profession containing moral principles of medical practice). HIPPOCRATIC OATH I swear by Apollo Physician and Asclepius and Hygeia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money, to give him a share of mine, and regard his offspring as equal to my brothers in male lineage, and to teach his art – if they desire to learn it – without fee and covenant,; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and the pupils who have signed the covenant and have taken this oath according to the medical law, but to no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, nor even on sufferers of stone, but will withdraw in favour of such men as are engaged in this work. Whatever houses I visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. If it fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot. HIPPOCRATIC OATH 1. 2. 3. Where in the text you can find the relation to the teacher? Where is in the text described the principle of maleficence? Where is in the text described the need of confidentiality? INTERNATIONAL CODE OF MEDICAL ETHICS OF THE WORLD MEDICAL ASSOCIATION – 1949 Compare with Hippocratic oath: 1. Any act, or advice which could be weaken physical or mental resistance of a human being may be used only in his interest. 2. The requirement to be „loyal“ to his patient. 3. Doctors must not use „medical knowledge contrary to the laws of humanity. 4. The requirement that a doctor must practice his profession uninfluenced by motives of profit. MEDIEVAL MEDICINE The body was considered as a temporary physical box and the development of scientific medicine was neglected. Monastic orders founded charity hospitals all around Europe. LEONARDO DA VINCI (1452–1519) He anatomized human bodies and he painted several anatomic schemes. ANDREAS VESALIUS (1514 – 1564) MODERN TIMES Modern science tried to dominate nature, to understand the way nature works. Medical science began to adopt the same attitude towards medicine that science had adopted towards nature. Sickness was no longer seen as a change in the balance of forces in the body. With development of bacteriology and germ theory of disease, it was decided that specific microorganisms were responsible for specific diseases modern medical science felt it could dominate and destroy disease by destroying the microorganism. MODERN TIMES There is complete belief in scientific progress. The doctors assume that their duty to the patient and society is to use every possible known medical method in every situation. BUT it can lead to the ethical problems – for example: 1) How much medical care should be given to a patient who is dying? 2) Who would only benefit very slightly from medical care? 3) Why did these ethical questions or problems appear? MODERN TIMES Answers: 1. In most situations there are only limited resources available: medicines, staff, equipment. 2. An individual patient may be given health care which he or she doesn´t want. What about the Hippocratic oath today? What function does it fulfill today? What does the Hippocratic oath mean to you? HIPPOCRATIC OATH TODAY Today the Hippocratic oath reminds students the importance of their profession, the need to teach others and the obligation to never knowingly harm a patient or divulge a confidence. The principles state in the oath are found today in many of professional codes of ethics. Do you know any of them? What does the shortcut AMA mean? WHAT IS THE SUBJECT OF ETHICAL CODES IN MEDICAL PROFESSION TODAY? Abuse Accepting patients Allocations of health resources Confidential care of minors Euthanasia Fee spliting Financial incentives for organ donation Gene therapy Ghost surgery HIV testing Mandatory parental consent to abortion Physician-assisted suicide Quality of life Withholding or withdrawing life-prolonging treatment. MEDICAL ISSUES RELATING TO BIOETHICS Abortion. Allocation of scarce health resources. Cloning. Euthanasia: active and passive. Fetal tissue research. Genetic counseling. Harvesting of embryos. HIV, AIDS and ARC. In-vitro fertilization. Organ donation and transplantation. Quality-of-life-issues. Random clinical trials. Stem cell research. Sterilization. Surrogate parenthood. Withdrawing treatment. Withholding lifesaving treatment. THREE STEP ETHICS MODEL Is it legal? When applying this three-step model, if the situation is clearly illegal, such as inflicting bodily harm on another, then matter is also clearly unethical, and you do not even have to progress to the second question. However, if the action is not against the law, then you should ask yourself the second question. Is it balanced? This question helps to determine if another person or group of people is negatively affected by the action. In other words, is there now an imbalance so that one person or group suffers or benefits more than another as a result of your action? For example, in the case of a scarce resource such as donor organs, does one group of people have greater access? How does it make me feel? This final question refers to how the action will affect you emotionally. Would you be hesitant to explain your action to a loved one? How would you feel if you saw your name in the paper associated with the action? Can you face yourself in the mirror? EXAMPLE 1 A patient in your hospital needs costly long term therapy to survive and the hospital will have to bear the cost. Should you authorize continued treatment if doing so would mean forgoing either needed emergency room renovation or a salary increase for the nursing staff? What should/would you do? EXAMPLE 2 A severely defective newborn is delivered at your hospital. The infant might survive for six months to a year with advanced medical technology. Attending physicians and invited medical consultants support the parents request to let the baby die without further medical intervention. You, the administrator, are aware of recent federal regulations („Baby Doe“) requiring treatment of handicapped infants. What should/would you do? EXAMPLE 3 You have patient in your hospital whose upper brain is irreversible total loss of all upper brain function activity. A person can be upper brain dead, but have a fully functioning brain. Such a person is unable to chew or swallow, but his/her lungs and heart function without a machine. He/she can be kept alive for many years (e.g.30) by means of artificial nutrition and hydration. Total loss of upper brain function is not always irreversible, but no one has ever recovered full function after total loss for many years. There have, however, been a few cases of partial recovery of the function after total loss for a year. Do you think this person is alive? THERE ARE THREE QUESTIONS 1. 2. 3. Do human beings with no capacity for future consciousness (e. g. Upper brain dead people) have right to live? Do human beings for whom it is virtually, but not perfectly, certain that they will never have the capacity for consciousness (e. g., PVS patients) have a right to life? Who has the right to decide whether a PVS patient will go on living? (a) God, (b) only a patient, (c) only the family, (d) only the state, (e) some other set of people? WHAT IS THE SOLUTION? It may be useful to consider the idea of futility. Futile medical care would be when resources are used for a patient who has actually reached the limit of medical care. REVISION 1. 2. 3. 4. 5. What does the word „hubris“ mean? How did the Hippocratic medicine understand the processes of health and illness? Why is the question of how much medical care should be given to a dying patient an ethical problem? What is the difference between Ancient Greek and modern medicine? What is futile treatment?