ETHICS MEDICAL (Greek
ethika, from ethos custom, temper, character) — the section of ethics — the philosophical discipline studying questions of morals an object of a research to-rogo are moral aspects of medicine. In narrower sense understand set of ethical standards of professional activity of health workers as medical ethics. In the last value E. the m closely adjoins to a medical deontology (see the Deontology medical).
Ethics medical cover a wide range of the problems connected with relationship of medics with patients, their relatives, with healthy people, and also among themselves in the course of treatment of the patient. A subject of a medical deontology are hl. obr. questions of development of ethical standards and rules of conduct of the medic at his communication with the patient. However, in spite of the fact that the concepts «ethics medical» and «medical deontology» are not identical, they shall be considered in dialectic interrelation.
Principles of professional ethics, including AA. m, are interconnected with social and economic conditions as well as the general ethical standards. During each historical era according to the class morals dominating in this society the principles E. m had idiosyncrasies; always there were universal extra class principles of a medical profession determined by its humane essence — the aspiration to alleviate suffering and to help the sick person. If this primary obligatory basis of doctoring is absent, it is impossible to speak about respect for moral standards. So, in Ancient India it was recommended to undertake treatment only of such person, the disease to-rogo is curable; it was necessary to refuse treatment of incurable diseases, just as the patient who did not recover within a year. Norma E. m are defined also by the level of development of medical science, from to-rogo actions of doctors in many respects depend.
Moral requirements to the people who were engaged in doctoring were formulated still in slaveholding about-ve when there was division of labor and doctoring became a profession. From an extreme antiquity profession of a physician was highly honored because the aspiration to save the person from sufferings, to help it at illnesses and wounds was the cornerstone of it.
The most ancient source, in Krom formulated requirements to the doctor and his rights, consider carrying
shchiyesya to 18 century BC. The «laws Ham-murapi» adopted in Babylon. Questions E. m found reflection in the most ancient monuments of the Indian literature — the code of laws of Manu (apprx. 2 century BC — 1 century AD) and «Ayurveda» (see), «Science of life» (3 — 2 millennium BC, on other sources 9 — 3 centuries BC). There are three editions of «Ayurveda» — this medical encyclopedia of antiquity; the latest, the most remained belongs to the doctor With at a game those. In one of books of «Ayurveda» it is told what shall be the doctor, properly to it behave as well as what to tell to the patient. The differentiated approach to patients attracts attention: it is possible and is necessary to treat the poor, orphans, strangers, but at the same time it is impossible to prescribe medicine that who in disgrace at the rajah. With the advent of social inequality the attitude of patients towards doctors also becomes not unambiguous: representatives gospodst
vuyushchy classes saw in them servants, common people — misters.
The invaluable role in the history of medicine, including in creation of ethical standards, was played by Hippocrates. It possesses maxims: «Where the love to people, there and love to the art», «Not to harm», «Vrach-filo-sof is similar to god»; he is a creator of the «Oath» which worried centuries bearing his name (see Hippocrates an oath). It is remarkable that the II International deontological congress (Paris, 1967) found it possible to recommend to add an oath with the only phrase: «I swear to study all life!». The III International congress «Doctors of the world for prevention of nuclear war» (1983) made the offer to add national and international codes about a professional ethical duty of the doctor, to-rykh «Hippocratic Oath», point obliging physicians to fight against nuclear catastrophe is the cornerstone. Such addition was made also to «The oath of the doctor of the Soviet Union» (see below).
Hippocrates for the first time paid attention to the attitude of the doctor towards relatives of the patient, towards the teachers, relationship between doctors. The ethical principles formulated by Hippocrates gained further development in works of antique doctors of Asklepiad, to. Tsel-sa, K. Galen, etc.
In the period of the Middle Ages representatives of the Salerno medical school called by the Gippokratovy community were engaged in development of questions of the attitude of the doctor towards the patient (see. „Salerno code zdorovya11).
