MEDICINE ETHICS
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RF_MP_2_PART_1_SUDHA.pdf
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QUESTION
I
E U T H A I A S I A
Literp.turc
The Liaacro
Li.iacra Quarterly
Quarterly, AKril, 1938, .p.38-42, April, 1947
(whole issue); Hcvenbur 1950,p.3-9 etc;
G. Kelly, Medics uoral problems, London 1950,p.115-127;
E. Healy, Medical Ethics, Chicago, 1956, p.266-271;
Ch. McFadden, Medical Ethics, Philadelphia, 1955.
p. 140 - 150
J. Saiidai's, Points of. Medical Ethics, CBCI Publication,
p. 71 - 72;
Eacyclcpedia. e f Ethics and Religion, edited by J.Hestiar,s,
roo _
rm
■. Vol. v. p. 598
- '601
Medical Moral Problems, edited by ?.Flood, Vol.Ill,
London 1955; p.259 - 299;
Definition
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^utl^anasia-in the strict sense: '
To cause death (or assist in causing-death) to a conscious
certainly incurable patient' who requests that his agony (physical
or psychical.suffering) ba terhindtad by a calm
cahc and painless
death ("liberating death").
Euthanasia*in wider sansa:
a.) To cause death at the i.'.stigation of pity - to an un
conscious dyinr patient, to nens^ers, the seriously
insane, etc. ("nerciful death") ..
b) tc cause death - for the sake of society - to asocial,
dangerous persons, in general to persons who cannot
live amoral life within the society ("eugenic death").
This causing death for' the sake of the society nay go
tc the extent cf disposing of "useless" persons (at.,ed etc)
("eccieaic death")
"It is .lot, eutha.ia.sia ta ^ive a dyi.v; persen sedatives
reexaly _<r tlie allaviatian 'of paia^ avea to. ths extent, ei
depriving the patient of the use of sense and reason,
when this extreac ...ec.surc is judged necessary. Such
sedatives, should net be given before the patient is
properly prepared..for death; nor should they be ^iven to
patients who are able and.willing tc endure their
sufferings ..far, sniritudl' ncfives" (Ethical and Reli icus
Directives.p..5, Cgth.
Asc..U.S. and Canada)’’. ’
ZxathrcpGla■gical facts history
Euthanasia, in various degrees,, is found oiiangst primitive
people both in East and- West. It was practised in ancient Greece
and Roae and ccnsidered by.certain authors as honourable; the
Judaea - Christian tradition- rejected
- -----any
tomfcr:
of. Euthanasia
as against the sacrednes-s cf 'Life (God
(rr'A being the author of life);
Also hindu traditions stress the s acrodness of life (respect for
Li n).
^21;- ......
V. ... ' . f' /y-y :
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Jhi-... ..
..... . -
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.
:*
Thoms Mere, in his "Utopia" describes how his "Utopians"
(not he,'hinsa1f’ ) accept.euthrnesin, when approval has been
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Frailcis Bucou, in his
out^sl^Stridufeg'ShS!?1'-113*1^ SUr0?“' tC ■•>12o<i fOT
--iorn society cuthaiiosia. in various
has been
G;:tc;lt cf-etgaaised disposal of’ the
uarit.-aa ...itier s Germany.
.
’^-Q1 t*ie oxtoat tc which this society •’s nnro^Htnri
With natqruiisrs, -thQ idea of collective ef^ici^cv
as lt <?*“ with the Sclents; the value of
t^Fto^t-'^
T^st ail, aad euthaaesia
1^“GC
t"P Juridical system under
~**+. **’^fc'r
7™r^ss«ca> Oa the other head., to the
t'l0C?^YVY‘'iiC-‘--a-SGCiGty PrcSGrves spiritual values,
■a--lcIcacy yields tc the respect due to the
-u......
qua person,' whether he is weak er stroi' -ec?~
eutha-icsia aever receives leca'v!
hlacft&vfoSrtj?1
270)
r3jocts ia U " ■
r..c . C;1 Cr;'cb-;r 17, l£50, the ?Ierld hedicdl Associatioi cctr'esed
o; aateeanl' aedccal assaciaticas of forty ..ae di^^ent
“ rcsclutica ^-ich called eutho-iesia’
l«iccl A^alatto-
VS
gniats tc be considered
1•
S£cigA. ccaseouences or accept,>ace cf euthanasia:
loarJg St^eFf^r^eSlS^LSs'S^it
t^lSd’158!^^??^?8"- dcvhati°^ I4 wral principles i's^li ely
iu4?F:,d ft ^thanesio.caa be justified in one case, it cZn be
“FlslV
act'-ure taoori.es wo invent, but "facts --ac_..t year^ nnowa tc the Whole :world" (Ststenant CBCI,~1953)
CM
~c ^3=rs uaatXcaod
^+.44_ 1
•? ,
n. Bciiaar. ai.v» 1 vp.■?
raa<ni-“o^
F®SXSCr?rc>in. England, shows that t^°
(A.‘Boiler*
c^??e;d!;r 7^0 than voluntary euthanasia
K..x.u.r, sna u^t..^^sc aactor, London 1251, p. 105 - 111).
2*
Sequences for the nodical profession in particular '
The practice af euthanasia would greatly lessen conhi^aice &FWt^^^^iniu^a;r.w!?° 'F Suavely ill sight readily
”-Vt?1- judge hrs case incurable and so
to’-Gi3^'7Z?7CF;a TIFF
By a- uaans uninportaat
the SlthFdFe'tscpn.
insdlised autbaaasia upon
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The elevated coiiccptien c£ the dignity aad the high
seriousness of the physicians calling wore act easily gaiaed*
It was after ceaturies of ceaviaciag proof that the sole purpose
“paysiciaa was to proloag life aad relive paia that
^eaiciae
able to advaace* It was oaly after Law ao acre
deaaaded xarallxbilty ca the art of the physciciaa, but oaly
ti-at degree or skr^l, kaovledge aad care coruicaly possesed aad
excercised by the average reputable practioaer ia the locality,
0**01 itwas possible for neeiciae to iuprove the accuracy of
aiagaosis aad to better the uetheds of its treatoeat, aad that
ca—e about attar oaly oae develcpreeat - absolute coafideace that
w‘;?*-}ly aiu, or the physiciaa was to proloag life aad to
re^iee sufreriag. Mow there a-.e those who would assiga to the
physician a duty cf shortening it (Healy, r.2G9)
3.
Ccnscqucaca fcr
.C
co- tha patient
a) Suthanasia is bad medical practice. "The doctor oust
sustain hope fcr the incurable persen". There are eiiample.s
that an apparently incurable dying patient get curred; revealing tc a patient the fact that he is incurable nay
cause greater suffering and nay become an obstacle for
possible improvement.
b) Euthanasia is failing in true service. Tc assist a
person.in living up to the challenge of a very difficult
Situation (as an incurable illness is) may well be a
greater help tc the person th-n assisting him in escaping
_rom it. "Maa is net a more animal; pain is not the
greatest evil.
Suffering accepted (from the hand of Gcd)
has an immense value fcr man" (cfr. points, p.72)
F-^adoKa.-itc-l questioa
A dectcr aces ict deal with j-aias or deseases but with
persons._ His vocation, to assist the person who need his help,
rs not United to assisting hin in recovering health or aliviatrng pain but ezteads to assisting the person, in the way he can
on., as well he in the eulfilLaaat of hia fuadaneatal task, which
nay lacnaae the duty to face suffering and approaching death.
(’-ily if the patient has the right to die can a doctor
assist hm oy causing death.
Jherefcra, the fundamental question is: has a aaa the ri^ht
to ana nis life under certain circumstances.
, ‘'?c C-7C, c“-} Give permission far murder; no private individual
or^puolic authority is allowed directly to take away or shorten
It-.o or an inacceat person. To do sc is an iafriagaaent of God's
-ooain over life and is this contrary to the natural noral
law" (Statement CBCI, 1253)
Things are cor r.an to be "used" and ccnseq-ently can be
dis^GGod of c.according to man's needs. Man is net a "thing" tc
be used aad <ccnsaquently cannot ba disposed of according to his
-iQQds ar wishes
per
hc_.< Man is a person.
Els being conscious free
izrplias a.i uricaaditiorjal1 task, the task to realise his true self
ia oxistia^ for the ether (Gad
_d, man), ia the concrete circumstances
ia which he fiads hiraaalf. This unconditional task implies;
aaci-ig the cbnlla-igcs af life tc the bast of one's
c-ie's abilities under
all cirausistaac-as*
HOTSS Off y.^EpiCAL ET^ICS^.
purpose of the proposed discussions is to focuss •
tr"e ££?ci~ic clnracter of an ethical approach
Pr5-Cfical Ttestxcas’ and ca the fundamental i isi^ts
implied in any moral judgement.
m.igr.ts
X=Ss£2Kli£;Ji
fi==£2B=3&iyEi)=£g=;£ys2isAL2=3IHI£§
Definition of Ethics
etymologically, the word ’u^.i
ethics’ refers to a) customs,
customs.
manners (ethos) and b) inclinations;
; tciideacies, attitudes
Thus1t1^ UCI? 'ethics' indicates: a science
o- hal-aving anu or attitudes revealed in these f--- ; of ways
briss of behaviour.
, .
Iu cur context, the term 'ethics' refers to- "t-’-n nb-?ir,cd
bai^ “
L
--a' likK; co"?
so
an piasigfcJt
-^trre os man a.id consequently to judgements> oa good
-ja ev.ll m maa'.s actions and attitudes.
J^c..^xes
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o
B ^'•plu.iatxon: Ethics is a pa.*-*.losophic *e:*.’loctioa oa beiap
i** tails world. This ref lacticon reveals
that this being is:
a*i Orwistia-' - at .-this world -‘ with others
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eoyocc tho/ldoo •Uhi.rf' or 'i.V our btil - in God", - it un- J
cur being in this world, - 'the
niQi^aing.. o^. »/amaa anistenccr9 , - ■ hiie
aatidre or nan’'l«
■Hoc
Discovering the nature of man is discovering a task
» " h
-■*at gives meaning to our- beih^•g rree.
■This'task r man himself and can be described in
general .terms as 'ccnceras
.to*.-realisation", - "becoming ones1 true self
in existing at this world,, with others, in ’Gdd°".
This task
,-- is an unconditional task (duty), ■“ a task which
Jtan
man 'finds1 (objective idea1),
- a task" to which asaa exists"
(destiny).
It is in the light o.a a growing understanding of the
meaning of Znxian exists rec ;a:‘C Cy^soqucTtly of xa1 s -fundamental
task that we discern ‘ssod’ and evil9 in man’s actions and
attitudes.
gTHICS AHO SCIK E3
.
“ botV e£fct.ts t0
This 1'efi;
~ the true -latarc
W b= «^4:h
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Therefore: Whereas ethics reveals- a task, - science deals
with the enperical consequences of man’s actions and attitudes.
Chorees- ethics uncovers the inportence'of man’s actions in
relation to his fundamental task (their ’’moral value”), science, in describing the empcrical consequences of actions and
attitudes, shows their ’usefulness’ with regard to desired goals.
For -b;ampie: varices scionces deal with marriage, - they
state the empericnl implications (physical, psychological,
social etc.) of certain ways of living. They teach hew certain
desired goals can be achieved, and undesired situations can be
avoided. Those sciences reveal the various possibilities
regarding e.g.: marriage. These sciences, however, cannot
reveal the meaning of married life, the ’idea’, or ’ideal’ that
must become reality, in the actions and attitudes described by
the sciences.
Ethics on the other hand, is concerned with exactly the
meaning of marriage, - with the ’values' to be realised in this
human encounter.
Ethics, -however, presupposes science• For, ethics is not.
a reflection on an abstract idea but on a concrete reality, e.g*
mrried life, in the concrete situation in which man finds himself.
Scientific research is needed to get a better knowledge of the
reality on which ethics has to reflect, that is: acts and
attitudes in which moral values are to become real.
Using a traditional terminology we could say: science
studies the ’’laws of nature”, i.e. the properties of things, how they will ’behave’ in given situations, - ”what will happen
if-.
Ethics studies tlx ’natural law”, ii.e.
.2* the ’nature of man’
- hew one should ’behave’ in a given situation in order to
realise the meaning of human existence in that situation.
ETHICS, A :ID .A ■ITl-mePQLOGY
(Scientific) anthropology is a scientific study of man,
describing^his attitudes, customs- his judgements and feelings
regarding forms of behaviour etc. As science it examines the
originand consequences cf these attitudes etc. As science how
ever, it does not judge those attitudes, judgements etc., in view
of a philosophic insight in the true meaning of human existence.
Anthropology is not ethics.
The conclusions cf anthropology, however, will be helpful
for- ethics in so far.they throw light on the human life on which
ethics reflects,
ethics' aid mgpal TEHOLCGY
Moral theology studies man; the meaning of life in the light
of religious traditions, e,g. in the light of the Christian
revelation:. - scripture and tradition.
The-insights cf moral theclogy, however, are'of yititcrest to
Ethics in sc far- as -a deeper knowledge of religious traditions
(Hindu, muslim,- Christian etc) gives‘Wider knowledge of facts
about man,- and nay direct and focuss our attention"i4 the philosop
hic reflection. The conclusions cf ethics, however, are not
dependent on traditional judgement cr specific religious experience.
..3e<
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JTzTCS AID ;; JTCAL ZT’HCS
. nodical ethics is ethics dealing with situations
Shc*rtc'1?» attitudes) typical for the acdical profession.
‘’Medical etnics" includes "nodical professional ethics",
tout is. t-at part or ethics tisat deals with questions concernr?tGuic-3.1 pro-GSsic-n gs such (e*3* rclatio-i to the
patient, colleagues, professional secrecy etc.)
ISDICAL STOICS
"FCSSrHC KADICIJE"
Forensic nediciae deals with legislation in nodical
natters. It studies the implications of existing laws and
evaluates legislation on medical matters in relation to the
common good.
forensic medicine differs in purpose and method irciu
etnxes as it studies legislation not'in relation to a philosophic
Hauerstoidxng of the meaning of life, but in function of the
CGtmoa good, unich is the yorpese of law.
Jhough ethics and forensic medicine differ in purpose and
netaad,
conclusions of forensic medicine are important for
at*mcs as tno lagisLi.ticn to which one is subject is a factor
tnat must oa tumen into account in deciding man’s duty in a ^iven
situation.
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TRMISPLANTATICi-I - THE MORAL IbbUg
"As a result of medical progress, our technical
decisions may become easier, but moral problems,
on the contrary, will be increasingly significant•" (Dr. J.
Hamburger, 3THICS IN MTDICaL PROGRESS, Ciba Foundation Symposium,
p. 136). Transplantation is one such field. Hundreds of people
have been kopt alive or helped to live because of transplanta
tion of various sorts. Yet grave moral questions are being posed,
and one reason for heart transplants going out of vogue, at least
for the present, is precisely the ethical issue.
INTRODUCTION:
1. MEDICAL APPLIANCES:
These are mainly of two kinds:
i) homoveable a.g. dentures
replacements,
o -S* orthopedic
valvoB, etc.
a) Prosth□scs:
ii) Built-in
b) Artificial organs;
j machine, arti
i) Temporary o.g. hoart-lung
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IZ 1 H ’
ficial kidneys, etc.
so far nona are available
for human beings, though
an animal has boon fitted
with an artificial heart.
t z
ii) Built-in:
problem connected,
connected witn
with tne
tho use 01
of
There is no special moral proolom
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J5''
to use any: c
off them io
is a morm'
moral1 'dothose, though the decision
cision that must bo guidod by moral values whice must be up
held in .all medical practico .
These are of throo sorts:
2. TRANSPLANTS:
a) iluto-transplants: io. thoso that take place within tho
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body of the person himself e.g. skin,
cartilage> bona.
.
t
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rl 1T A
) Homo—'transplant»s; i«Q« those that take place from thu
body of one person to that of another.
These include: blood transfusion, organ
grafting o.g. of cornea, kidnoy, liver.,i
heart, otc«
c ) He to ro-t ransplant s:; i.o. those that take place from tho
body of an animal to that of a human
person o.g. sox-glands, organs (inci
dentally, the first heart transplant
over performed was that of a chimpanzee ’ s
heart to a 64-year old man, in 1964
in tho U.S.A.)
In the case of auto-transplants, wo could follow tho aciago:
“good modicino is good ethics". In tho case of hotoro-transplants, tho grave question of possible "personality changes
must bo considered o.g. Popo Pius XII stated that the trans
fer of an animal sex gland to a human Poing woulu have to be
rejected as immoral because of tho groat disturbance to froo» dom which would likoly follow. The integrity of personal lif'-and personal identity prevail over prolonging lifo or any other’
possible advantage afforded by such a transplant. Finally,
homo-transplants present more serious problems, and we must
now considor these separately.
Tho ethical situation changes with the
source for obtaining the organ to be trans
planted A
a) Cadaveric transplants: Thosoj involve tissues and organs^ removed
"from cadavers. It must be accepted that a
person has tho right to bequeath organs of his body for use
after his death o.g. corneas. This would be an example of love
J. HOMO-TRANSPLANTS:
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for one's neighbour. In the case of a person who has not so
srMatiX“84°Sso?X ”S °x?oof:h?f p?0aeu=o
of presuming such consent, or acting without it le.g. as
happens in some teaching hospitals and. research centres), js
a violation both of the law and. of the rights of the relatives.
Since cadaveric transplants present fewer ethical problems,
doctors should work towards making their use increasingly
• feasible, medically. There are indications of better prospects
in this respect, especially with regards to the use o^ cada
veric lungs and livers.
11.is refers to tissues and organs removed
This
in"the course of ordinary surgical opera
tions e.g. when kidneys are removed in the case of urethral
cancer or the creation of a subarachnoid ureteral shunt. With
our present scientific know-how^ those present an advantage
over cadaveric transplants because cf the contractile nature
of the organ, while,at the same time, they do not involve the
ethical complications which are present in "living conor transplants” (see below).
b) "'Free transplants" :
This refers to tissues and organs
provided by living volunteer donors.