Huge influence on development E. the m were rendered by doctors of the East, and first of all the outstanding scientist-Encyclopaedist of 10 — 11 centuries Ibn-Xing (Abijah
is valuable) — the creator of «A canon of medical science». Considering various parties of profession of a physician, Ibn-Xing emphasized originality and identity asking for medical care: «... Each certain person possesses the special nature inherent in it personally». Attribute it saying: «The doctor shall possess
an eye of a falcon, hands of the girl, wisdom of a snake and heart of a lion». One of the main ideas of «A canon of medical science» is need of disease prevention what efforts of the doctor sick and healthy shall be directed to. To this idea also thoughts of the doctor and the writer Abu - - Faraj living in 13 century are conformable. He formulated the following thesis in the form of the address to the diseased: «We are three — you, a disease and I; if you are with a disease, you will be two, I will remain one — you will overcome me; if you are with me, us will be two, the disease will remain one — we will overcome it». It is remarkable that else in ancient times the problem of the attitude of the doctor towards the patient was considered in respect of their cooperation and mutual understanding. The big place, on an equal basis with requirements to the identity of the doctor, his human qualities (to decency, honesty, kindness), was allocated to need of continuous self-improvement because the low-skill doctor does to the patient harm that is gross violation of ethical standards of doctoring.
Development E. m in Russia passed the same way, as in other states. «Izbornik of Svyatoslav» (11 century) contains the instruction that monasteries shall shelter not only the rich, but also poor patients. Set of legal norms of Kievan Rus' «The Russian truth» (11 — 12 centuries) approved the provision on the right for medical practice and established legality of collection by doctors from the diseased of a payment for treatment. In 16 — 17 centuries the doctor foreigner coming to Russia had to practice in the boundary city in the beginning and to cure someone. The requirements to the doctor formulated by Peter I in the Sea charter though its duties were considered in a separation from the medical rights were quite certain.
The capitalism which succeeded feudal society generated new classes and the new public relations. Significantly also ideas of morals, including of moral bases of doctoring changed. In «The manifesto of the Communist Party» it was noted: «The bourgeoisie deprived of a sacred aura all kinds of activity which were considered honourable until then and at which looked with reverential awe. It turned the doctor, the lawyer, the priest, the poet, the person of science into the paid hired workers» (K. Marx and T. Engels, Soch., 2nd prod., t. 4, Art. 427).
In the conditions of the arising and developing capitalist society in Russia much for promotion of a humane orientation of profession of a physician the advanced Russian scientists S. G. Zy-belin, D. S. Samoylovich, M. Ya. Mudroye, N. I. Pirogov, I. E. Dyadjkovs-ky, S. P. Botkin made. Especially it should be noted «The word about piety and moral qualities of Gippokratov of the doctor», «The word about a way to learn and study applied medicine» M. Ya. Mudrova and N. I. Pirogov's works representing «alloy» of love to the business, high professionalism and care of the sick person. In formation of the principles E. the m a big role were played by progressive representatives of territorial medicine, to-rye considered a moral duty to help the poor and the disadvantaged. Democratism, self-sacrifice were always inherent in the best representatives of the Russian medicine aiming to live interests of the people. General fame was gained by «the Saint doctor» F. P. Gaaz who became the chief physician of the Moscow prisons. Its motto was: «Hurry to do good!» The humanistic orientation of activity of the Russian physicians is versatily described in works pisate by A A. P. Chekhova, V. V. Veresayev, etc.
In Russia graduates of the highest medical educational institutions made the so-called faculty promise. The big place in it was allocated to the relations between doctors: «I promise to be fair to the associates... On conscience I will do justice to their merits and efforts...». These words had to remind doctors of their moral duty in the conditions of not goodwill and the competition characteristic of bourgeois society.
Many progressive foreign doctors, such as Nobel Peace Prize laureate A. Schweitzer, the honorary member Meditsinskogo about-va surgeons of the USSR R. Lerish, the famous pediatrician, the fighter for peace B. Spock, etc., called that diseases of people cannot be turned into means of a profit, but could shake a basis of bourgeois outlook and morality.
For the last decades prinya! a number of declarations, codes, rules, to-rye are designed to define ethical standards of behavior of doctors. In many countries (France, Germany, Italy, Switzerland, the USA, etc.) there are national codes.
A number of documents has the international character. It is necessary to carry «The Geneva declaration» to them (1948), «The international code of medical ethics» (London, 1949), the Helsinki and Tokyo declaration (1964, 1975), «The Sydney declaration» (1969), the declaration concerning the relation of doctors to tortures (1975), etc. However in the international documents on questions E. m are not always considered specific conditions of life of this or that country, national peculiarities.