Cardinal ethical issues are involved hore since it touches upon,
two individuals, the donor and the recipient. One has to consider
the risks both to the donor as well as to the recipient.
c) Living donor transplants:
TWO SPECIFIC zdSAS THAT AkOUSE 3THICAL
REFLECTION.
a) Blood transfusion: This procedure has literally saved thousands
---------- of lives, has prolonged others and maoe pos
sible major surgical operations. It provides one of the best
ways in which a man can bo a good neighbour. Barring serious
accidents of typing, sterilizing and labelling, reactions are
rarely serious and they occur in not more than in about 5/o oi
transfusions. Th e overall mortality rate is probably not
higher than 3 in a 1000. However, it.is hard to bo sure of
avoiding the transmission of hepatitis, syphilis ana malaria
(in some parts of the world). Moreover, as wo learn more about
individuality in bloou groups, the developmentof a dangerous
sensitization is a risk always to be kept in mina. finally,
there is the danger of taming the procedure far too lightly:
"topping it off" or "giving a pint more just to ba on the safe
side", has sometimes, ironically, resulted in death.
4. HOMO-TRxiNSPLANTS
How does one act when the patient refuses
to accept transfusion for religious
or rather‘ reasons which
.
-'•
n
/(e.g.
_
—
, Vi ' n Witnssses,
- vt n a
S
not^modical
Jshovah's
are nou_ iiiuu-xuctA
^<.(5.
~11 4 — -P
---- -- f'lor
- - racial o bigots
. ~ \ o<
.
.
' -1
-•
__
~ TO 11
r> <-1 /-»<1 c? r\-yy
Q T. Q Q 1
who refuse to have blood from inferior
races or castes)
.
Should the doctor resopct the prejudices of parents, when
saving the life of the child is involved; or3 of an adult who
refuses to be transfused?
1) Many feel that the parents’ or patient’s wishes should be
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respected, because they are considering not merely their
physical welfare but their spiritual welfare and future
life - and, therefore, this takes one out of the realm
of medicinee No doubt one regrets being thus constrained.
Others feel that the refusal of the parents make it a
police matter, just as a proposed human sacrifice would.bo,
and they would consequently seek a court injunction to
carry on a transfusion» Strangely, the Courts oi Law
not speak with one voice on this matter. Among the various
reasons for authorizing a transfusion of a child Respite
the objections of the parents, is that the chil<x is not
yet free enough to choose its religious convictions, ana,
therefore, must be given a chance to live in oroer to
choose its convictions. In the case of a mother who neeaea
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a transfusion and. refused, it, the court ordered, it to be
done, because the mother had no right to sacrifice herself
and leave her seven-month child without her services. In
the case of adults, one reason for upholding transfusion
is that since an adult has come for medical treatment, and
Insists on it, he must accept the treatment advised and
recommended. In any event, in the case of anyone who refuses
a blood transfusion, the doctor who feels that he should not
respect the wish of his patient (croftho parent of his child
-patient) should seek a court order to do so.
/
) Organs from living donors: Two questions have to be posed and
answered;
1. Is the procedure justifiable medically?
2. Has the donor the right to mutilato himself?
In reply to the first qusstion,the major consideration revolves
around, the immunologic compatibility of the recipient with the
available donor-organ, dads are presently about 100 to 1 thau a
recipient will get a tissue type that exactly matches his own.
ttonce.tho doctor, who would like to do all ho can for his pationt
because ho has a deep and irrepressible concern for his patient s
needs, should bo careful to also consider more the immunologic compatibility of tho available organ than the need cf the patient
in itself. This would sometimes mean that a surgeon would oe c.n
strained not to transplant, since tho well-being of a parson is
to bo understood to bo more than a mere prolongation of life.
It is interesting to note that for kidney transplants, except i
in ths case of identical twins, probably no more than 15 patients
in the world have survived more than 3 years. The proceciure is
of unknown value in terms of the five-year or ten-year prognosis
(cfr. STHICS IN MEDICAL PROGRESS, p. 67)
.In reply to the second question,two points must be considered:
a) The risk to the patient. It has been calculated that the risk
of nephrectomy to the donor is as follows: 0.05% as a Post-*
operative accidental risk, and 0.07% as the risk of any kind
occuring later to affect the remaining kianey. However,, this
statistic must not be lightly interpreted,and physicians must
have a conscientious concern for the better procurement 0-J
organs which will obviate the necessity of risking a
b) The consent of the patient. Especially in this area when the
donation by a close relative, or twin, affects the saving
of a life, it is difficult to assess the genuineness of
consent. The donor can ba pressurised both by other members
of his family, who might oven consider him expendable(.) arid
by an innor oressurc exerted by his own social and religious
education concerning the value of self-sacrifice,^etc. Tie
doctor should be specially sensitive to freedom oi consent, •
Sometimes the help of a psychiatrist 1st oml^sted.
While it remains true that doctors should work towards pro
curing organs from cadavers, the question remains; within our
present limited options, can a healthy person donate one of his
heaUhy organs to’savo tbo life of anothor? Tho answr houIo
aoam to bo In tho affIrmatlvo. 'or, if »on°°uS.a???!Jtfor his
man can, in self-sacrificing love, lay o.own his life for his
friend" when this is an act of service to the other,
°o^d
also accept that he bee premitted to give a healthy orgqn to
save the life of his friend. However, in arriving at this
decision the following must bo considered:
1) Is thoro a proportionately gooo. reason.''
ii) Is there a reasonable’hopo of success.
1A
Will tho 1 damage1 caused to tho. donor be such as t
ill). Wil
from loading a normal human existence r
3iv)/ Has his consent been duly obtained?
4
5. TRANSPLANTS IN THE "TWILIGHT 101:71’ - 11V ‘ Nd PERSONS OR bEAL1
Wo said,above, that the procurement of organs grom cadavers
would obviate many an ethical difficulty. The question about thmoment of death has become a thorny^one in view of now procoduies
that can keep up certain physiological functions (heart beat,
respiration) even though irreversible brain datEago nas occuxed.
Physicians, lawyers, philosophers and thooioglans must apply
thoir minds to a re-defining of "the mament oi death .(Se- nOoOS
on EUTHANASIA for details about the criteria for determining thmoment of death).This will affect the determination of the con
dition of tho donor - is he -live or dead? But the central problem
of organ transplantation will romain, and wil- have to be sottl-d
by different and independent norms (see below).
Once again in this question, as in so many
otheis which wo have considered in cur course
we
realize that there are disturbing cases in
of Medical Ethics,
Lo find ready-made solutions by ostabwhich the doctor cannot hope to
should
guide himself by tho basic prin
lished standards. Tho dotor s'
ciple of concern‘for the person of the other. On the one hand,.teen,
he should beware lest " zeal for research.is carried to the P01^.
which violates tho basic rights and immunities of a human person ,
on the other, he must work out together with experts ±rom other .
specialities concerned with man (e.g. lawyers, philosophers, social
scientists, theologians),some moral guidelines.to assist him as
he treads tho paths of progress in medicine which ho hopes will be
to the bonefit of man. below is given, by way of oxamp-e, a seu o
PLuidelinos drawn up by two doctors with regard to transp-an ,.aui —
of organs (c?“ HaSmon L. Smith, ETHICS AND THE NEW MELICINE,p 121)
6> FINAL CONCLUSION:
1® Compassionate concern for tho patient as a total person is
the orimary goal of the physician and uho investigator®
2. Organ transplantation should have some reasonable possible
lity of clinical success.
.
J. Tho transplant must be uiidortaxen only with an accoptaD_o
therapeutic goal as its purpose®
4. Risk to the healthy donor of an organ, must be kept lew.,
but such risk should not be a contra-inciication to uno
voluntary offei1 of an organ by an inxcrmco. d^n^- .
5® There must be complete honesty with the patient and his
family, including every benefit of available general
medical knowledge anc. of specific information concerning
transplantation.
,
.
6. Each transplantation shoulu be conducted, under a protocol
which ensures the maximum possible addition to scientific
knowledge.
..
.
7. Careful, intensive, and objective evaluation of results
of independent- observers is mandatory.
8. A careful, accurate, conservative approach to the
dissemination of information to public nows media
is desirable
( urs. J.R• ElRinton and Sugeno D.Robiii)
Medical progress is going to throw up ma.n^ questions to
which’no preliminai’y system of medical ethics can proviuo
immediate and certain answers. 1’he ethical training of a docuor
then, cannot he limited henceforth to the teaching of a few
ready-made rules® To quote Dr. J « Hamburger once again:
”To produce doctors who> are strong men, who ara not only
honest and just in thought, but efficient in action,
-- -- j of the value of human
to develop-, in them an awareness
them
life; to convince id
-- that
’-I--’- their vocation is an ex■ '
1 and to -;t.he group
tensive obligation to the individual,
of facing the
such, it would seem ai'c the best means
;
over increasing difficuloios of medical ethics
(cfreETHICS IN MEDICAL PROGRESS,pn 37 )
•
•
__ —. —, H
4* Vs -n z-s fi I I
gnHctm
(Catholic
OSGAN OF THE CATHOLIC MEDICAL GUILD OF ST. LUKE, BOMBAY
Editorial Board
Dr. A. C. Duarte-Monteiro
Mgr. Anthony Cordeiro
!\lo. 86
Dr. Juliet D’Sa Souza
Dr. C. J. Vas
SUPPLEMENT TO THE EXAMINER
May 13, 1972
IN SEARCH OF A CHRISTIAN MEDICAL ETHOS
By Fr. Denis G. Pereira
Chaplain, St. John's Medical College, Bangalore
We must now explain the word ethos. An ethos is
time when codes seem outmoded and almost
“
~
’ .or from medical ethics.
’ \ and1 ethics seems to be little more different
from
a medical code,
/“^inoperable,
than a convenient way of
ol doing business, jwhi
jWhen Whereas a medical code provides the framework for the
secularism is making inroads into faith, and religious acceptable form of behaviour that would safeguard the
indifferentism is gnawing away at the
T entrails of reli- doctor, the profession and the rights of the patient ;
gious fervour
and medical‘ethics would represent the systematisation
ask • “Is there a Christian Medical Ethos ?” But, of moral judgements involved in making medical
■ in an age of searching — inexorable, rigorous, incisive decisions ; an ethos is the value-system that influences
and honest — this question must be asked by every the formulation of both code and ethics. The ethos is
sincere Christian doctor, if he is to find meaning in his the way a man experiences, sees, and relates himself
being both a doctor who is a Christian and a Christian to, the world and to his fellowmen—is his fellow-man
who is a doctor
a thing» an object, to be manipulated and used lor
About 20 years ago. at an international meeting of self-aggrandisement ; or, a rival over whom he must
Christian doctors at Tubingen, Germany, the question gain ascendancy, exercise control or wield power ; or,
was posed : “Is there a place for continuing to run a neighbour, his neighbour, one who makes an impeChristian hospitals?” Whereas some, among them rious demand on his love and respect one for whom
clergymen, challenged the propriety of having ‘Chris- he must care in his need, and for whose benefit he must
tian’ hospitals, the assembly came to quite the opposite strive to ameliorate the social and ecological conditions
conclusion at the end of the meeting. The assembly of living ?
.
. .
of Christian doctors felt that there are problems,
L seems obvious that in arriving at an ethos parti
mysteries, perplexities connected with healing, living cular to his profession, the doctor should consider not
1
------ -z—, only the existing code, but also the convictions and
and dying, to which secular medicine has
no answers,
and upon which the Christian Gospel ol the death and
and ethical behaviour of conscientious colleagues. But,
we may well ask, is this ‘medical ethos’ to be restricted
resurrection of Christ does throw light.
Is not this the perennial question we keep posing to to a lowest common denominator of accepted values?
ourselves : What difference docs it make that one is Can a doctor be satisfied with an ethos based on a
a Christian? Does his Christian faith make him a moral values (if
; one could truly
. speak of such), on
better, or different sort of, doctor than his non-Christian values determined by the utihty- , or, efficiency-, or,
regulate
a materialistic
colleagues, leaving aside their respective technical proJit-, principles that: so r”1form
competency or diagnostic skills? A Christian doctor society? Can an ‘everybody-does-it” principle
;
mst answer this question if he is to find the meaning the basis ol a justifiable medical ethos .1 Is there not
and relevance of his faith in his professional life, and room for a Christian medical ethos ?
accept courageously and cheerfully the challenges that
r-umcTTAv
an increasingly secular climate of opinion and attitude DIMENSIONS OF A CHRISTIAN MEDICAL
will inevitably pose to his Christian conscience.
.
ETHOS
When speaking of ‘difference,’ we must beware not
A Christian medical ethos must spring from the
to think in terms of ‘better’ or ‘worse’. The question, Christian faith. It must spring from the understanding
as C. S. Lewis rightly suggests in his book MERE the Christian doctor has of his vocation in the light of
CHRISTIANITY, is not whether being a Christian his faith. A Christian physician who models himself
makes you a better man than someone else who is not, on Christ—whom Christian tradition has given the
but, rather, whether being a Christian has made you singular title :
The Great
Physician —would
a better person than if you were not a Christian. To obviously have a set of values which he would not have,
use a commonplace medical analogy : to ask whether were he bereft of this faith.
Miss Buxom is healthier or not than Mr. Pehlvan
1. The Concept of healing :
To a great degree, the
because she takes Multivits and he does not, is a mean- formation of a Christian ethos would depend on whether
ingless question. The real question is whether there is a Christian concept of healing. It is to be
Miss Buxom is healthier because of the Multivits than noted that a very specific sign of the Kingdom of God,
she would be without them. Hence, we should be mentioned in the Gospels, is the healing of the sick,
asking ourselves whether the right understanding and Even the forgiveness of sins is linked with the healing
living of Christianity makes better persons of us or not. process. “Go, sin no more. Your faith has made you
In the same way, would it make a difference to the whole” (where ‘wholeness’ refers to total well-being,
doctor’s understanding of his role and mission in life which is an adequate definition of health). Is it too
that he has accepted the challenge of the Gospel, much of a surprise, then, to note that the ultimate
through a personal commitment to serve his ailing injustice is described, among others, in terms of refusal
neighbour after the example of Jesus Christ? Obvi- of health-care : “I was ill and you did not come to
ously, we are speaking not of the nominally Chris- my help” (Mt. 25, 43) ? A Christian doctor through
tian doctor but of one whose vision of Jesus, the his work of healing shares in the mission of Christ ;
Great Physician, brings him to see his calling to be a he proclaims the Good News through his ministry of
doctor as a mission ; of one who takes seriously such- healing, thus extending the frontiers of the Kingdom of
like sayings of Jesus to his disciples (among whom he God, or, if one dislikes the triumphalistic overtones,
counts himself) : “You are the salt of the earth. . . makes the kingdom more present among men. In
you are the light of the world.” Such a doctor would this ministry, he is God’s instrument, doing God’s
legitimately be expected to ask : Ts there a Christian work of redemption. Both his personal life, then, and
his dedication
dedication to
to his
his healing
healing function,
function, must
must proclaim
proclaim
medical ethos ?’
his
ATa
70
SUPPLEMENT TO THE
EXAMINER
May 13, 1972
the presence of God.
Besides, he will accept the the right spots, and on responsible persons in public
obligation, before God, for the health of the individual office, to ensure that health-justice is provided for those
for his total health as a person, and, through him, for all who, in his Christian conscience he feels, must be
those who need his care. He is, in a word responsible cared for, and when such care can only be provided
to God, and responsible for his fellow-man’s health, by public agencies. To give an example : concern
and is bound to provide the best ministration he can in for the rights of the unborn, in the face of liberal aborthe situation.
tion legislation, must make Christian doctors want to
This last phrase may sound like a pious cliche, but, do something about getting a different sort of social
as a Christian, a physician must ask : “Before God, legislation (that would, for instance remove social
what is the best ministration in this situation ?” In stigmas like illegitimacy) passed, and about working
other words, can one rest content with the status quo for the setting up of counselling services for distraught
of current medical practice and accept the ‘non-choice’ women seeking abortion and Homes where, they may
approach that characterizes so much of today’s medical be helped to have their babies with dignity and without
services? Is the Christian doctor — and, by extension, “fears.”
the Christian medical institution and the Ghurch(es)—
The Christian vision of man, as it is worked out in
to view his medical mission as meaning ‘to provide the the community of believers, must further influence the
best care to those who come to him,’ or, must he go development of a Christian doctor’s ethos. This
further and assume responsibility for those, too, who understanding of man will bring special light to bear on
do not come because they are either ignorant, or can’t some problem-situations, such as those which come up
afford the fees, but are in fact most in need of his care ? in genetics and human reproduction, medical experiOur Christian concern must determine the way we mentation and the dying-event. Further, it will affect
fix our priorities. A pediatric Mission-hospital in one’s dealings with one’s patient, and the respect due
Africa had an excellent record of service and of care to him coupled with the obligation of not taking adprovided to every child that was brought to it. At the vantage of his helplessness to feed one’s greed. It will
same time, during the 50 years of its existence, the determine the nature of the medical secret, the obligainfant mortality rate in the area served by the hospital tion to respect the conscience of the patient, and his
remained at around 282 per thousand births. While right to know the truth about his illness.
providing excellent care to the children, brought to the
2. Other dimensions : One could bring within the
hospital, its authorities had failed to provide basic, scope of his Christian ethos the doctor’s obligations
life-saving care to the numerous children that were to, and relationships with, his colleagues, especially
dying of ‘neglect’ in the surrounding area. It’s excel- the junior doctors who have to set themselves up. Too
lent doctors were too busy saving a few at the expense many doctors enter into a rat-race for patients, and
of the many. In terms of costs, one could say that the bigger practice, at all costs! Not merely professional
cost of saving one child on whom, say, the equivalent decency, but effective charity — really caring enough
of Rs. 500 was spent, whereas, if the same amount was for one’s colleagues, and their welfare, as to want to do
diverted towards providing even basic medical care, something about it —■ should determine right relaten children instead of one could have been saved, tionships. Is “group practice” a Christian answer ?
was, in fact, Rs. 500 plus 9 deaths. We need specialised Or, entrusting part of one’s burgeoning practice to a
hospitals and specialist doctors and excellent care ; junior colleague ? Each Christian doctor must find
but we also need to think in terms of the greatest good his Christian answer to the demands of love in his own
for the greatest number. It is a case, therefore, not of life situation.
“either-or” but of “both-and.” Incidentally, in the
Still another dimension is the Christian doctor’s
above mentioned case, the infant mortality rate was relationship with his own family. His absorption in
brought down to 78 per 1,000, within five years, through his work, whatever the motive he professes, may make
the action of a concerned pediatrician, newly arrived, him not care enough for those for whom he is obliged
who requisitioned the services of 15-year old girls, to care.