«Hippocratic Oath» is the basis for the Geneva declaration, but found reflection and the most acute social issues of 20 century in it. So, phrases are introduced in the declaration: «I will not allow that religion, the nationalism, racism, policy or a social status exerted impact on performance of my debt... Even under the threat I do not use my knowledge in the field of medicine as opposed to laws of humanity». The last thesis, being an echo of World War II, fixes provisions of «Ten Nuremberg rules» («The Nuremberg code», 1947), in to-rykh inadmissibility of criminal experiences in public is emphasized.
«The international code of medical ethics» («The international code on a deontology») concretizing a number of provisions of «The Geneva declaration» is approved by the CEO of WHO and is the most widespread document, on to-ry researchers of problems E refer. m in the bourgeois countries. In it the attention to questions of payment of medical assistance, to inadmissibility of enticement of patients, self-advertisements, etc. is paid that quite brightly illustrates a number of the moral parties of profession of a physician in the conditions of private-capitalist medicine, its discrepancy to the developed and recommended moral principles, discrepancy between ethical installations and social reality.
At the heart of E. the m lies in the socialist countries the socialist ideology which is based on the principles of humanity and the state character of health care. In socialist society contradictions between a professional duty of medics and the public relations are liquidated. The community of philosophy predetermines lack of significant differences in moral installations of physicians of the different socialist countries. At the same time in nek-ry of them on an equal basis with the state health system the private practice, the choice of the doctor is allowed; besides, there are nek-ry features in the legislation, i.e. in private questions of the rights and duties of doctors.
As specified N. A. Semashko, «ethics of the Soviet doctor are ethics of the socialist Homeland, these are ethics of the builder of communistic society, it is communistic morals, it is truly human morals standing above class contradictions. That is why we do not tear off a concept about medical ethics from high ethical principles of the citizen of the Soviet Union».
N. A. Semashko allocated three main questions of medical ethics: attitude of doctors towards patients; attitude of doctors towards collective (society); relations of doctors among themselves. However questions of the attitude of doctors towards relatives of the patient are not less important. All these provisions concern not only to doctors, and equally to all medics.
Development and studying of questions E. m and a medical deontology gained in the USSR further development in works of physicians and philosophers
of H. N. Blochin, B. E. Votchala, I. A. Kassirsky, F. I. Komarov, Yu. P. Lisitsyn, G. V. Morozov,
H. N. Petrov, B. V. Petrovsky, 3. P. Solovyova, I. T. Frolov, E. I. Chazov, S. S. Yudin, etc., and also number of writers-doctors.
Moral questions of activity of medics found reflection in accepted by the Supreme Council of the USSR in 1969. Bases of the legislation of USSR and federal republics about health care (see the Legislation on health care) and the USSR approved by the Decree of Presidium of the Supreme Council on March 26, 1971 the text of «The oath of the doctor of the Soviet Union».
The fact of introduction of the oath emphasizes the importance of a medical profession. Along with other provisions in the oath the role of the doctor in protection and improvement of human health, in the prevention of diseases is defined. It emphasizes a preventive orientation of the Soviet health care. Considering an important role of doctors in fight for peace, the Decree of Presidium of the Supreme Council of the USSR of November 15, 1983 to «The oath of the doctor of the Soviet Union» made the following addition: «... understanding danger which is represented by nuclear weapon for mankind, to struggle constantly for peace, for prevention of nuclear war» (see the Oath of the doctor of the Soviet Union, t. 21 and t. 25, additional materials).
Scientific and technical progress caused emergence of a number of new moral problems, including willows of area E. m. For the last decades in the USSR a number of works on E is published. m and medical deontology. Two all-Union conferences (1969, 1977) are held. In
1983 under the auspices of the USSR Academy of Medical Sciences the scientific and methodological conference devoted to ethic and deontological questions of modern medicine was held.
In 1970 questions E. m were discussed on the X International congress of therapists in Warsaw and on the International congress of historians of medicine in Bucharest. In 1973 these-to-deontological questions of medicine in the conditions of a scientific tekhni-cheskoy of revolution became a subject of discussion of a special symposium of the XV International philosophical congress in Varna, and in 1974 — the XVIII International congress on applied psychology in Montreal.