Further, living as he does in an underfrom the local mission school, to provide the basis of developed country, the Indian Christian doctor cannot
health education and health care. (This is a line of absolve himself of the obligation of thinking in terms of
thought and action
that GPs.,
with a large
and com- the needs of the country and the community, in fixing
.
.
J
fortable practice, could fruitfully consider). We need whether he is going to specialise or be a G.P., whether
constantly to re-evaluate our <concept of “service” in he will practise in the town or in the mofussil, whether
the light of the Christian imperative of “caring. he will serve in the country or go abroad (to get jobPerhaps we ’would find plenty of which to be ashamed satisfaction, or to ensure the security of himself and his
in our “service.
”’
family).
This is an ethical decision from which the
•
The Christian’s one guiding law is that of love, which doctor cannot escape, for, in fixing his “priority,” he
someone has paraphrased as meaning : “to care is determining the measure and quality of his service
enough about others as to want to do something about and charity.
To be, in India, an U.S.-qualified
it.” How does one “care enough” in a Christian way neurosurgeon, may mean that one restricts one’s service
especially when we know that needs will always exceed to a microscopic minority, composed in the main part
resources ? There are no ready answers, but we must of those who live in the larger metropolitan centres,
keep asking ourselves the question, often an agonising and who can afford the fees. Of course, the country
one. One suggested criterion for helping us fix our needs specialists — but the decision to be a specialist,
priorities is that of the “Poor.” The “poor” are not or not, must be taken in accordance with his Christian
necessarily the poor in any simple economic sense, but vision of the demands of love in his life-situation,
rather the neglected, the ignored, the rejected, the dropFinally, his Christian ethos must make him care
outs of society, those who are not cared for and to whose enough for himself, giving himself the time to relax
rcare no prestige is attached. Where there is a pioneer- and to pray, to build up the resources of his faith, so
ring need to do this, because nobody else will give that the frustrations of growing in age may not make
ennui' *to
others.
.attention to it, then it is a Christian calling. As Chris- him a_ cause
---------of
r--------1----tians our particular, though not exclusive, concern is
Conclusion : The Christian doctor, indeed, must
to care for those who are not cared for ! Each Chris- keep searching for a '’specifically Christian medical
■tian doctor must listen for this specific call of God, in ethos.
His, faith, which he must ever strive to keep
the secrecy of his heart, to such service within the alive, must make him view his task not merely
’ / as a
.'framework of existing situations.
iprofession 1but' as a calling, a mission, i.e., a °‘being sent
Another aspect to this ‘service’ must be considered, forth’ to carry out, in its total sense, the healing work
It is not always, nor only, a question of what a Christian of Jesus. While loyally giving ear to the teachings of
t doctor should do in terms of individual service. Prac- the Church’s Magisterium, he must remember that he
ideally speaking, much, in a developing country, has too is a partner in listening, and active sharing, in the
to be undertaken by Governmental agencies. The process involved in making moral decisions relative to
Christian responsibility of the doctor, then, would also complex medico-ethical problems.. He must be prezconsist in exerting himself to bring pressure to bear on pared to, and, in fact, conscientiously ask, the daring,
May 13, 1972
SUPPLEMENT TO
THE
EXAMINER
71
if upsettino-, question : '‘What more does God expect That is the risk involved in the search ! But the search,
from me?” ’ “Am I really caring enough so as to fix the in Christian tension, must go on and the Christian
right priorities according to the mind of Christ whose doctor must be prepared to act according to his Christian
minister of healing I am, and to the promotion of whose insights. A medical ethos based on such Christian
kingdom I must dedicate myself?” Many questions Searching will certainly make a difference—hopefully,
are unanswerable, or are not immediately answerable, for the better !
THE FAMILY DOCTOR
(An Eulogy)
By Dr. Fred Noronha
jT is perhaps no exaggeration to say that no greater the family he treats, he often can and does detect the
] honour, responsibility or obligation can fajl to the presence of an unwholesome environment or unhealthy
lot of a medical practitioner than to become a Family trait or attitude on the part of one or other member of
the family. It is not uncommon for an alert Family
Doctor. For such an assignment, he needs not only
Doctor to avert or nip in the bud, by his timely interthe scientific skills of his profession, but also human
understanding, courage, wisdom born of experience and vention,, an abnormal situation. Many a conscien
tious Family Doctor has saved an emotionally insecure
emotional maturity if he is to provide this unique service
child from future tragedy, effectively diverted a floundetn his fellow-men. The Family Doctor is not a mere .
~ .
r • r
healer of disease, he is also a friend, confidante and rmg adolescent from the path of delinquency,, successneaiei ui uiacaou,
Mo
(Art q fully advised againstt a b—
hazardous
marriage, averted
counsellor to the family he treats. He is, in iact,
’ ’•
suicide in a depressive, restored an alcoholic to sobriety,
privileged person.
In his traditional role, he not only •
1 an elderly patient to lead a happier life despite
endeavours to prevent and cure disease, whether ol
his
disabilities
and performed a hundred and one in
body or of mind, but also enters into a more personal
relationship with every member of the family. To tangible services which his unique relationship with
only
him, each of them is a person and, he attempts not c’y th6 Family made possible.
The Family Doctor is often faced with the sadder
to consider the physical and psychological problems of
f medical oractice. Few problems
aspects of medical practice. Few problems are more
pmpSfA'cSte
di.lra.ing tb.n .ho.e printed b, the p.iimi wiih
incurable or fatal disease. With tact, and deep under
„"E11ieu..,dgrp£ —
standing of human nature, the Family Doctor knows
have a beaung on ic o-ives them inteffi- when, what and how much to say about the illness,
him, on the health of his fam ly Hegives^intem
Doctor has
gent and humane care wi
, y p
<
..
.
often succeeded in bringing warmth and cheer to the
standing. For lum,
PaUent is mot;a mere collectmn
situations He d
to
of interesting signs an
V I
,
L emotions draw heavily on his humanity, mature judgment and
ordered function, ise
g
RnHv mind and intuitive talent on such occasions and be careful to avoid
but a complete person, mac
B
• a ^misanthrope unnecessary psychic trauma both in the patient as well
soul
He really cares
hj P^r eve“u^ as in his relations by avoiding words and actions which
could never be a good Family Doctor even though he
ntiall introgenic> An indiscreet remark, a
might be a bn lan lagnos ician.
solemn bedside conference or an ominous frown For
A dedicated Family Doctor brings to the ailing patient Examples could each of them cause untold harm to
and his anxious family a feeling of confidence and
anxjous patient of his relatives. Yet he, owes a duty
security. Illness often creates problems for the patient tQ
patjent to encourage him to prepare himself for
and members of his family such as, interruption ol daily deadl both in the material as well as in the spiritual
domestic or occupational activities, financial embarrass- piane When death occurs, there are the survivors stricment, fear, anxiety or depression. Moreover, illness ^.en w|th grj,ef who also need his attention. Often, he
sometimes profoundly alters personality or constitutes necd not do or say much in such a situation, His mere
i threat not only to the patient s bodily integrity, but presence and a few consoling words may help lighten
also to his status in society. A person in such situations their sorrow and feelings of helplessness.
often seeks the help of another on whorn he can rely
rj.Ee essendai difference between the family Doctor
as a trustworthy friend. The Family Doctor fulfils and his other colleagues lies in the former’s professional
the need admirably.
attachment to the family he treats . He is above all,
The Family Doctor’s grasp of the patient’s personality, a personal physician to the members of the house-holds,
background, hereditary traits, environment etc.,, places and his service is personalized.
From this relationship
him in the unique position of being able to know his there flows a two-way traffic between the Family, and
■ '
patient in his totality,
a fact which enables him to the doctor. Genuine affection, mutual respect, loyalty,
evaluate symptoms more accurately and intelligently, confidence and trust in the doctor on the one hand, and
early.
An early diag- concern,...
sympathy, professional integrity
and often to diagnose an illness
i
,
. on the other.
nosis generally implies less suffering, speedier• cure and Such is the foundation on which a most fruitful doctor
less expense to the patient.
patient relationship thrives.
Strange are the psychological attitudes which some
Some people, unaccustomed to the ministrations of a
patients adopt when ill. Some appear to take a secret Family Doctor, might conclude that such an entity does
delight in illness and resent anything that threatens not exist save as a figment of one’s imagination. The
their invalidism ; others refuse to face facts or bellittle fact is that changing patterns of society and a variety
their symptoms ; others again, try to adjust their dis- of other circumstances are creating an atmosphere in
torted personalities to the environment by one or other which the Family Doctor can no longer function qua
of those devices known to psychologists as “mental Family Doctor and may soon face extinction. On the
mechanisms,” and so on. These phenomena are not other hand, since no other system of medical care can
susceptible of solution by the use of precise scientific fully and satisfactorily replace this unique institution
methods, but require profound experience of human it seems reasonable to expect a resurgence of the Family
nature and some degree of maturity to probe beyond Doctor in future albeit in a new garb.
The family
surface motivation and behaviour, see accurately and Doctor of the future will, like his predecessor be a nondeeply the problems of another human being and tackle specialist and very human General Practitioner who will
them satisfactorily.
care for his patients and not merely treat them. He
One often hears of tragedy stalking unnoticed, in will of necessity, be equipped with superior training and
certain families, merely because its roots were not knowledge, and adapt himself to an entirely new pattern
detected early enough or not at all. The Family of society. He will steer clear of all those influences
Doctor has a grave responsibility in such situations, which tend to turn him into a superb technician fit only
Fitted for the task by training and practical experience for the practice of a soulless medicine and preserve the
as well as his intimate association with the members of truly humane character of his noble profession.
72
SUPPLEMENT
TO
EXAMINER.
THE
May 13, 1972
(’"'’I III O
and association with the activities of the Guild. She
vJVJfiLuLz
1>L VV O
a|so referred to dedicated work of Dr. Menino De
Our column ‘Guild News’ was held over for want of Souza in several spheres, civic, academic socio-cultural,
space in the past three issues. A brief account of some and political, particularly in “fund-raising” for several
of our activities during the last quarter is given here:— charitable and educational causes. His Eminence, in a
very eloquent reply, thanked the Guild for their greet
Annual Mass
ings, and good wishes. Tracing his associations with
The annual Thanksgiving Mass to celebrate the feast the Guild from 1938, he congratulated the Members
of St. Luke was held at the St. Xavier’s College Chapel
for maintaining a high standard which was due in large
on Sunday, 17th, October. The Rt. Rev. Dr. Simon
measure to the Presidents and the Committees. He
Pimenta, Auxiliary Bishop of Bombay was the celebrant said he was particularly happy to read the Guild
and preached a very impressive homily. The frater Bulletin regularly since 1949 ; Stressing that the bul
nal repast followed at the college cafeteria. Welcom letin was indeed ‘an accomplishment,’ he exhorted
ing Bishop Pimenta, Dr. A. C. Duarte-Monteiro, our members to see that it appeared uninterruptedly. Dr.
President said that in keeping with the past tradition
Menino thanked the President and Members of the
the Guild took the first opportunity to invite c—'"' Guild for their felicitations and good wishes. He said
new Auxiliary—representative of our Patron—as Chief he followed very keenly the activities of the Guild and
Guest. His Lordship then spoke in glowing terms of
congratulated the Committee for the progress they
the good work Bombay Catholic doctors were doing; he had made in recent years. He said Dr. Duartc-Monsaid he was happy to be admidst them and offer teiro, who was Guild President for four long years
prayers foi' the living and the deceased members at the was greatly responsible to give it a ‘new look’ and a
Thanksgiving Mass. Dr. C. J. Vas, Hon. Secretary c
“good shape.” Dr. C. J. Vas, the Secretary then pro
proposed the vote of thanks.
posed a vote of thanks.
The function—punctuated by recorded music re
Biennial Meeting
After breakfast, Members assembled at the College freshments, and ,variety
. of
t ~games for young and old—
ChaFr. proved
J^ovc^r to be
berquite
qijite an
^enjoyable
Council room. The retiring President was in the Chair,
enjoyable one_due primarily to
The Biennial report printed for the occasion reviewed
efforts of^ the office-bearers^ and assistance, of
the”activities of the Guild for the two years April 1969 Drs- Terence Fonseca, Miss Carole Duarte-Monteiro,
Duarte-Monteiro,
and
to March 1971. Tlie
The audfted
audited Statemem
Statement of
of Accounts,
Accounts, benzyl
Ucnzy!
Duarte-Monteiro,
and young
young Fonseca.
Fonseca,
as well as the Report were duly approved and adopted. This may henceforth turn out to be a regular feature
to -enable members
with
At the elections that followed, following Members cons- of the Guild,
*"
x- their families
meet
at
a
get-to-gether
during
X
’
mas
Season,
and orga
tituted the new Executive Committee :—
Dr. Juliet De Sa Souza, and Dr. Eustace J. nise sports, games, or X’mas-tree for children.
De Souza were elected President and Vice-President
respectively; Drs. C. J. Vas, (Mrs.) F. de Gouvea Pinto, FIFTH ASIAN CONGRESS FOR CATHOLIC
(Mrs.) J. N. F. Mathias and Terence Fonseca, were
DOCTORS
re-elected while Drs. Olaf Dias, Miss Charlotte de
(Bangkok—1972)
Quadros, Miss A.C.’Duarte-Monteiro, and F. Pinto de
The Fifth Asian Congress of Catholic Doctors will
Menezes were elected as new Members. Messrs. C. N.
Dr
A.
C.
ta
k
e place in Bangkok, early in December this year.
de Sa & Co. were re-appointed auditors, L.. x*. —
Duarte-Monteiro thereafter
thereafter thanked
thanked the
the retiring
retiring com
com-
recalled that on the occasion of the IV Asian
Duarte-Monteiro
mittee
for
their
assistance,
and
dedicated
service
Congress
held in October 1968, the assembly had
mittee for their assistance, and dedicated service
rendered during the two years that elapsed. He recal/ authorised the Catholic Physicians Guild
led that he was President for four years, and he felt of Thailand to organise and play host for the V Asian
happy to hand over the Guild to his successor in a very Congress.
■ • An unique feature of the filth Congress is that plans
good shape, judging from the activities
undertaken,
arc formulated to include it in the First
Ecumenical
financial oiauiuiy,
stability, juuuamy
solidarity cio
as enow
also relationship
llliauviai
iviauvnoiuu with
vn-cx*
.
.
the Junior Guild. He then vacated the Chair in favour Conference of the Catholic Organization and the
of the new Pr^identV^
ed all members for electing her unanimously, and as sored by the Asian Regional Executive Committee 01
sured them that she would maintain the high tradtions the FIAMC (International Federation of Catholic
referred * to the Medical Organisations) and the EACC (East Asian
established by her predecessors. She
S’
Duarte-Monteiro
Christian Conference), although with a separate prodedicated service rendered by Dr.
who gave a ffresh
1 1life,
’p full
r ” ofr vigour and colour to St.
A Tentative Agenda of the Fifth Asian Congress is
Luke’s Guild. The meeting terminated with a prayer
outlined here. Further particulars of the First Ecume
and vote of thanks to the Chairs.
nical Conference, as well as of the Asian Congress of
Cardinal Gracias and Dr. Menino de Souza. Catholic Doctors will be given in our subsequent issues.
Felicitated
Tentative Agenda.
A special function—Tea-party—was held in the Subjects for discussion
Junior Gymnasium Hall, St. Mary’s High SchoolI
’
—
- * - - — Status and Bylaws (as amended and
1.
F.I.A.M.C.
approved by the Convention 1970).
Mazagon to
felicitate
our
Patron, His EmiE
(fl) Membership problems (National Organization
nence, Valerian Cardinal Gracias, on his Episcopal
Silver Jubilee, an also Dr. Menino De Souza on his and Fees).
being the recipient of Papal Knighthood. This
(6) Regional Executive Committee problems (Meet
funciion was fixed for the 23rd October last, the 71st ings, cost for travelling, duties and obligations).
birthday of His Eminence. Unfortunately he was not
2. (fl) How does the work of your organisation
in town, as he had to attend all Sessions at the Synod benefit from F.I.A.M.C.
of Bishops from 30th September to 6th November.
(6) How can Catholic Medical Organisations in
On his return after five weeks he was caught—to put Asia benefit from one another.
(c) Closer relationship
between Doctors, Nurses, and
it in his words—“in the stream of deep anxiety for the
rela
future,” The Indo-Pak conflict and circumstances that Para-medical workers.
followed. Despite the fact that, 2nd of January hap- ~ 3. Closer relationship among Chirstian Medical
other func- Organisations in Asia.
paned to be a day when there were several
j
(a) Joint Regional Conference ?
tions in the city, St. Luke’s Medical fraternity mustered
(Z») Joint National Conference ?
quite a good strength with their families and children,
(c) Joint National Committee ?
in the nature of a large Family Gathering. The Presi
(rf) Joint Activities of National Level ?
dent Dr. Juliet De Sa Souza, gave expression of the
feelings of joy of Members, and offered felicitations on 4. (a) Election of Regional Executive Committee
behalf of the Guild to the Cardinal and chevalier for Asia.
De Souza. She referred to our Patron’s keen interest
(Z») VI Asian Congress—Where ? When ?
.
-■
3-
.
.
.
.
-
I
She
KHedi cal
U|
ORGAN OF THE CATHOLIC MZDICAL GUILD OF ST. LUKE, BOMBAY
Editorial Board
No. 83
Dr. A. C. Duarte-Monteiro
Dr. Thomas C. da Silva
Fr. Anthony Cordeiro
Dr. C. J. Vas
SUPPLEMENT TO THE EXAMINER
October
16,
1971
EDITORIAL
Our attention was drawn to the following comments that “the Hippocratic oath prohibits euthanasia, the
in favour of ‘mercy-killing’ in ‘The Times of India’ belief being that as long as there is a spark of life a
under the heading “Human vegetables” (Current man must be kept alive,” he concludes that there is
Topics, May 4th): “Thinking and talking about the certainly another side to the problem, and that the
unconventional may be distasteful to most people but issue needs to be openly debated in a calm manner.
this is an essential activity for man, the social and It will not be out of place to reproduce here what “The
intellectual animal. Twenty years ago free and open Himmat” writes in an editorial entitled “Of life and
discussions about sex or abortions were taboo, but Death,” wherein it compliments Pope Paul’s firm stand
thanks to the efforts of trend-setters such of the hypo on abortion and mercy killing :—
“The Vatican is to be complimented for its clear
crisy surrounding them has been stripped away. Eu
thanasia (or mercy-killing) is another subject which is enunciation on abortion and euthanasia. In a letter
mill considered by confirmists to be unmentionable.” to the International Federation of Catholic Medical
™In support of his plea, the critic lays stress on the Associations’ meeting in Washington, the Pope said :
views of Lord Ritchie-Calder, the noted British science ‘Abortion has been considered homicide since the first
centuries of the Church and nothing permits it to be
populariser and professor :— ,
_
“As a result of mental illness or degenerative diseases considered otherwise to-day.’
‘
" j some unfortunate people turn
such as multiple
sclerosis
tuin
for pUtting those who suffer from incurable or
inLu
zxnrujjva; when advanced age compounds then
their pajnfui diseases to death, His Holiness says :-j- ‘With
into zombies;
disabilities, they become little better than human vege out the consent of the sick person, euthanasia is mur
tables ...”
der. His consent would make it suicide.’
The learned professor poses the following question :—
Indeed a society where one satisfies one’s desires
“How merciful is it to keep them alive with all the
without any responsibility for the consequences, and
resources at the command of the modern medical prac
where the laws are created to encourage this irres
titioner ?”
ponsibility, cannot be considered a mature and civilised
Obviously the critic has considered man only from
the socio-intellectual viewpoint, disregarding the ethico- society.
As an answer to the above question posed by the
moral, and even the rational one. The Catholic view
point considered from the latter angle, teaches us to Professor, above referred to, we publish in this issue a
by the Chaplain of St. John’s Medical
respect human life, which is the basis for civilisation. talk given
_
Fortunately, in the same comments, while pointing out College, Bangalore.
EUTHANASIA
♦
By Fr. Denis Pereira, Chaplain, St. John’s Medical College, Bangalore
“Death” says Francois Mauriac, “is that terrible
ec r^EATH in America,” says a recent article in NEWSL/WEEK, April 6, “is no longer a metaphysical mys thing that happens to other people.” In a world
tery or a summons from the divine. Rather it is an frenzied with the pursuit of pleasure and comfort, ob
engineering problem of death’s managers—the physi sessed with its egotism, “death is an affront to every
cians, the morticians and statisticians in charge of citizens’ inalienable right to life, liberty and the pur
supervising nature’s planned obsolescence. To the suit of happiness.” (A. Toynbee speaking of ‘Death as
nation that devised the disposable diaper, the dead are being un-American’). But for the Christian, and the
only a bit more troublesome than other forms of human man of faith, death is not the end but a stage ip. living—
waste.” And a little later, quoting an American the process of dying is in reality the art of living mean
psychologist, the article goes on to say : “The dying ingfully in and through the process of dying. Death
no longer know what role to play. Most of them are is the gateway of eternal life. It is the moment at
already old and therefore worthless by our standards. which we ratify the fundamental options we make in
There’s simply no place for a human death when the life. If‘to live is to choose,’ then to die—if that death
dying person is regarded as a machine coming to a is human and meaningful—is also an act of choice in
simple words, a truly human death is one in which one
stop.” (Kastenbaum)
It would seem clear from the above that any dis ACCEPTS to die. This is what Dr. Elizabeth Kublercussion of euthanasia must necessarily be preceded by Ross, in her book ON DEATH AND DYING hints
ao-reement on a proper philosophy or theology, of at when she quotes one woman, who finally bowed to
death. What does death mean to us ? Is it ‘a machine the sentence of death after steadfastly refusing to ac
coming to a stop?’ Does it merely provide ‘a bit more cept the fact of her impending death, as saying: “I
troublesome form of human waste?’ or is it
in the think this is the miracle. I am ready now and not
eyes of us doctors, the great enemy against which we even afraid any more.” She died the following day.
must fight with all our resources, backed by patiently It is to be noted, however, that the acceptance of death
acquired knowledge,” and if so “is it reasonable that we is not to be taken to mean that the person has the right
should be indignant, that we should indulge in barren to impose death on himself, to ask another to shorten
irritation, before this inescapable condition of human his life, or to place in another the power to end it I We
have no right over life, even though we may have at
existence ?”
times a right to die ! And this brings us to the ques
tion of euthanasia.
♦ Talk to St. Luke’s Medical Guild, Bangalore, on April
Etymologically, the word EU-THANASIA means
22, 1970.
58
SUPPLEMENT TO THE
EXAMINER
October 16, 1971
dying well But that is not what it has come to mean
patient, in the doctor, in the lawyer, in the priest, in all
in legal* or medical parlance. From its original mean who share a responsibility for life.
ing of “dying well,” a perfectly innocuous and healthy
2. Man has a right to his own dignity as a person
philosophical value, it has come to mean “easy dying,” even in approaching death. Therefore, once the rea
which is not the same thing, for this implies medical sonable means to keep him in life have been exhausted,
intervention to cut short the process of living in order he is not bound to destroy his dignity by expecting to
to accelerate or rather induce death. Other words be kept alive without being able to live, to think, and
used to describe it are “mercy-killing,” “merciful to feel as person. No one is bound to ask for medica
release,“voluntary. euthanasia” or “easy death” tion that would prolong the agony of death. The same
(which, incidentally, is the name ol a society started in principle is valid for the community; its members are
England in 1935 to push euthanasia legislation through not bound to prolong the agony for a human being-.
Parliament), and “the termination of life by painless
3. There will always be complex situations and
means for the purpose of avoiding unnecessary suffer borderline cases where a clear moral judgment can
ing.” It is easy to see how ‘mercy killing’ can turn not be formed within the short time available . In this
into ‘convenient killing’—but let me not anticipate.
case we have to respect those who, animated by the
A. EUTHANASIA in the strict sense means : “to first two principles, make a genuine effort to bring
cause death (or to assist in causing death) to a conscious, about the best decision even though they may fail to
certainly incurable patient who requests that his agony find it there and then. Yet the effort itself was good
(physical or psychical suffering) be terminated by a and the resulting situation should be accepted as the
calm and painless death.” Here we can distinguish only reasonable one in the circumstances.” (L.
between ‘direct euthanasia’, i.e. where the assistance is Orsey^S.J.)
rendered intending death. This is murder, or co
4. “I would urge that we promote the idea of bene
operating assisting in suicide, or both, and is never mori, a dignified death, in the dying patient. There is
allowed. And we can speak of ‘indirect euthanasia’ no need to prolong the dying process, nor is there any
or the administration of treatment {e.g. to alleviating moral or medical justification for doing so. Eutha
pain) with as a side effect, the acceleration of death. nasia, that is the employment of direct measures to^fe
This last would better not be called ‘euthanasia’ at all. shorten life is never justified. ‘Bene mori’ that i^J
J. Fletcher calls this antidysthamasia’ (not prolonging allowing the patient to die peaceably and in dignity
the process of dying). “It is not euthanasia to give always justified.” (J. R. Cavanagh)
a dying person sedatives merely for the alleviation of
[JV.R.—This conclusion presupposes (1). that all con
pain even to the extent of depriving the patient of sense cerned act in accordance with the will of the patient; (2).
and reason, when this extreme measure is judged neces that the patient is dying. The dying process is the time
sary. Such sedatives should not be given before the in the course of an irreversible illness when treatment
patient is properly prepared for death, nor should they will no longer influence it. Death is inevitable.]
be given to patients who are able and willing to endure
B. EUTHANASIA IN A WIDER SENSE: Eutha
suffering for spiritual motives.” (Directives Catholic nasia in a wider sense is less complicated to deal with
Hospital Association, U.S. and Canada). It is ob ethically. It includes:
vious from this directive that the person must be helped
(a) To cause death, at the instigation of pity, to an
to live meaningfully through the process of dying. unconscious dying person, to monsters, the seriously
The real problem is: to what extent must a doctor/pa- insane, etc.
tient prolong life? Always and at any cost ? We
(Z») To cause death, for the sake of society, to a socould perhaps be helped if we d
‘
distinguish
between cially dangerous person, to persons, in general, who
‘Prolonging life’ and ‘prolonging the biological process cannot live a moral life within society (the so-called
of dying’; or to put it in other words, we could visualise ‘eugenic deaths’). This causing death for the sake of
cases in which the prolongation
life may'
“ r „ of
, biological
i
society may go to the extent of disposing of “useless”
not really be living meaningfully, whereas acceptance persons, the aged, etc.
of death may be^ living this moment as a human being’
One can easily see, especially in the light of the Nazi
even though biological life is shortened (of course with atrocities of World War II, how fraught with terrible
out being directly terminated, which is plain murder consequences the admission of such a principle woulc
even if done with the consent of the patient.)
be ! “From a purely medical point of view shortening
Take the case of a dying person who is ready to die or taking the life of a patient for the relief of pain is
and wants to die. He is suffering. He is surrounded unnecessary. Moreover, it is a confession'of professional
by medical apparatus. He has hardly any contact failure or ignorance” (Dr. Graham). Further, “the
with his environment, his friends, his family. His practice of euthanasia would lessen the confidence of
children are kept away, and visitors not allowed. patients in their physicians, for the patient who was
Would not a doctor be justified in instructing the gravely ill might readily fear that his physician would
nurse to take away the instruments and allow the chil judge his case incurable and so administer poison to
dren to be with the father even if this may well mean end his life” (Healy). One could imagine the con
an earlier death? Indeed, this may well be the best fidence one would have in confessional practice if the
way to help a person to live—through the process of priests were sometimes justified in betraying the con
dying meaningfully, even though the duration of the fessional secret. And lastly, as B. Bonhoeffer who was
process is shorter. Keeping a person alive is not neces himself executed in a German prison camp, put it:
sarily helping him to live, for living means more than ‘•‘we cannot ignore the fact that precisely the supposedly
i.:/
/
’ survival.
.........................................
■’
'
biological
And in this case the
duty
of living worthless life of the incurable evokes Irom the healthy,
1 ----- well. (The question- as to
■
from doctors, nurses and relatives, the very highest
becomes the duty of dying
whether a patient is bound to accept, and the doctor measure of social self-sacrifice and even genuine he
bound to prescribe, extraordinary means to prolong roism,” and, we may add, has been the inspiration for
life could be discussed in this context—but this would much real research and advance in medical knowledge
and practice (cfr. the heart transplant surgery by
take us far out of the scope of this talk.)
doctors who “would not give up”). Truly, euthanasia
To summarise this part, I will now read out some is bad medical practice.
norms with regard to “indirect euthanasia.”
Conclusion : In the course of the last few months,
1. “A human person owes it to himself and to his two of the Associate Professors of Medicine of our Col
community (to his family, to the society in which he lege, both excellent Hindu gentlemen, addressed our
lives) to keep his life intact and not to destroy the pre-professional class students. One of them, when
value that it represents. Human life lived in a per asked about euthanasia said he would never practice it,
sonal way is the best that we can find in this world. because it was a doctor’s duty
? to rprotect. life, ___
and he_
Nothing else comes anywhere near it, in the hierarchy would work to the end to prolong^it ; the other, with
:
It follows that both the individual and the touching candour, said : ‘There are times when I can’t
ofn values,
w . At those times I must
community has atduty to do what can be reasonably help my patient to live longer.
done to preserve human life. This duty exists in the know how to assist my patient to die well, saying the
October 16, 1971
SUPPLEMENT
TO
right word of encouragement and helping him to ac
cept his sufferings.’ In the face of death, this is exactly
what a doctor should do. “We have helped our’ pa
tient” writes a Catholic Doctoi' in an article in CAHIERS LAENNEC, December 1946, “in his suffering;
we now help him to die, to die well, or more truly to be
born again into eternal life.” And he adds in the same
article : “do not let us change by a merely spectacular
attempt at medical intervention this last and precious
contact between the living (i.e. the patient and his
family), and this final possibility of colloquy with God
on which eternity depends .... Shall we by a gesture
aimed at the entourage, rather than the patient, and
which does not even hide our human medical impotence,
shall we run the risk of obstructing the light of this
last vision of God, and thus prevent an adherence
which often remains . . . the assurance of a happy
eternity for the patient ?”
Notice, the emphasis on
the patient’s right to die a human, meaningful death.
And he concludes, and with this so do I, “in the appre
hension of these serious realities, let us, on the contrary,
pursue to the end our true role as doctors—our role of
respect for life—towards all and inspite of all. . . The
tranquil death which we desire for our patients, as for
ourselves, is not necessarily the unconscious death
^■which drugs, even prudently administered, can pro^■hpre. We ask above all, a peaceful death with the soul
^mt peace and abandoned to goodness and mercy which
opens to it the gates of eternal life. The sweetness of
death is in that vision of light and life.”
THE
EXAMINER
59
the government mostly through the individual State
Governments. The government spent a great deal
by way of shelter, food rations, immunisation and
sanitation programmes in most of the camps. On an
average the government spent Rs. 3 a day on each
refugee and at present we have nine million ! The
Indian Catholic Charities—Caritas was also doing a
tremendous amount of work in looking after about
70 refugee camps. A number of other organisations
such as CARE, CASA, OXFAM, Medico Interna
tional, S.C.I., Red Cross, Hindustan Steel, Ramakrishna
Mission were also very active. It provided, medical
aid, shelter, clothes and food to the refugees. Salt
Lake -which was one of its biggest camps, was nearest
to Calcutta and supplies were therefore brought in
more easily and regularly. Transport to the camps
further north was difficult and made worse by the
floods. In addition, those camps also dealt with a con
tinuous influx of fresh refugees under a persistent fear
of military attack.
My first visit to the Camp created lasting impressions
on me. I still remember walking through the sands
of Salt Lake towards the camp. There stretched before
us miles of endless barren sandy land with not a tree to
be seen except for a few on the distant horizon. But
this very land was teaming with two hundred thousand
refugees trying pathetically to adapt themselves to
hostile
conditions.
We could see hundreds of
little tents huddled closely together and endless
rows of barrack-like sheds built of bamboo-matting
covering the shed completely except for the many
little doors. Each door led into a dark damp area
of about 20-30 sq. feet. One could see a few sad faces
By. Dr. Henrietta Moraes
of the inmates peeping through and viewing us with
TPHE poor intern is considered neither a student an air of aloofness ; women garbed in tattered clothes
| nor a doctor. His budding potentialities are and burdened with naked hungry-looking children,
underestimated, and though he himself may overesti- spiritlessly trying to lightt a fire with a few damp twigs
mate them a wee bit, few realise the enthusiasm and or coaxing a listless child to eat what little food they had.
dedication with which he could perform perhaps a Some of the children, with the starvation and hardship
few small wonders in any medical situation—if only they had gone through, wore the brooding expression
of the old on their sunken faces. One hardly saw little
he were given a chance.
When I heard of the urgent medical need of the children playing together. There was no trace of
Refugees, I was drawn by sympathy and also by the curiosity or cheerfulness in their expressions.
Fresh arrival of refugees brought a wave of depres
challenge it offered I was full of enthusiasm, prepared
to fight against the diseases of the refugees and to make sion upon us. But it was something we were always
myself feel worthy of being a member of the medical to see. They had treked wearily with their bare feet
blistered and swollen and with hardly any clothes.
profession.
The Bombay University was preparing to send a When it rained, their meagre flimsy clothes clung to
v.w male interns but with its usual fatherly and dogma- their skins as they walked along at the same weary
cally conservative attitude, it refused to send interns pace, in no hurry to seek shelter. There was 1hardly
of the weaker sex (though after a lot of consideration, a day that a complete family arrived at the camp.
it has just sent a few lady doctors too).
Everyone We would often see a woman alone with her children
at home, supported by a host of friends and relatives, and perhaps an old helpless relative. Many of the
decided that I would not return in one piece if I left. men folk had been killed, some 1had stayed behind to
Finally after a lot of persuasion and many promises fight. Occasionally,
~
, a woman would tell us that her
that, literally bound me to spend more time safeguard- child or parent had1 died on the way, of exhaustion
ing myself, I was allowed to go. I am very grateful and starvation, or that she was not sure of the existence
to the Indian Catholic Charities—Caritas, for it was of her husband or older sons. And then some would
through them that I left.
beat their heads to the ground and cry helplessly.
I travelled to Calcutta with two compounders who The refugees were so reconciled to their fate that it
had also -volunteered. At Calcutta, where Caritas was really heartening when one saw a ;youngster helping
has its headquarters for its Refugee Relief Work, it an old disabled man to the dispensary, or a few little
.
’
~
—
’
—
«
------ .
was decided
that we
work
at ’the
Salt-Lake Camp.
There
boys• fighting to
get into—
a puddle of water or a group
were many volunteers who had come through Caritas of young girls peacefully singing a few songs.
The future held no promise and they were so bereft
from all over India and abroad to help in the relief
work. It was wonderful meeting these people who of emotion that one rarely saw one refugee volunta
had come with an abundance of enthusiasm, cheer rily helping another.
Of the refugees, ninety per cent were helpless women
fulness and selflessness to volunteer in the service of
the refugees. I would love to mention them here, but and children and the same percentage of them were
perhaps I dare not, for I could never fforgive myself Hindus. Most of the refugees at our camp were
if in my thoughtlessness I mentioned some and forgot illiterate. Most were landless farmers by occupation
and very few had an occupation or trade.
a few.
Our greatest problems were nutrition, unemploy
It was truly this spirit of dedication, co-operation and
thoughtfulness on the part of the volunteers towards ment, sanitation and the continuous arrival of more
the refugees and to each other, that got us so involved refugees. Conditions were such that men worked
in the relief work. One realised that however vast for no payment. Every morning there were crowds
and urgent a situation, nothing could be achieved of men waiting to be employed but so many had to be
without some organisation and co-operation.
turned down. They were not permitted to go into
There were over 900 camps all along the eastern the city to beg or work as there was so much unem
borders of West Bengal, Tripura, Assam, Meghalaya ployment among the local people themselves. To
and Bihar. Most of the camps were organised by keep the refugees occupied arrangements were under-
AMONG THE REFUGEES
60
SUPPLEMENT
TO
THE
EXAMINER
October 16, 1971
way to start schools for the children with the few educa
ted refugees as teachers. Parts of the camp were cleared
up for play fields for football, etc. There were sewing
We offer our congratulations to the following students who have
classes for the young girls and women. The men
passed the University of Bombay Examinations held in April
would soon be employed in bamboo matting.