At many scientific forums devoted to problems E. the m, was discussed a question that medical equipment, the equipment, numerous laboratory analyses alienated the doctor from the patient and depersonalized the patient. Against the background of the progressing specialization and improvement of technical equipment of medicine not only complete perception of the patient can be lost, but interest in it as to the personality is quite often lost. This phenomenon is called abroad a dehumanization or depersonalization of medicine. The gap in the relations between the doctor and the patient increases, possibilities of psychotherapy worsen, to a thicket there are situations when treat a disease, but not the patient. All this creates premises for disturbance of the initial principles forming a basis to profession of a physician.
For all that that the equipment, especially computer, promotes objectification of diagnostic, medical and predictive processes, the medicine was and remains alloy of science and art. A. F. Bilibin wrote: «During the doctoring not one wing (science), but two wings — science and art shall be used. For the real flight (doctoring) the wave of both wings is necessary. Without penetration into inner world of the sick person that is promoted by art, doctoring is defective». The same thought was lapidarno expressed by B. E. Vot-chal: «„The aware doctor“ and „the good doctor“ — not synonyms».
In literature on questions E. the m is a little given attention to a problem of aging of the population, to growth of specific weight of persons of advanced and senile age that is noted for the last decades will also become even more noticeable in the future. Medics are insufficiently familiar with psychology of aging, termination of the prof. of activity, loneliness. It can be an origin of mental injuries at patients.
In the conditions of the increased opportunities of medical science and practice there were new problems connected with medical genetics, regulation of birth rate and abortion, experiments in public. «The Nuremberg code», «The Helsinki and Tokyo declaration» and decisions of the XV conference of Council of the international organizations of medical sciences (Manila, 1981) approved by special committee of WHO are specially devoted to the last question. According to these documents similar researches shall be considered from the ethical point of view by the independent commission, at the same time is emphasized that interests of examinees shall prevail always over interests of science and practice. The humanistic orientation of the documents concerning experiments in public certainly deserves positive assessment. However no document can provide everything that is connected with such researches, in particular individual portability, degree of voluntariness of consent of the examinee, etc. Therefore one of tasks E. the m is a specification and development of ethical standards in relation to the arising new types of experiments. The national and international scientific and medical organizations are engaged in the practical solution of this task, and in nek-ry especially acute cases creation of the special commissions with participation not only of physicians, but also representatives of the public is reasonable.
Due to the development of health care there is a number of the new questions connected with observance of a medical secret. Owing to increase in number of the persons having access to information on the patient (doctors of various specialties, the registrar, the statistician, other medical staff, representatives of the trade-union organization, etc.), this problem is beyond only medical. Besides, the increased education of patients causes their keen interest in diagnoses, results of researches, the forecast of a disease. It is necessary to consider both circumstances because the medical secret assumes nondisclosure of data on a disease (if it does not contradict interests of society) not only to people around, but in some cases and to the most sick. It is necessary to protect the patient from those data, to-rye can do harm to its mentality and ability to struggle with a disease. Non-compliance with a medical secret by the medic involves measures of public influence. In the special cases which caused serious consequences involvement of the guilty person to criminal liability is possible.
Achievements of resuscitation, the increased possibilities of long maintenance of functions of a number of bodies and systems at the irreversible termination of function of a brain (see Death of a brain) took out on the agenda a number of the serious moral and ethical and legal problems connected with determination of reliable criteria of approach of death and behavior of the doctor at a bed dying (see Death). Principles Soviet E. m assume unconditional need of struggle for life of the patient with use of all possible means. Intentional acceleration of a lethal outcome remedilessly sick of in a false manner the understood humane reasons — an orthothanasia (see) from positions of the Soviet medicine is inadmissible. There are no international documents on this matter in a crust, time.