1971
Endless hours were spent by the refugees in patiently
standing in unending queues, often in the scorching
Third
sun or heavy rains, for bread, rations, medicines or
Miss Premila Robert D’Silva
water. Caritas was supplying 20,000 loaves of nutri
Miss Philomena Faustine Lewis
fied bread daily. Even though one loaf was given
Mr. Eric Joseph Francis Pinto
to every four persons, there were many who went
Mr. Vernon Patrick De Sa
Mr. John Austin D’Souza
without bread and waited their turn the next day or
the day after that. Each time they received the bread
it was ticked off on their ration card.
Second M.B.,B.S.
We had a well supplied dispensary with a separate
Miss Mary Margaret Carrasco
shed for minor surgery, bandages and injections.
Miss Maria Prisca Colaco
We examined about 600-700 patients a day.
Miss Sandra Frank De Souza
We would go out every few hours among the queues
Mr. Ghipriano Serafinho Fernandes
Mr. Gregory Michael Fernandes
and bring in the serious patients who often without
Miss Aruna M. Fernandes
murmur would patiently wait their turn. These
Mr. Christopher Joseph Lobo
patients would be admitted to our hospital. It gave
Mr. Gilbert Dominic Lopes
us such joy when we were able to save many of them
Miss Alzira Francisca Mascarenhas
with the wonderful drugs and other medical aids that
Miss Sarita Joan Noronha
Mr. Arun Charles Pinto
had been donated so generously by countries all over
Miss Lorena Siqueira
the world. We had a simple but fairly efficient num
bered card system for the out-patients and we even
No Candidates appeared for the First M.B.,B.S.
kept an out-door and in-door patients register.
We realised how a few friendly words and a little
attention could go a long way to make these lonely
Our 20th Annual Social Gathering
sick people feel better. This was brought home to us
Members of the Senior and the Junior Guilds, are hereby inform
even more strikingly by a middle-aged man suffer
that the St. Luke’s Annual Re-union will be held at the Bombay
ing from cirrhosis of the liver. It was a chronic ed
Presidency Radio Club, Colaba on the 4th December, with Nelly
illness and there was not much that we could do for and her Orchestra in attendance. For further particulars kindly
him. As he had no one, to care for him, we let him contact the Chairman of the Entertainment Committee, Dr. (Mrs.)
remain in the hospital. When he made a nuisance Francisca de Gouvea Pinto (Phone No. 371630), or any of the
:—Dr. F. Pinto de Menezes, Colaba (No. 213010);
of himself, we did not hesitate to shift him to a following
Dr. Terence Fonseca, Byculla (No. 377264); Dr. (Mrs.) G. Silveira,
small empty tent. That night he hanged himself. Mazagon (No. 372958) ; Dr. John Fonseca, Mahim (No. 455623) ;
This had such an impact on all of us that it made us Dr. (Miss) Charlotte De Quadros, Bandra (No. 533103) ; Dr. John
feel guilty. Frustration may have driven him but if V. Ribeiro, Santa-Cruz (No. 538877) and Dr. A. A. Soares, Chemwe had been a little more friendly and attentive we bur (No. 521352). Students may please contact representatives in
the respective Medical Colleges.
could have saved him. We immediately decided to
reserve two big tents for those old and chronically ill
patients who had no one to care for them.
Our hospital housed two hundred patients in a few
sheds and tents. We had two tents for maternity
cases ; two tents for the old refugees ; two sheds for AN APPEAL FOR HELP TO THE REFUGEES
children; one shed for adults and one for patients
It will be recalled that at a Meeting of various organi
with diarrhoea. With the admission cf many of the
patients we had the rest of the family in the hospital zations of Bombay’s Medical Practitioners held on tl
too—living round the patient. If the mother accom 9th April, 1971, a Committee known as the ‘Bomba>
panied the sick child there was often no one else to Medico Bangla Desh Aid Committee’ was formed, an
care for her other little children. Most of the patients it was also decided that medicines and money be col
were admitted for pneumonia, typhoid, cholera, dysen- lected to help the refugees.
try, nutritional deficiencies, measles, chicken-pox
At another meeting of the representatives of St. Luke’s
and infective Hepatitis. . Diarrhoea in children was Medical Guild, the Catholic Nurses Guild, the Catholic
quite the most persistent problem and would remain Relief Services and Caritas India, held at Archbishop’s
so with poor sanitation and nutrition. We had House on June 22, it was decided to appeal to Catholic
transport at our disposal throughout the day to Doctors including Interns, as also to the nurses and
transfer patients with acute surgical problems to the compounders to work as volunteers among these refugees
city hospital. If it was not for the dedicated work in Bengal. It is heartening to note that a batch left
of the Sisters of Charity, the volunteer nurses and Bombay on the 12th July, 1971 in response to this
helpers (among them many were refugees) it would appeal. However, the need for volunteers continues
not have been possible to run the hospital.
more so because replacements will be required for those
The dead bodies from the hospital and camp were who are due to return on the completion of their period
kept in a tent among sacks of sulfur and bleaching of service. While appreciating the generous efforts of
powder till they were disposed off. The refugees our members and their families to alleviate the suffering
had been deprived of their Motherland and later their of these refugees, we urge them to continue their activi
dear ones. It was only death that emotionally moved ties in the collection of drugs, surgical dressings, clothing,
these people—but only into a deeper and unapproacha coverings (particularly blankets), mats, sheets, sarees
ble gloom.
and the like, and deposit the collected articles at aijy
One cannot say what the future holds out for the one of the centres given below. For the convenience
refugees—but with the blood, sweat and tears that of members there are three different localities, North,
these people have shed, we with them pray that Bangla South and Central :—
Desh will be a reality.
1. St. Peter’s Parish (Bandra), for the suburban
I had spent one month with the refugees and though
there was heaps of hard work we had our moments of members.
happiness too. Caritas had provided all its volunteers
2. Sodality House (Seva Niketan), central areas.
with homely and comfortable quarters. Returning
back after a heavy day’s work or a strenuous night
3.Nirmala Niketan (School of Social Work), 38,
duty we were always sure to have waiting for us just New Marine Lines.
the things we desired most. Our experiences at Salt
A. C. Duarte-Monteiro.
Lake will remain as vivid memories never to be forgotten.
OUR FELICITATIONS
MEDICAL
EaPERINTATION
( Below are given excerpts from an excellent book by an English
doctor who spent years ’studying this subject and kept a bulging
dossier on th© same. Many moral principles are highlighted
which have relevance to the whole field of medicine. It is
to be hoped that- the reading ^of these notes will be profitable
to all doctors and medical* students. )
-
'it--
-vl-ir
HUMAN GLINEAPTGS
by Dr.M.H.r^,,
Pappworth *
(Penguin Bocks)
rHE PROBLEM: For several years a few doctors in this c
'
country and in
-n of their
coinmonc
concern'
Of meocal knowledge, many clin
Zea} '-o extend the frontiers
of the fact that th^ su.MecV
temporarily to have lost sight
individuals with common' bahts' \nd i n' ®X-D®rlments are in all cd* ses
be cured. As a result it hi-'Vp™
m
C53efj sick people hoping to
investioator to t--ke -i L ft
conmon occurrence for the
not fully oLlf,
nu Lie bPntentL°l ‘hhh,
Pollert, are
consent if they w-ro aware- to'-vbto,W!liC/: ;oey would ndt
distress which'is in no way Lpccltp- tf to .vnial 3nd physical
with,
some
“ffeX
sZZTvi °f ’
Tn;but• t°Le ^ult'yacknoRpdnKTWntiTf'bTf1M! 1)cllnlea 1 research wst oo
must go
2) ?Sri"joSt? o?fHosedSnare ^‘US1lY’n°n!exrs(eeS!rdS
Pa^S.
moral integrity,but an^svnandino r? cla2lcal research act with tie highest
illegal practices. 3) Unles”
reUcrt t0
«» probably
unethical practices of thL riSrl^Rf,:“fF st°>=S probably
tha
4U
outcry will eventually be
"It behoves^heiredlcai^profession to^k^+S656"0’’ tp- 18)
s:
s ”EF !
~-
its confidence,
■ indeed
K
c
on
be
sought
S s'-'b accept
-ce’p"? tne fact that some
Wh*
limits
JHAT CCNSTITUTBS a%ttFTAB.e
‘
.
)’ (p.20)
tteaic±ri- is something new
anretpr*^
science oi experimental
in our minds the old fa-i th t
.
i
•
s caPafcle of destroying
patients whom we hav-’unXrt-^n :’triQ d«c-cors,are the servants of the
patients,the complete true? ±? lit?re f°?anCi in the minds of the
of their loved ones in ouf >
c,??S?lace their Hves c_
f
or the
lives
" :he moral obligation 4-o r.^rfnr
i
H.Ogilvie,Surgeon)
regard tc the senfibilitv wpl'<ff
aS h^m3n experiments only aft
be violated. ”(Dr.S. S^Ketty7 ^pfai)^ Safety oi' the. object must ;.-r oue
sever
cure^RR
act of a doctor
- ‘-
experimentti on
his in the
one when the acts of th® phv-ici it"'
P’'°olem becomes a kn'tiy
of the patient present but ‘towards StirntFin^ n°+' ti"ard th' benefit
requires the exolicit consent o? S? fS 1 i 9?neral. buch action
more than this;lt requires profound t^unh+e-,! ?atlenh It -also requires
part-of the phvsici .n.fcr +be
1+^^ x
‘{ousiac-r.p.tion cn the
oeses so great'it i.; .not reXnaM 1 X C£ “^cine are in some
eoequately informed as to the fu'1 "inrhlf Xpf^t‘l3x
Pa‘fcien't car be
his trust in the physiXn" VXlX? atlOnS-?f
his conse t means.
rve should,! think for
;
r0° GasilY
say ' ’yec'{Dr.Beecher)
patient which is not’qeni^iTvXr{urP°^es>rogard anything done to the
therapeutic benefiFo? as lonlrfSn^/5^"1^ f°r his di«ct
33 constituting an experiment aSo fal?in tX ^’^nosis of his disease,
of the term’experimentsImldicin-rfuf^ therefore within the sccoe
meoicxne .((Prof.McCance-Prof.of Expel.Med.)
• . •2
I'
i
/
mfcWb,tiOne human bei
• r
’
•
: •
ThhS
f-iends rnmh
WltS
•
. *'
iNi 44'ifl’
fill
is in di
?ran b?inV5 COIh—d
2
?
’
■
•
tr
■
’‘.'.I
l:4
■ f
H
M
fp.^3)
to assJsFEfmflhe
hnhih 2 rendF itprecipitate their relationship,
Kh p b?tween,two I.’s, like between two lovers,
C811ed SUCh a -I’tienship .the’
“s‘SpJ®:£‘£;fis :■= c, Biv' .p..»
Experimentation xs. the only basis on which they Set bS? eJen tho^h
rat,hr
supect m the grammatical sense,he is not the subject in -?he
real personal sense. Every effort is made to depersonalize him aJd
lc• elimin..ue every subjective factor.
Invoked by the drive for
outj*’ (Dr^Guttentag)^C(pj24)bl<>n’ ob^GCt:L’vi‘ty is ’the password throulh-
oain if the .-■xperimJni t’
1 tV® Patlent has personally something to
; vwtX
But lit noth dlrectV. concerned with the relief of his
Pi f•
' ,
the position is entirely different if there is no
likelihood of the patient himself benefitting.
S^y^rS.^ocous to th, hardened ezperi-
^ly^h
fesTT'*;?
he
n?r;„SLS?din a
recorded ’ in -od?bl i^n d+red by rhe subjects of experiments, is rerely
ins
"
Svfv
?
•
‘IF?:"
is pe“-n
°f the patbnt * Mld t°-be
?n
hP V the core &f The 'matter.
real indication1?
no possible
a ’real
and th?profn?heUd“?orPOi?L?e?“din9 lisks and ri»hts of
P^lent
J’s^d^^^cXtin?1111?9-"9
psychic integrity in medical
wnnnric n-r-
Plus
-nn 1 ;
H ZPo'pcj--
‘° E?iAnkln.u
“4“^ 0XP^i’
no? ^?™rl?Se^™n«;ed?rlaUr *"503000 onos.on unUpectlng
hope of making'scientific rii^id^a'Se---'?ln9 investigatecl, solely in the
and the pursuit of new sc-iih? TS* 5 ^lence is not fch* ^Himate good,
precedence owr JoralV ic J
k^wlxa9e s*uld not be allowed to • ke
Which is no? uncSonlv
the tw° 2re in conflic'- The statement
intore-rina tn'tnn ? +h
i J 1
? rese.3rch workers,'It would be •
9 *
,though natural ana,doubtless,frequently true,is
•4 • -
•*
f
2 <-•
■
Dr. Guttentag defined as ’experiments in medicine’ ’’experiments
on the sick which are of no immediate value to them, but which are
made to confirm or dispute some doubtful or suggestive biological
generalization. Recently this type of experiment has become more
and more extensive.” (p.22-23)
I
PHYSICIAN-FRIEND: ’’One human being is in distress, in need, crying
for help; and another human being is concerned
V
end
wants
to
assist
him. The cry for help and the desire to render
E
it
precipitate
their
relationship. Theirs is the relationship bet
R
ween
two
I
!
s,
liKe
between
two lovers, f
*
friends,
pupil and teacher.
S
I
have
called
such
a
relationship
’
the
mutual
obligation
of two
U
equals
1
.
s
- 5
not in itself a justification for making experiments of whatever kind.
The v/uliare of the sueject must also and always be taken into account.
Any human being has the right, to be treated with a eortain decency
this right* which is individual, supercedes every consideration of
what.nay benefit science or contribute to the public welfare. No
physician is justified.in placing science or public welfare first and
his obligation to the inaividualr who is his patient or subject,second.
i,
.
■
■
t
,
.■
.
,.r
>
i
■
; ‘hl
'
cor.tz-lbute* to”the public weiKref’Vit*, .. wr wiiat,
No physician
- ;._s obligaor sulgect, second. No doctor,
chodsermartyLhfe-“K^cA " ?rf4"si his ldeS
> has the
4
the riaht
rioht to
■is'
rlf^flrst and hJs
uo^
tJ-S
e of
result
The ERIT1SH'fnicALtcSt'LfieS4 i?0qV'J J;e'
of expeXen^tiiZen ,
an
h‘l-'lth,oi others."
!SS
' JZdne
or .
-dfca! ethics, as'enMciated
u
.42-43)
thr
OiljO.n
00 od
can r-. Justified
m tne broad notion that in the end othurZ-lni',
benefit frorn' ;,uch
■ good with
+ U-+ u ; e, l'ntee, ait inflations always in mi rd • --hat wp must
■
protect life,
pZsonstnd Jot JimpVasnm^n^n'-S/S ^3+^4 W r^3t indlvidGZs
as.
Vanderbilt Univ ShvilLTZn '
Z-E-^urnpf.Dept.of Philosophy,
e?en more str™giyf5Xiy cLssillSfen SVtlcian has
the'
niatt er
’for the good of society’ is'ftZ'fZ Z
experiment..-1 j on as
Undoubtedlv.all sound n/ork'h -q -fs?
vv± tn dist-sste, evon aloKi.
hion-flownd^Ztlon.
das lts ultimate aim;but such
living memory as lev"; for n. t ‘fc^
within
y
ccv..r tor outrageous ends.” (Dr.H.K.Beecher)
:S6Sh”ttAr.?,g;i™’ffroiich,the “dit f'Lg-gr-;t6;;
WdfdBdFdZZxffi iUiS cXtv-N ui
s:tZth^±RL;-jf
is
■. awards
- even
immediately invoIved,
not at its inception.
' Z y means,
71^,...; 1* (p.'fZd) ’ oistrnctron Ocrycc hoc
ends and means. (Dr.
H.K.
Beecher)
cent
(Dr. H.K. Beecher)
account of most of the
. W MitscherUafaSdMs'iK.ed^tV':
lif hWlfA
oe it
value was .discovZedf^fGt’FZZ
Zf fhst R?Zin9 of me-di /
even
if something of value had been achieves it wouldZot
havZ/f a?Xd41T)iV'h3t wes ddone,
°n:.new
scientific
tr6th
.no new sci ent.-i-Fn’r +pe4‘h c^uld
“or-;
zzfZZZZxue . t0
srZeZzZZ-d-zzss r—
Yet those
suffering - that
science. Their guilt^w-s iZZxZ tl?elx' aim ■:as t0) scivtt
serve medical
in following this aim ariw that 1--4 15nG:FeJ *h® SL!tlerinU theyr caused
c... _
knew were certain to cause sufflrlng^^And this" practices
practlCas which
which they
"
'*
no^ ^n, prinexoJ-e
fZZ —
••Zdu'lriS^-
experiments which hU knowsr;uch he cau?es ■-’na per-sisting in
sufferer ha < net vobmtXd r
suifenng, especially when the
at the sole
"V Vst'Xf(n: USr"’ bUt iS SU1»eCteCi t0 it
&__CODE CONCERNING] :rUI7Z\T P’XPFPTMrnr./ ttont
fol 1 owing princ 1 p 1 cis :
*
T TI°-
i Z,
be concerned with the
pi oZZ or underZZZZZ
lxp.'“:u”ent'? shouid be contemplated,,
!.o those of th- ZZZZZ Z Z Were in ^rcumstances idenrlcul
to submit himself ZZZZZZ.ZZZ ci' would even hesitate
had any resp-ct or affectinn ° -ZS-°wri family,or anybody for whom he
more than the subject is ruiAous/® 1(p3 23CJ th& expG2?imenter is wrth
4
.1.
9
r; i
- are made. Further,the co,- -id-.rcticns 'invoIvod
is not hitXbl5 t0 prev®n-t JhclL bein'; adequately understood by one who
I n-rdnbdTkt1 V?
.iwo £s?entlal Pieces of information are
■ +pi-n '-'-i-b.^dtelr withheld from the ' consent inc; volunteers', namely
Jtndl,‘e Proceoure is experimental and that its consequences arc unpi -.^C'.able. Moreover,m keeping a subject in the dark as to what
' in
V- /° 3Xoic\ 5 refu- 1^he experimenter is,
in To<. L,guixty of -a rraud. (p. 232)
b. ,77Z:?'r.^nClpp? ?,r Proh:Lijitjd subjects: Experiments should under no
+b + b
f b° P^tormGa on mentally sick patients,whatever may be
the technic-;! designation of their particular illness. Nor should
experiments ever-be performed on the 'aged or the dying. This io^ows
from taking the above two principles seriously. (Especially with
cannot be saved7!?9-t®stin9 out of
drugs,where the patient
in p&ace ) (p 235V COmmon
that he should be allowed to die
4- g^Ancipl^f^r-avious animal e.w.rrimentati on: This is suggostod
v‘
..principle' of the experimenter's competence: The parts played
+X P®0^1® whe are actually unqualified modically should be limited , ■ A"
to wha s they can do with complete- safety.
(p. 240)
6. The, principle of proper records: If a patient consents to be subject
or an experiment,what has been done- to him is virtually part of his
W^iect of proper records is th-' against a patient's
iiity_.-..-.-..tt.,against, those ci tne doctors and again. .. the interests of
,
}
JQ .-ipthe above, I am opposed to inhuman clinical, research and
{
i
i
eon+r?h^+ed; every consideration of what may benefit mankind,what
V- Y , ' etribu.s ^o public welfare,what may advance medical science.
-.nd h^°btS ■JL!S"liiGd, ln Placing science or the public welfare first
+ h' P1-uo his patient second. Any claim to act f&r
.J* dC;0CI
S0C3-efy should be regarded with extreme distaste and even
4 wor-IbC
ai ''e
^Qh-pown expression to. cloak outrageous acts.
-h wcr.^ny .-nu does not. justify unworthy means.
f
T
i*
(ibid, suppl.)
'■>
/ •
!‘
**%**-X--H-
r
!
■t
k
H
-r
- 4
2. The Drinciplo of valid, consent: (sea first fivo clausas of Nurem
-----------berg
Cod.o
) To To
obtain
the the
consent
berg
Code)
obtain
of the patient to a proposed, investigation is not in itself enough.
Owing to the spacial relationship of trust which exists between a p
patient and. his doctor, 310st patients will consent to any proposals
That are made. Further the considerations
(see text)
QN
DEATH AND
DYINS.
The Doctor face to face with death : Death is a frightful,
fearful happening, which, we are convinced, "happens to 0*h®r
people", (Francois Mauriac). Yet it is something
e oc
to face routinely in the course of his practice. He must f00®
St X the dying patient but also his relatives to whom he has
1.
SX^ntaVXX^^Xlna STi'SM
the doctor must ask himself: 'what is death ?
ytawed as a
nroblem in the life of the doctor himself, if it is vioweaas
frightening horrible, taboo topic, he will never be able to face
competence and commitment. Ho must inspire in his patient h
comperenee
0 tho hopQ of recovering health. But
2 to XX is to ta fto^ tten the highest poirt of ptaeohel
freedom is the courage to face peacefully
o PfXt% death as
imminent death. If the doctor considers the Patient s doa^
the enemy to his profession, death as G
not help
then in his desperate struggle against death he.-.will not neip
the patient to serenity and balarre, strength and effective
personal freedom in the face df .death. As a famous pgsici ^
writes- "Not only for the dying'patient but also for tM.TOctor,
reXstXg Sth generate an intensification of ^do
lt allows the physician a full commitment to life wJ^out th
obsession which considers death as the greatest of evils, i
then can freedom mature.
2.
nWhat is the meaning of deaWf beiow
&
guidelines.
....
(a) north is something which happens to a persog.. Whereas
‘death can be considered from different angles cvtological physiological, philosophical, theological
eLh plrson’apprehends his/her death as an_^niqueiy
expressive event. It is not -a machine earning^ a
ston1 nor ’a bit more troublesome form of y^an
CX:
affront to - “‘““•XX.)
life liberty and the pursuit of happiness (Toynbee),
tat on IntotLly personal, thing - « *«• tn1^.
The process of dying is in reality the art oi_livi g
meaningfully in and through the process of dying.
XXbelongs to life as birth does; the walk is
n
in the raising of the foot as in the laying it down.
(Tagore).
...2/-
:
2
: ■-
(b) Docth is a real factor in, the meaning fulness of life •
In the feco of death, says Viktor Frankl, as absolute
finis to our future and boundary to our possibilities,
we are under the imperative of utilizing our lifetimes
to the utmost, not letting the singular opportunities whose ’finite’ sum constitutes the whole of life pass by unused.
(c) Death, for the believer, is also a significant religious
event : It is, as it were, the occasion on which wo
ratify the fundamental options wo make in life. Those
who, .for example, believe in Jesus Christ, and in his
passion, death and resurrection, as a salvific event,
gain a new vision of death. Christ transforms death
into the greatest manifestation of trust in the
Father and love for all mankind. For the Christian,
death opens on to life eternal. Every doctor should
try to be cognizant of the hope and faith of his
believing patients, the better to help them to face
the prospect cf death with equanimity.
3.
The.Moment of Death : In view of organ transplantation, this
question has acquired special significance. After all, a person
dying is still a person living, and he keeps his elimtntary
human rights up to the moment when life becomes extinct.
In short, the principle that brain death is synonymous
with the death of the patient (or death of the person) has
found universal agreement. A Halyard University team that
studied this question in depth give the following criteria:
’’It stated that in order foi* brain death to be designated the
subject should be in deep and irreversible coma; manifest a
total un-awareness to external painful stimuli; have no
spontaneous muscular movements or responses to external stimuli;
have no respirations when not in resuscitator; have no elicitablo
reflexes; have pupils fixed, dilated, and unresponsive to light; .
and have, an isolleptric KEG (flat Em), with the foregoing
characteristics having been maintained over a period of 24 hours.”
(Archives of Internal Medicine, 124 - August 1969 - p. 226-227)
4.
THE PROBLEM OF THE,PROLOGATION OF LIFE'AND EUTHANASIA. n
The right to live humanly implies the right to die humanly , i.o.
with dignity and in freedom. Does this mean that the patient has
the right to end his life or the doctor to assist him in doing
so? In a recent document, the American Hospital Association
approved a 12-point Declaration of Rights of Hospital’Patients,
which grants to the patient the right, among others, ”to refuse
treatment, to the extent permitted by law, and to be informed
of the medical consequences of his action”. This implies that
an adult patient with no prognosis for recovery has a right to
die without medical therapy. The point is: would this ’’right
to die” justify the patient in asking the doctor to end his
life, or justify the doctor in presuming this consont and
acting in such a way as to cause death ?
THREE POSSIBILITIES : In the management of terminally ill
patients, or patients whose brain has suffered massive
destruction to the extent of being irremediably non-function!ng,
there are throo major options :
(1) withdrawal of artificial and/or mechanical life-support
.. systems (i.e. non-interference with death);
...3/-
[
4
- : 3
-
(2) administration of pain-relieving drugs which will have
the effect, among other effects, of accelerating the
of death)
death process (i.e.. hastening
---'
life-terminating
(3) administration of death-inducing
or
^tion calculated
to cause death) .
agents (i.e. deliberate i--------- -
T think it is arguable, says L. Hamon Smith (ETHICS AND THE NEW
is arguable, says L- Harmon
. 167) that options 1 and 2 are
properly underpatients, but that optioni 33 is
is not.
not needed
“®^ed if we
no^nZditorinees)
dispensability (i.e. the non-manditonnees)
stand and apply the dispensability (i.o. the non wia
I?'botS Ordinary and ordinary means which ere not
2 and 3 is a fine one,
reinforced by the awareness
solonoo ma technology hw. dovolopod iu»iy possibxlltieo
the ethical wisdom and moral
exercising humanely re;
«
— _ —Uk-.
I -9 ’ri O C*
[ O J/
£ sssC—'-pon.it!.
SOME NORMS ; In arriving at a morally discriminating decision,
the following norms should bo kept in mind.
(1) ”A human person owes it to himself and to his community
(to his family, to the society in which he lives) to
iX hl. Sit IhtMt and not to de.tpoy tho vfc ttet
it ?enrosents. Human life lived in a personal way is the
b^st that we can find in this world. Nothing else comes
anywhere near it, in the hierarchy of values.
fallows that both the individual and the community has
a duty to do what can be reasonably done to preserve
human life. This duty exists in.the Pliant, in
' doctor, in the lawyer, in the pnest, in all who share
a responsibility for life*
has a right to his own dignity as a person even in
(2) Man
approaching'death. Therefore, once the r0®-s°na^19
+
Xs to klep him in life.have been .exhausted he is not
bound to destroy his dignity by expecting
P
alive without being able to live, to think, and
feel as person. No one is bound to ask for medication
that would prolong the agony of death. The same
principle is valid for the community; its members arc
not bound to prolong the agony for a human being.
(3)
(4)
There will always be complex situations and borderline
cases where a clear moral judgment cannot be formed
within the short time available. In this case we
have to respect those who, animated by the first two
principles, make a genuine effort to bring abou the
best decision even though they may fail to find i
there and then. Yet the effort itself was good
and the resulting situation should be accepted as
the only reasonable one in
in the
the circumstarcos
circumstancos..
"I would urge that we promote the idea of benemori,
a dignified death, in the dying patient. There is
no need to prolong the dying process, nor.is there
ary moral or medical justification for doing so.
Euthanasia, that is the employment.of direct
measures to shorten life is never justified.
'Bene mori* that is, allowing the patient to die
peaceably and in dignity is always justified.
-:4sEUTPUNASLA : Etymologically the word means ’’dying well”. But the word
has now come to mean ”easy dying”, for it implies medical
intervention to cut short life by causing death. We must
distinguish between euthanasia which is claimed as a legal
right, and euthanasia as a moral option.
(a) Legal euthanasia: Advocates of • euthanasia as a
legal right of every citizen can be understood
to . speak of euthanasia in two senses:
(i) in the strict sense : i.e., ”to cause
death (or to assist in causing death)
to a conscious, certainly incurable
patient who requests that his agony
(physical or psychical suffering) bo
terminated by a calm and painless death”.
(it) in a wider sense : This would include:
(a) to cause death, at the instigation
of pity, to an unconscious dying person,
to monsters, the seriously insane, etc.;
(b) to cause death, for the sake of
society, to a socially dangerous person,
and in general to persons who cannot
live morally useful lives within
society (the so-called ’eugenic deaths’,
and disposal of useless persons e.g.
the aged, mentally retarded etc.)
The judgement on this has been succinctly formulated by
*Pope
v v Paul VI when
he wrote to the International
'
Federation of Catholic Medical Associations: ’’Without
the consent of the person, euthanasia is murder, His
consent would make it suicide."
(b) Euthanasia as a moral option : Here.it is
customary to distinguish between (i) Direct or
positive euthanenia: i.e. the rendering.of
assistaree in order to cause death, This can
never be allowed, (ii) Indirecl^rjiegative
euthanasia: i.e. the administration of
treatment, e.g. for the alleviation of pain, which
has as a side effect the acceleration of death.
Here, we could also include the stopping of those
procedures which only prolong the process of
dying, while they hold out no hope for life.
This should better not be called euthanasia at
all, and in fact is morally licit.
FI NAL
SUMMARY
Me can summarize all that has been said above_, in^an 0fga^2ed
way, by quoting extensively from a lecture given by Dr. G.B. Giertz
at aGiba Foundation Symposiumi on ETHICS IN MEDICAL PBOGRESS: with
sne'cial'referenco to transplantation. Ho writes: "pie subject of
^thanasia poses now problems in medical ethips. The CQ^r£
is whether we can establish the moment whon life ceases to have any
human value; this is essentially ^0 same cental problem^ in
-bortion, although it is then a question of deciding the time wnc
life begins to have human value. Both problems force us o ©c- p
to the question of whether man can draw such a boundary
a
SsXS the obligation to protect life. There are essentially two
possibilities.
r‘ , One is to leave the.duty to Poteet an pro
lacks the
human nfo
life unconditional.
unconditional. Such a view implies that man lacks
...5/-
-:5s-
right to determine the length of life and to
^^^^^"for
nnd .tet a veluntlo one. The
so? of
which there are strong advocates m Sweden, ip
rci3niring damaged
phllosopy sets. "Is the physlolon's virtuous skill
individuals and sending them ac
o 3
. .
derived
deprived of
of the
the power
power
grave changes in personality, with poor oig
f h
of locomotion, actually a gain from the aspect of
l3
Is
i-i-Pati*? Tn ibis connexion ihe economic fnevor nas
the
___ L
1
-to nigM ’rs&s#
fireSc
uhrt is not, «d dlrsot our rusouroos to tho
former?
foptir has entered this discussion, namely
More recently a third factor h
attitude is that in
the question of the dignity of life
yto
go that the
the treatoent of the hopeless CB33 w°
a life as possible
pationt, in spite of everything, can 1
~
medical effort
and is freed from pain as far as possible.
th th t appears
is concerned with achieving these ends. We choose We^pa
S’Se“L^Tt“213h?h£So «d »«rt soon °XtXi“th
should take this into eccoun
is n
ir^
oAllowed to run its course.
P—-r.S^oXdt for «
-
The
* *
o rosplrotor -ten there Is no P?=rtblllV of
Ji.”*S" -... ..... .
Such an <
_
spell disaster to our
considerations
.Plarely.mQ?. 1C€^eO^|rein°fromPtreatment because
U
'“'w - ------------object of killing the patient, because it is not in the patient’s
it does not serve any purpose,
killing by medical means! death has
interest. I cannot regard this as have put up, and wo must accept the
already won, despite the fight we
,
L =« enable us to solve
fit
Onlylh» rnoognlilon of thin Unit
i the thought of death an agonizing one the problem that for many has made
of life when it has already been
the fear of an artificial prolongation
bereft of all its potentialities.
n0*0*0*0*0*0*0 *0*0*0*0”
r■ ■
iiVJxAx
U
l-'l-Lu
tl
11 Death belongs to life as birth does.
The walk is in the raising of the foot as in the laying it down.”
( Tagore; STRAY BIRDS, GCi^VIlf )
Death is not only an essential character of human life, it is also a real
factor in its meaningfulness. A doctor’s duty towards human life includes
his duty to help a man to die in peace and dignity. What is the duty of the
doctor in respect of tolling the dying patient the truth? Below are some
quotations that might help seeing oneYs’ responsibility in this regard.
” There is no single categorical rule about truth-telling. It all depends
on the individual patient, his condition at the time, his temperament
and frame of mind. The modern doctor is unwilling to,’lie’ to the paiient.
He feels he serves the patient best by telling the truth. But that plunt
phrase might be supplemented by the words of the New Testament about’ speak*
ing the truth in^love”. Speaking the truth ”in love” may mean. at-tinkes.
‘_1
keeping silent. n” ( W.L. Sperry; THE ETHICAL BASIS OR feDICaL PRaCTICEAp.122)
1.
2.
” I believe the question should not be stated, ’Do I tell my patient?’
but should be rephrased as, ’How do I share this knowledge with my pa^*
tientj’ The physician should first examine his own attitude toward malignancy
and death so that he is able to talk about such grave matters without undue
anxiety. He should listen for cues from the patient which enable him to
elicit the patient’s willingness to face the reality. The more people in the
patient’s emsrironment who know the diagnosis of a malignancy, the sodner the
oatient himself will realise the true state of affairs anyway, since few
;ople are actors enough to maintain a believable mask of cheerfulness over
a long period of time. Most,if not all, patients know anyway. They sense it
by a changed attention, by the new and different approach that peop'.e take
to them, by the lowering of voices or avoidance of rounds, by a tearful' face
of a relative or an ominous, smiling member of the family who cannot hide
their true feelings. They will pretend not to know when the doctor oj* rela
tive is unable to talk about their true condition, and they will welcome
someone who is willing to talk about it but aldows them to keep their defences
as long as they have the need for them.
Whether the patien is told explicitly or not, he will nevertheless come
to this awareness and pay lose confidence in a doctor who either told him a
lie or who did not help him face the seriousness of his illness while there
might have been time to get his affairs in order.
It is an art to share this painful news with any patient. The simpler it
Is done, the easier it is usually for a patient who recollects it at a l_t_r
later
date, if he can t ’hear it’ at the moment.... If the news can be conveyed
with the reassurance that everything pc sible will be done, that they will
not be ’dropped’', that there are treatments available, tnat there is a gliipsu
of hope even in thtj most advanced cases, the patient will continue t<b have
onfidunce in the doctor, and he will have the time to worii through the
Afferent reactions which will enable him to cope with this new ana stressful life, situation.” (Dr.E. Kubler-Koss, M.D. : ON DExiTH iiND DYING, P 32-33)
3. "There is but one Truth of which we are in all circumstances the servants.
. . Jxnd what do we find most often abo.ut the sick, and with increased inten
lies:
sity as the condition of the patient gets worse? Jk real conspiracy of lies:
pious lies, it is said, though they serve mo.e often the prince of lies than
the G-od of Truth.
What would we say of the duty of truth towards these sick? Is it not the
beginning of charity not to deceive? Of course charity excludes neither
_
"
prudence nor delicacy. But
the patient■_ who ’has always
relied on the sincerity
when n.lxx,
in health, ------never
had
reason
to ~~
complain
of those about him; who, wboix
has ----nrvr
h--'
”
„4.4. 4.,,^3
con„
of their truth or of their solicitude - preserves„ 4.^^
the same aptitude
___
'
■
of
danfidence when he becomes a patient. H© relies on his own an the hourger, and it is in that hour that they conspire to deceive him, to create
for him the illusion of a security which no longer exists, and of a lope
which is already beginning to fade. The first duty of the doctor is to re
veal to those attending the patient and to the patient.’s relatives the aariger
and the possibility of a fatal issue. 1his revelation is not to intensify
the conspiracy of silence and of falsehood surrounding the patient, but to
seek collaooration in preparing the patient to hear the truth.
Nothing is gained by delay. The more serious the patient’s condition
becomes, the more difficult it is to tell him.
His friends may find it too difficult to inform the patient, and:
and so
a9
a
u
ty
they may default. It then becomes possible for the doctor,
demands of him, to act with that simplicity
n " 4”’ and in that manner which his
heart dictates to him.