In a basis it is administrative or penal professional acts (or divergences) medics disturbances of the principles E always lie. m. At the same time non-compliance with standards of morality more often is not a subject of law or the legislation. At the same time the public, various public organizations and when offense is not caused by not box-rigiruyemymi features of the identity of the medic — own conscience act as the judge. Crimes of medics are considered in criminal codes taking into account features of this or that country. Many researches are devoted to this question. The serious moral conflicts arise in connection with medical errors. By the definitions existing in the USSR, they do not contain an element of premeditation and criminally are not punishable (see. Medical errors). Abroad (USA, Germany, France, etc.) cases of presentation to doctors of the claim for an occasion of overdue hospitalization, wrong treatment, etc. became frequent. Requirements of compensation consider courts, medical associations, the special commissions of «conciliation», etc.
In 1956 in Havana the joint scientific committee as a part of representatives of the International Committee of the Red Cross, International committee on military medicine and pharmacy, the World medical association to participation as the observer of WHO adopted «Provisions for armed conflict». The document says that requirements E. m during armed conflict are identical to the principles E. m in peace time. The doctor is obliged to give necessary help to the patient irrespective of his
race, a nationality, religious or political convictions, belonging to this or that belligerent party.
On taken place in Prague (1974) IV International medico-legal conferences the opinion was expressed that in connection with emergence of new moral and ethical problems in medicine creation of the medical right is reasonable. This point of view was supported also by representatives of the USSR.
AA. the m cannot be considered in a separation from the attitude of society towards medics. The increased education of people, great opportunities for acquaintance with medical literature which not always is correctly carried out a dignity. - the gleam, work, edges sometimes turns into the simplified training in self-diagnostics and self-treatment, brought to a nek-swarm of «deromantization» of medical professions among the population. To a certain extent it is promoted by increase in number of doctors and lack of accurate system of definition of their suitability to this profession. All this creates premises for the increased insistence to medics, especially to the moral parties of their activity.
Doctors shall possess a broad outlook, to be versatily educated, conceiving specialists and at the same time the attentive and cordial relation to compensate costs «to technicalization and mechanization» the profession. The oath, to-ruyu representatives of any peace specialty do not give, emphasizes uniqueness of activity of the doctor. The profession of the doctor assumes an organic combination of humanity, a civic duty, high moral qualities and profound professional knowledge.
Doctors of many countries of the world, first of all socialist, take the increasing part in a peace movement on the earth, for prevention of nuclear war. Recognition of it was award in 1985. Nobel Peace Prize to the international movement of doctors «Doctors of the world for prevention of nuclear war» (see Doctors of the world for prevention of nuclear war, t. 29).
See also Ethics.
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ky R. V. Questions of medical ethics in the international and national documents, Owls. zdravookhr., No. 2, page 61, 1982; Medical ethics and a deontology, under the editorship of G. V. Morozov and G. I. Tsaregorodtse-va, M., 1983; About fundamentals of medical medical ethics, under the editorship of K. T. Tadzhi-ev and V. I. Pripisnov, Dushanbe, 1981; Petrov B. D. is a doctor, sick and healthy, M., 1972; P e tr about in H. H. Questions of a surgical deontology, L., 1956;
Petrovsky B. V. Deontologiya and medical ethics from the point of view of the Soviet surgeon, in book: Urgent vopr. modern medical, under the editorship of M. I. Kuzin, etc., page 60, M., 1983; about I e, the Deontological principles in treatment of the surgical patient, Theses dokl. Vsesoyuz. a symposium, it is devoted, to a problem of relationship of the surgeon, anesthesiologist, resuscitator and transfuziolog in complex to lay down. hir. patient, page 3, M., 1984; Semashko N. A. Chosen works, M., 1967; Elsh of t to it N. V N. Dialogue about medicine, Tallinn, 1986; Etikopsikhologichesky problems of medicine, under the editorship of G. I. Tsaregorodtsev, M., 1978; Dash U. Century of Fundamentals of ayurvedic medicine, Delhi, 1978; Experiments with man, ed. by H. R. Weber, Geneva — N. Y., 1969; Frenkel D. A. Law and medical ethics, J. med. Ethics, v. 5, p. 53, 1979; F r i t s e h e P. Grenzbereich zwischen Leben und Tod, Stuttgart, 1979; Monnerot-Dumaine. Dehumanisation de la m6decine, Presse nc^d., t. 75, p. 157, 1967; Protection of human rights in the light of scientific and technological progress in biology and medicine, ed. by S. Btesh, Geneva, 1974.
H. V. Elyiteyn.