P.T .0.
a
2
If we are really disturbed about the patient’s condition, without our
hope being;shaken, it is best to act before all opportunity is lost. Let iss
'bring this uneasiness of ours clearly to the attention of our patient, rather
than’dissimulate it under an appearance of reassuring and deceiving joyiility.
It is not necessary to shout this uneasiness, but wo can axlow our patient
to divine it foi1 himself .
The patient who has noticed our troubled -expression as we' examine him
will question us. Let us not answer immediately, to give the impression
that we are hesitating before a truth hard to hear. This deliberate silence
will already be, for the still conscious patient, a warning of danger.
If the patient insists , before we leave him, let us admit our concern
and specify the'deterioration in his condition.- This avowal on our hart wl 11
'make his way clear to him. From that moment, his attendants, duly and clearly
informed, will create even all unconsciously about' the patient this atmos■ phere of inquietitude favourable/warning, which the patient already! expects
and is ready to meet without surprise and often with gratitude. At the next
visit, the patient will-watch our expression and, not finding there the-re
laxing of tension ho booed for, will perhaps demand the truth about his con
dition. io this request" dictated by his material -concerns and by his spiri
tual, we have no right to answer; with a lie. to lie at this moment is.to be
guilty,more than ever, of betrayal; because the consequences of our lie can
be irreparable, both' in the material and temporal domain, and in the spiri
tual domain for eternity.
These rules hold good in other, less dramatic circumstances which con
tain a sufficient element of uncertainity to justify words calculated to
imply a warning. It should be given regularly when a surgical operation,
even though not urgent, is indicated and the patient desires to oe told
clearly how grave the intervention will be, if there is any danger involved.
If this is serious and constitutes a risk which is real but indispensible
to the conservation of life, our duty is to recognise it without exaggeration.
The patient who desires especially to ’set his material and spiritual house
in order, has a right to the truth. The mildest of operations is not exempt
from complications and can end by being fatal. Of course, it is not necessary
to give these technical details of complications which happily are the ex
ception; but to the question: 1 J-his is not serious, is it, J-octor?1 - we
can always answer: 'Every operation is a serious matter and must be treated
by both doctorand patient as a serious matter. It is best, in every casep
to take all necessary material,and spiritual precautions, ihat it will be_even
technically the best psychical preparation for the operation. 11 (p.94-96)
The tranquil death which we desire for our patients as for ourselves
is not necessarily the unconscious death which drugs, even prudently
administered, can procure. We sack above all a peaceful death, with the
soul at peace and abandoned to goodness and mercy which opens to it the
gates of eternal life. The sweetness of death is in that vision of light
and of life. "
( Dr. J. OKincZyc , °urgeon and
Professor of the Faculty of Paris
I!
in NEW PROBLEMS IN MEDCIAL ETHICS No. 1 , "Death
*
L
DO a mere formal
•g X A M X
THSi
TH^ EXAMINATION ITSZLF:
■at I c
s
FSe^SsSd^dy Sd^rSL^yXr'Hc^S
'^brou^ht; about a stake of overiatiguo
nciiitv and clearness of mind at the examination. It is folly uo
a gw vSo facts a( the last nonent at tho ixpsnso ol general vigoui
in an the US. X? ouch hasty eram,ting should, by chance prove jexpful
vnCTr--r-ithiq or th-it Question, it produces at tho saure tiiuo uiuudlo
hcadedness^lassitude and wearine ss which will certainly affect one J per-
for^ianco as a whole. Koop in mind two rules;
•vt a jzood night's sloen before the day of tho examination.
dolSrX! cultivation o<' a nightly elated, but prevailingly
cool and collected,franc of mine offers tho oast conditions tor
rucc°ssful p,rformanco in examinations. Flurry ano. examination
nerves may inhibit the more skilled, operations oi tho mind. (uo
remember to trust your mind and memory - they arc- dolicataij baJuanc^
Romember the following:Re-W-rocall of known Ilearned) facts;
- be inhibiteo. oy fatigue,
1) Recall of what is known may
affected
by
the inhibiting emotions — fear.
Recall
is
also
adversely
cf
t
.
2)
anxiety. (Cultivate coolness. ) concentrat ion of attent ion ano.
5)
f^rjlay of U» »1«1 over the total
4)
field of relevant information.
RECALL
lix- assimilation, TnKES TIME. The student s first concern
on onwrln.s tho oxplnrtlon hall
o&'eLlf.
the maximum possible tito be
avuiimuie xwx uu- F
Th-, maxi-nun ti’^e is allowed to the process of revival when an inxcja-
l^feuA-o planning tp^swor s oo the V.HULE oi^Z^r?
The preliminary preparation of the answers to the whole of the paper
sets in motion a process of revival which may still go on (u.icon
luncon"ft^tjur thoughts have turned to other things. tibutativ«H o£ym«“ eaj whilst thB conscious mind is conoornsd llth
writing down tho answer to one question, tnu unconscious nine i»
'engaged in preparing tho answer to the next.
TtiS WRITTEN E^MI.IYT ION:
’ , ana
—• will imply three steps; thinking, planiiing
Doing a good paper
sKin through ths wlkols paper
anything
JRh groat cafe to bocoao aware
writing. Bofor? writing
’
.
to dotorains its scope._Koad the
of answer oxpocted.
of thb specific ttype
.
WTV,nnontiv the first reading of an examination paper , produces a
one should devote to each question.
°
hat- a tSS’to
ma s sy
way specified." (Conti)
to understand tho specific poxnt asked by
TEE ORaL EXAMINATION: Tale care
answers jnust likewise
-----------------------the eexaminer.
xSnt va^uo and
—
thexaminer. The □:xposition
observations ma£e a
be
precise
and
to
tha^point.
G-enuralities
ana_yaguo
be precise and to tha^p<------ - &"avoided, but also precipation
poor impr-e
ssion. Life
impression.
Lifole^s—s-'rnl st G
which only causes confusion.
—
,
+ •,
llnnlly do notr^goct^our
is not a duel but a species of c°-oporation
- -tudont',s mind ( however
to expose the bottomless pits oi ^^ncu^- lrit,or“stG^ ln tha little hills
much he may suspect
to bo
otherwise even plain.
qy^r^ire^SJUtio.) wrUdj
a measure of pardenauj-t pi.-.a.
ao
(
-W
HOW
.1
jl
TO
STUDY
le
JSSt,?dy
t0 b@,Productive then it must bl
action Thrnn thi
ro-erly ana methodical. Method is order in
action. Three things are requirea: a w^ll-nlqnn^H
n
a correct combination of study and r-st- and a ri
°“tab10<
to tho different subjects.
M
a' ri£kt approach
a)
Scheduling the_ time: A time-table is absolutely necessary. It helps
<
make efficeint use of available time: it trees
tRS f3eli^ ?f
indecision, and.at the Ec time
closes the door on temptations to laziness, unrestrained curinqitv qnH
^P^V1fat'ion:
of memoriaation and/concen^ration should be
Suort. In general it is better to devote two or three consecutive hours
to a single subject (diversified
by changes in the methou of work alternating reading with written work) than to attempt to ropfoauce
aitemating
in private
stuoy the
1
i'hif
riVata stuay
thO' routine
routmo of school. The
time-table should.lie fdexidle
' - ’
lole,, especially
with reference to intornal subdivisions.
Periods of study and re st: 7To keep^oneself ixi good physical,
me tit al
.
....
onGfg timc-taiJle
.
and emotional health,
must be a^balanced combination of work and relaxation <of' study-timo
BhBTr 7r+HSCrGatiOn and r'SSt" ThG normal Btuu-y poficu has tlhreo
phases. (1) tho warming-up
phase in
inertia has
arming-up^phase
in which
which initial
initial inertia
has to be
overcome. (2) ths phase oiffiull output, l.o. <of~ relatively high [cfficicncy, during which the learner worss at his best. (( 3) A slowirjg-down
phase that starts with the onset of fatdgue-ani bcreooH?
b)
ORDER AND MSTHOD;
„ . .
according to tho curve u±
of , cfflcioncy and
fatigue the most suitable length of time to bo devoted <continuously
to a subject must be guided by the following .consixieration_.'_2---- : a short
pcrioo seems inadvisable for it may^ot allow tho second phase to run
fully, too lengthy a period may be^prbfitablo ■and
:
ovon harmfiuU-due to
and b(?racioni- Study only defoats its own
__ ond
----- if coniinucd whan fatigue and boredom arc caused not by a lack of interest
SninAhnh1 nG°GSSlty: Subjective signs of fatigue are mature’s"
warning that, a change of occupation or rest is neodod. Thar- are g me r f?rc:t°rorgies in markon which he can draw but only “at
1QQ
ofuciuncy - n the effort and abuse continue it will result
in over-fatigue which reduces the efficiency of worx. THErKFQhE
Some- for-a of relaxation should be taken for a few minutes in uv-rv
work should cease for two or throe consecutive hours in
a^ , one complete- day of rest and recreation should be reservea in
every week; and a holiday of t#o to three weeks should be taKon after
several months of work.
c)
Right—approach to the different subjects:
In the first place follow
gi/^a by tho professor or the text book. Bach subject doeiancls a methoo.
and approach proper to itself. Keep in mind the object of your study
as this is identified with one’s vocation. Tho more difficult ahd
— ossentlal tjnings should be mastered first, the rest follows easily.
2.
GETTING THE MOST OUT OF A STUDY SESSION:
a) Pre pare for stp-udy: A short prayer to calm the mino, and having
ready at hanu ail the material necessary for
study - text book, reference-book, pencils etc. - arc indicated.
b) Get straight down to work; Initial inertia will be overcome by
, ,
working by the rule of your time-table. The
x^rool?mof concontration is tho problem of the "will to worm" r
c) Be
------activo;
.
and methodical in your activity. Study is personal assidilation. Get an overall, view of the enLire
subjoct.
Road, with an Inquisitive mind. Try
M to recall, and reflect
inor-nt .(( "study
for
life" ■ so +L
’-'4 you
------ can
1on what you
’ vvg .loarnt
ou '-tn
"Study
for
life"
that
speak on it)
d) Study calmly: ii Above all,, let
us
not
hurry,
because
wo
have
ho tiiie
lot
becausetine
action, nnzic-ty, too.^KU
'l ./' Worry is antidote a. by
.'' <
(Dupuy trank.,
st results ar’j never secured by ;.uverish -.•□nergy born of the fear of failure .Build self-conf idencl ,^
byr
making the most of the powers with which you aro endowed, dtp as
well as you can what you can uo best. More ver, one should be a
a 1L„_
lit/bJ-o.
more, exacting in one's demand for proof oil one's own incomoeience.
nAallY’ lt’ should be noted that the proof of the absence of
ability is always longer than the proof that it is oresent. If wo
w
.Ofico porformed 1 task^that is sufficient prrof that we can do it.) '
G> j.rotoct your solitude: Your room and the set time of study must bo
„
,
,
considered as sacred. Neither the inaisirotion
you*’ work S nOr a ni8conceivod charity must be allowed to Interrupt
•F
E X AM!
2 1 C -i
4. MWIWW
THE £XA&IblATION B^
ITS3LF:S rSeli-resSd’toiy ^rX^^ToO?
dl^etio^in.-atudying^^. the days immediately
e^Tth^
---■-"brought about a state of overfatigue, you are HKely to be lacing In the
•n^c^ssarv ability and clearness of mind at the oxamination. It is fpxxy
er“ in l
So foots at tho last noamt al tho sxpsnso of ss.ioral vigour
In all ths anaftsre. If such hasty oramalng shoula.oy ohanco, prove hsiptul
xn ^nswerin^ this or that question, it proauces at tho same^timo muadlohcadedness, lassitude and weariness which will certainly afxoct one s per
formance as a whole. Koop in mind two rules:
'Vet a jjood night’s sleep before the day of the examination.
1) The deliberate cultivation
a Mightl; slated, but proyaixrng-y
2)
cool and collected, frano of mind offers tho ocst conditions for
successful p...ifornanco in examinations. Flurry ana examination
nerves may inhibit the more skilled operations of tho minaJ
remember to trust your mind and memory - they arc aclicately balance*-
Rc adj recall of known
1)
2)
5)
4)
learned) facts;
hamember the foflowing:~
xu,
is known may be inhibited by fatigue.
fa ar.
adversely
:—„ w affected by the inhibiting emotions
anxiety. (Cultivate coolness. )
Recall is blocked by a type of over* concentration of attention and
consequent restriction to the free play of ths Jiii'id over tha total
field of relevant information.
RECliLL
lixe assUilation, TxUES TIME. Tho studsnt s first concern
Recall of what
Recall is also
The orelVninarv oreparation of the answers to the whole of] the paper
sets in notion a process of revival which nay still go on kuncon
sciously) after our thoughts have turned to other things, f igubatu.
Iv one night say, whilst the conscious minn is concorned with
writing down the answer to one question, the unconscious mxad i-engaged in preparing the answer to tha next.
TEE WRITTEN SXAI4IJAT1ON :
n^i-nn- a mfir1 nairr will imply three steps: thin&ing, planning aria
writir- BefSr- w?iti^/wthing it is good to sKin through the whole paper
dotornfne its scop^ Sad tl airections with great care to hocone aware
of thb specific typo of answer expected.
WTV,P.,ont Iv the first reading of an examination paper, produce s a
(d «?*). /IX approx!^ Wo w..o
one should devote to oach puestlon*
• Teachers
” write as neatly ana as legibly
.
v as possible
.
--------- 3 Lhat are
tendency
’
to
ovoraark
no
a
t
papers
and.to
unaor-marK.
papo
have a
recheck it
or
di^fV'ult
read.
handing
m you/
’ pap^r,
messy
1
entirely;
odo to?h«
you Before
hnvo «.
all Wat
»ao
roquxroa ano Ln tho
way specified.” (Conti)
TBS. 0RA1. gWUNATION: Ta&o cars •to
ise
ds
Sori^stSn^^
and vague observations pa£e a
but al6°
which only causes confusion.
—.
' -—
Finally, <
f lonorance in the student s aind (. howevsr
much he may suspect them to be
a measure of paraenau.^ px ••••-■
/
) cCe/xOrv of an othorwise eyyn pl^JP’,
0 N
E X A M I N a T I 0 N S
attitude that ho is studyWhoeverr abouts the rather elegant
shows
complete ignorance of
oi .
for exams r’»ii
~
ini for life and not l-WaTU
eP^-ea and wll done.
the educational valuehe will not be prepared for eitner oi wnt uwu. xx
in all probability, he wni uu YconscieWioGl rWision, because we mjjst
examination obligas us to mj a conseientiousv^v^J0J’re®°^s® Wq thus
Questions
which
would never > onlv- —after an exam doo
prepare even those quo
stl?rLf\.w
^c^v<we
,-n-r+.«n
dooss
around arid do it more thoroughly. Often only alter
cover more lb ’ that he has really begun to know the subject.
a student feel
INTKODUCTION:
exam
pplies
definite
in pK^ that a oertadn total
student
date. The way to Hull, they ^ay,
P
obigetive - an intermediate goal
set to work each day with a wull-oefii
J
covering the entire syllabus)
on the road to his ultimate ae st mat ion [
° proprltt3 working habits
PREPARING- FOR AN dX/iMINATIONs
SZE, what
ROUTIj^E STUnfft
2.
not xpect too much.
PalnlaglJ,
“mo-To “t^
t ake
expect to learn 1------ -------t o be
absolute
ly
,p
c
rm
ano
nt
, pHne, and-bo iuS Oo’praparod td refresh his lemory Iron tine t|o . ■
sains, and he I
s<
Oi
4b, things he ^'■gg/Srihree, and only three, „a?B in which a fact
■, / -| \ -ba,,. r- notit,ion• (2) by using mnemonic devices; and,
method has its place
can be learned: (i
-rating relations. Uach mot..
to ho preferroo..
(5) by the perception of ^^s^g^Qthod. is in general
.
Xn^t is the quickest, and a^°^f^onic^cvices^J
brS^
do e-
S^^ean^rSX Xl^^^u^ects li^ —, provided the
eysrei does not l>-o“o^^Xrea,alns. -In every subject,
learned by being repeatedly brought to dlnd. buch^P^Xre^lent
bo Xee useful principles:
need not be’ ^“^XtlFl.^it h. Sore
Lhe cXot^. of1 facts -y^^ot - -orlted ^larger nature! systems
artificial soot ions
a)
t of the principles
of learning.)
and well distributee.
Jerlods of repetition should » rolatirely reref
— one sitting
b) ( Tn r-oetitivs learning the succus^ivo rep^u
la*
^aaing
_____tHan
J the
ire subject to a law of
grei^r'value.
enhanced by
greater value than the second, ano
^l^pcgiUons is
1-----sitings ano by decreasing thb
the number
ibo
“^IH^SBI^to^be^^^
i at
each. )
Sou^dternau
e ultb acts of
c)
SVre
to oc-f assimilation,
mistake „
is to
devote relatively
too mc^
,ocess
is
to C^vou,
little
to the nr
process
reception and relatively too
------devote at^east ^unit^o^
,Gn> }
\ snfc working rule is to o-. - operation of assimilation to every
5 Of
If it is true
3. REVISION:
--------- also true
re fro shin* 'the 'mino. concern- - •
noc. rienco the “^^^dT^oI&t/in-'ju-Tdo.tbo.otodo
obliviscence
facilitate revistop
'
1
is alroacly known.
■ be
' i designed to --------» '•Knid.hfhSiuKrstudJSUot
later slags in the process of
Ml) tePfslon’should not bo deferred until ashould ba distributod thrbu^hout
for the examinations, but
preparation i~•
notes which arc best,for
the whole course of study •
Tn general, the methods of taxing or rscor ing^t-oo^ aoapted
aCLaptg^ ior
for oiiccthe gene
Sain,ral,
purposes
a^bhote.XrredScWtheJrossnteo matorial
matorl
to
the
^iF-orS
reVrt
> to
_____
of
authors
argument andbefore
the
,, t i®
is det
detrimental to the acquistion o a
hasty
.crammingjust
a tost
ne r v o u sne s s which
lasting Knowloogo, ana,
i u or
does not help at examination
Topics dealt with in the present course
LECTURES:
—
I.
nf Medical Ethics
wh&t is MediCcl Ethics? (vs. mescal etiquette)
1.
Basic principles of Medical Ethics.
a total perspective,
2. The Concept of Health and social justice.
3. Health care priorities
relationship
4. The Doctor -patient
'oibility to the
- medical
individuax and community.
- the doctor vis-a-vis social legislation
- the nedical secret.
PROBLEMS CONHECTjmHJHE B3CTNNING OF LIFE
II.
Artificial Insemination
Genetic engineering
5.
6.
7.
III.
Abortion
PIW3LEwS CeNNEGTBD^2TF^SEXJ^rr]LAJmj^
Meaning of huaan s exuality
Contraception
a) Motives and methods
8.
9.
10.
11.
12.
IV.
Masturbation
Marriage oounBolllng ( e.g. VD of patient ana
obligations to partner; sterility, Inpotenoo)
integrity of the body and
OF THE PERSON.
15.
Mutilitation, sterilisation
psyohosurgery, psychotherapy, naroonnalysrs anc
Experimentation on human "beings
pROBLSMS CONNECTED
16.
17.
18.
VI.
homosexuality)
ppnw.nfaS C0NN3CTSD gITH THB —
13.
14.
V.
b) Morality
Ahn.' rr-alitry s exual Lty ( e. g.
Pci TH ^Hg^END OF LIFE.
The meaning of Death
' > the patient
Telling the truth to
life and the problem of Euthanasia.
Prolongation of -----
SPECIAL■SECTION.
19.
20.
Alcoholism and drug addiction
haemodialysis)
Transplantation ( Blood transfusion &
**********
1
JL'y/'
y
E X A M I N A I I 0
S
0 N
/
INIRODUCTioN:
dhoeve.r adopts the rather elegant attitude that h; is SuUi,*-*
ing for life ana not for exams shows complete ignorance
• ’r?5dune. "
the educational value
.
o'f
o;.xamlQation that is well prep-area, ana
In all'probability, be willl^n.ot be prepared for either of the two. a rM&l
examination obliges us to maze3 a conscientious revision, because-we ni a s t
a those
questions which we would never ask ourselves. Vo uh s s
prepare even
t
and do it more thoroughly. Often only alter awuxam CiO<J S
cover more ground
m
a student feel chat he has really begun to know the subject.
Perhaps the chief adyintago of, toe exam
.^OTl j_iGS iLI trie incentive i^ supplies
in prescribing that a certain total task shoula. be completed oy i ab'i’mi La
date. The way to Holl, they say, is pivid with vagUu lot jatibim. Iho stunent
~hiA^r eat to work each day with a w-'11-defInca objectivej -- an intu.i.\'i'icaiatd goal
that of coloring the eniirc syll.,ou£
on the road to his ultimate destination ( r
Preliminary adjustments eust be made to :aintain approoriato woi’Lin^ 5 -habitc
what
and a constant level of attention throughout the available ti-jo. t
has .boon said about making -a time-tablo ana reaping to it.)
1.
PR2PARIN3- FOR nN
EXAMINATION:
ROUTIN.S SIUDy: Whereas a student, ideally, desires to learn a buu,of •'
<v. facts quiexly, painlessly and once ana for all, he’ niust
■
'
■’
jtoo
.. qudi'ily.
.. \
rot expect too much. He must not■ try
to
learn them
He cannot
2.
expect to learn them quite painlessly, ana ho cannot expect .his knowledge
•
->
.
-i
.
__ i
i'i _
_x
1-.
v».-. z'!
zx +:■,.• o
A n . -V A •-.i/-'.
A + r> ijtq
to ‘ be absolutely
pormanont.
He must
be prepared
to
take V*his
■time, A-t^
taxo
./some paibs, and he must be prepared to refresh his memory from time to time
of the things ho already knows.
. Thero are three, and only three, ways in which a fact
ttfdan be Idamffcl: (-1) by repetition; (2) by using mnemonic dayicos; and,
(3) by the Sorco-otion of integrating relations. Jach method, has its place
^6 ana distinctive..utility. The third method is in general to oo preferredf
Often-.it' is-the quiefcost, and almost invariably'it yields the most; stable
organihatidri oi knowledge. The use of mnemonic devicos is not to be
7 des-'
pigj-G, ’ dad’ cap be 'Usefully employed in subjects like anatomy, provided the
‘ ’ system- db^S’. hot bo come Qvore labor ato .
can only
. ■" ’• ,
•nowovor, much remains, in every subject, which
- be 11'cArndd"by ■ being repeatedly brought to mind. Such repetitive learning
’"nAi-id
be c-onbiraly
nt ire Iv mechanical.
neud not/
not be.
mechanical, In fact, memorization is the more efflciont
the ■ le ss ■purely ropotitiyp it is. Here are three useful principle-s:
a)
dolldc.tions of facts may best OG memorized in the largei natural-. sy.stems
in the smaller vv
artificial
-sec.t'ions^
in which-thay arc found. rather than xla
-
iiito
tnoy* may be
into" which
which*\£oy
bo divided. ( 1his is a i-cscatem.cnt of the piincipl^to
+■ V. 1 ■' * T.T.V,
1 t-5j 1 •' inr.ih'<H
• -as
a a r-.-TA
tf'i
art’ nethod of learning. J
___
method
opposed
to thu ’’ppart
’.of the- ’ ’wfroV ’ i
'Periods o,f repetition should bo relatively bric-.f and vZoll aistilbuted. .
( tn repetitive le’Urhing the successive rophtitibns at any one sitting
ihb ill
first
l)ias
’ 'I
are subject to a lav- of di vinisbiag k- turns. .Cha
st reading
maaitix h
as
greater valuv than the'second, and the second gi-o iter yaluoi email the
d by.
•third. .’It follows that the utility of the rep.tmuis 12 cnflaflc-x_
by
augmenting the number of separate siitizigs ano. oy decreasing tnc num be 1
^ • •• .of re adings at e ach . )
’Repetitions should alto mate with acts of recall. ( The /.iosl coil* non
■c)
mistake is to' devote relatively too ’much time to the ^pi-oc^ es oi me i5e
reception and relatively too little to the piecess 01 ^assiiHilati on.
A safe working rule is to dpvote at least two units of time to the
’ operation of assimilation to every single unit devot/a to reception.)
•j
O'
'X.
■ .v
-
If it is true- that nothing is completely forgouton, it is
____ 7
___ ... of
...
,^.is of
also true that\nothin< is wholly
refro
sbiiig .. tbs r.ii’no. conc-jraobliviscence. rience the continuous ne^d for
7
,
ing what is already known. Two broad principles will guiao -uCp sthuoat.
(i) Methods of-routine study must be .designed to iaciiiLiAopjpviBi^i.
in
( ii)-Rpvision should not be deferred until a later■ stage
r1
" ' th J process
- — of
should
be
distrlbutoa.
ttWou
0hcu'..
-preparation for the examinations, but
— — —
t'be whole course of study.
’In general, the methods of taking or .recording notes which air bust for
the ma’in pu r'oo.so s of study arc also tifbsc that ar-j bet-t aaa.. ^-oa i-g offoc
al_ to
tive revision. Good notes are those that roduc r • tho pic
it •.-a
n W'j 11—or de re d statements of .e ssent ials. Eiaye vn ovoi'-ali picture- ca, •J: ...
authors argumont and then tr\r to fit in thervarious pnes. \
r'
hasty cramming just before- a test is do tr i cental
thv rcvult-n jh x .x
vbich
iti can open ihc
v/a;y
lasting knowledge, and, besides, it
-ho way
aui
i.
does not help at examination time.
3-
REVISION:
ax
I
E X A M I n—2—A T I 0
o
The first rule is: go to the exaiiin^tion with
a well-rested body and brain. If youi- lac a. of
discretion in studying during the da,ys !□ mediately\precoeciiag the ^x.r; has
brought about a state of overiat iguo, you are,
ly to be lacking in the
necessary agility and cleanness of mind at thh e-xamination. It is fc.x^y to
cram in a few ..mpre facts at the last moment at the -expense of general vigour
in all thQ* answers. If such hasty cramming should\by chance, prove ■•■helpful
in answering this or that question, it produces at the same time muddlehoadedness, lassitude and weariness which will certainly affect one’s per
formance as a whole. Keep in mind two rules:
Got a good night’s sleep before the day of the examination.
The deliberate cultivation ot‘‘ a Slightly elated, but prevailingly
cool-ana co lie etc d, frame of mind offers the dost conditions- for
successful p.rfqrmanco in examinations. Flurry and examination
nerves may inhibit the more skilled operations of the mino.. ‘(no
romember to trust your aind and .lemory - t-hey ire oelicavody oalanceo.)
4.
THE EXA^ILUTION ITbZLF;
■Ready recall of known (learned) facts;
huni'jTiibox the following: -
e.-D
’ 2)
Recall of what is known nay be inhibited by fatigue.
Recall is also adversely affected by the inhibiting emotions - fear,
anxiety. (Cultivate coolness’. )
3) Rec$il%is blocked by a type of over-concentration of attention anu
' * consequent restriction to the free play of the mind over the totai.
field of relevant information.
n
KDCALL
,
line
assimilation,
T/iKEb
TIME
.
The
student's
first
concern
4)
on entering the exaninaUion hall .should be to make provision for
the maximum possible time- to be available for the ’ process o^edall.
The maximum tine is allowed to the process df revival when qh initial
period is dcvotod;to planning the answers to the .WHCnE of t/no paper/
The preliminary preparation of the answers to'the whole- of. the paper
sets in motion a process of revival which maj/ st’ill go ;on •'( uncpn\ sclcusly) after our thoughts have turned to'-othor things^ Figufcativc’.ly, one night say, whilst the conscious mind ie conccrilcd with ’«
writing down the- answer to one question, the 'uncdlrsciou/d .dipd is
engaged in preparing the answer to the next..
';
:\
—
7S.. ,.
THE^MlTTEiSi Ta-iHI.NATION:
J
-i.
'
j\-
Doing a good paper will imply-three steps: thinking, •' planni-n^^nn
writing. ,Before .writing’ anything it is good to #skim through the. .whole/-papo-.
to do tc.pti inc itb scope, head the directions wit'h gr&at caro-.'to ‘ become,,, warq
. of thb* Specific type of answer expected.
■'
‘
Frequently, the first reading of an examination paptrr produce s a
paralysing effect: either at •no#'finding uno’s favourite quo st ^ns- thbro, ..
or simply because the paroicular..jis-scolu.;•ton of ideas nucoss.ary Lr the
answering of each question ha<e not yet o-s i arousoc , ana . s-, the ‘ ,ap a fooks'’
more difficult th ah it really, is. If one coup's cah, thaA f: jiing will spoil
vanish. If possible, startanswbrino tho easier qu-*eliolxS. Ahis Will
lessen the tension and help set in notion the associations necessary fur
the answering of the .more difficult ones,. /In case of tho oiificult questions
make a .mental or written summary (if permitted);. Fix approximately the timu
one should devote, to each question.
■ Finally, " write as neatly ,ana as legibly as possible. Toaohers
have ' a .tenclbncy to ovoreiark no at papers ana to undcr-aapk papers that arc
’nassy or difficult to road'. Before handing in your paper, rcchdck it
entirely; wsSte sure that yop have done all that was required, ana in the
y/ay specified." (Cent!) (
ilplt
: )
THE ORAL EXiUTTNATION: Take -caKs to understand tho specific point-.aSk.-d by
:———•
. thQ examiner,. The exposition and answers giust iixewifea
be precise and to the point. **>?norqA.itios and vague obsery-aticn's r.axa. a
poor impression. Lifeless slownsss-mnust be avoided, bpt also ^prqcipaticn
which only causes confusion. .
Finally; do not suspect your exaj.inc-r? nhpUdxaSrinatlon
is not a duel but a species of co-operation. "Tho exa-iiincr Ls noL cunc^rnoa.
to expose the bottomless pits of ignorance in.r. the stuu.ont s mind ( howe ysx
much ho may suspect thorn to be there). He is interested in the \1luL1l- yixls
of erudition which also diversify the scenery of an b.th'jrwiso oyon plain.
In this he relies on tae student to ho u.o him...
4
a measure •of pardonaol. prioo to
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1
PHILObOiTlY AND
- TWO. BRANCHED CF KNOWLEDGE
have all
r
no-joa
4-u Does 1science
->
-- the
— answers?
Can science give all the answeis.to the problems that a man faces, c"
1
■’
or to the
questions0 he is constantly
putting to himself? As persons committed
to
the
scientific
outlod^
? "" ; '
\ it is
gv-ou. to placu it m its proper
oersoectlvaproper perspective, and be conscious of its limits.
■KWHHH'r
and
j-mplieG knowledRu of facts (scientific kriowleeLtge)
■j.no -m insight rnto values (a philosophic intuition).
To know his duty, a doctor evidently needs knowledge ofl facts.
itO ku°w whapis the matter with the patient ("what is going on
Si6. l.l?nhlS/,con^iti0?1 can 136 influenced, improved. In oroer to know
nat^ io light and wrong, ho even needs to know what consequences his action
may nays for others, for the medical profession, for society, etc. 'io form
a moral judgement, the doctor needs infomiation that only science can give.
However, even the most complete scientific study of all the facts
□hat are relevant to the case leaves the ethical question still unanswered.
The sciences, in describing facts, tell us about the possibilities open to
man. x-i moral judgement, however, deals with the duty of man. It dials with
the question as to whether man has .any definite task in this world of pos
sibilities. Is_ there anything to be done, to be realised in this World as
described by the scientist? Is there any purpose in man's beinK in this
world? What is man 'meant' "to- be?" Has
”
’ '
existence
any meaning? What f is man?
Any moral judgement implies an answer to these questions?
2.
The question of the meaning of man is a ba»sic question today, It is the
basic question ol1 philosophy.
A. There are philosophers' (positivists, upholders of scientism)
who reject the very question itself . They believe that asming for the meaning of life is itself ”imeaningless". Tor them, all real knowledge ban be
reduced to science i.e. to empirical, <observational, knowledge. What goes
as philosophy,
science,
. - . they- say,
.. is either camouflaged
-.-x.-,
x.
poor poetry, or just
plain nonsense. Hence, they have only a place for science, and science can
only speak of facts, of possibilities, of 'usefulness*'. (NOTE: One can
understand the dilemma with which they are. faced. Thus, Bertrand Rtkssell
admitted that he had never been able to resolve the problem of how to in
tegrate into his philosophy the groat moral sentiments which he felt.)
B. Other philosophers ( the existentialists ) recognise the
meaningfulness of the question* They believe in philosophy. Science and
philosophy, they realise, are two different ways of approaching reality.
Though philosophy ana science are both efforts to know and under
stand the world in which we find ourselves, the philosophical approach
(method, attitude) differs basically from the scientific approach.
Science is observational. The scientist deals with observable
facts concerning man and the world in which he lives. His approach is that
of the onlooker, the observer. In describing the’nature of things* he
actually describes what he 'finds to be the case’, ’what is happening there',
’what may be expected to happen in this or that situation’.
Philosophy is reflective. It is man’s reflection on his own
being, his beine conscious - free, his being in the world, his being with
others. His reflection is a search for the meaning of human existence, for
the true nature of man, for the values to be realised in man’s actions
and attitudes. His question is not: what is going on there?.how explain
these facts? BUT: what does it mean to exist through and in these facts?
What is man? ^'hat does it mean 'to be human’? What does it mean ’1 to
to 1 be1 .
I
TWO SCHOOLS OF EXISTENTIALISTS:
3)
Questioning the meaning of life, some existentialists (Sartre) conclude
that life has no meaning. Though there is much that can be done . there
is nothing that should be done. Our being free has no purpose, no meaning.
’Living meaningfully1 can only mean: to live according to what you are,
that is:free’. ( "Remain free", " exercise your freedom, redeemed from the
slavery of established traditions and convictions, rejecting the ’masks’
society holds out to you." ). To them ’living meaningfully’ means: being
,no self, ^ny committment should be a free choice. ( Ono can understand
why life is meaningless, an absurdity - because this life, society, laws,
God, impose so many curbs on our freedom i.e the absolute- freedom the
existentialist dreams of.)
b) Other existentialists recognise that life has a meaning. Man's toeing
free is meaningful. There is something to be done, ^here is a task
which makes ’being-free’ meaningful.
QUESTIONS: Can science answer ube funuamental questions on man, has nature
*
the meaning of life, Goa, creation, desumy? Can we expect it to?
r
AM>n’tOtA.L
Med .Eth-2
WfflWIUMeM
INTRODUCTION:
The history of’ medicine offers many instances of medical
procedures which were considered medical curiosities,but
which become relatively safe and even recommended procedures for the
alleviation of some human debility or disease. Artificial insemination
is one of them. The ethical question is whether it is lawful or not, or
better, whether we have the wisdom, to exercise intentional and purpos
ive control over the generation of life. In simple language, cat? wo say:
artificial insemination is a medical possibility, therefore I can do it?
DEFINITION; Artificial insemination^Al) is a procedure which consists of
. 4
depositing semen, with the aid. of (instruments, in the vagina,
cervica±canapj or uterus, with the intention of causing pregnancy, which
by, ordinary sexual union, is deemed anliKaly or impossible.
Al is basically of two types: homologous, when semen is ob
tained from the husband (AIH); and heterologous,'when tho semon is sou
cured from a •donor (AID). When spermatozoa.of tho husband are confused
or combined with a donor’s seminal olasma (for greater soerm motility)
y)
the procedure is still called REH. There is also .iIHD or
or~G.il
combined
G.il (combined.
Art. Ins.) when the husband’s and donor’s spermatozoa are combined this is done more for emotional than biological reasons.
The common conditions underlying the election of one or
other types of Al include impotoncy or sterility of the husband, geni
tal debility or malformation in either spouse, dyspareunia (iu.diffi
culty or pain in intercourse) genetic incompatibility (Rh factor)or
hereditary disease.
.RDASONS .PUT UQRWiiRD:
In the case of AIH, the reason is that the couple
want to have a child of bheiroown, if they can,
In the case of AID: it provides an acceptable alternative to child, jssness in cases of a husband's sterility; that it allows a couple to have
a baby "at least half ours”; that it gives a wife the satisfactions of
maternity; that people can choose the sort of child they want!
WANING OF HUlAiN PARENTHOOD: To arrive at a moral judgement of this
■^complex issue it is good to agree upon
the meaning of human parenthood. Human sexuality is not merely a
function of bodily metabolism. Human beings both procreate ano. repro
duce, because through human coition two persons wish both to express
their mutual love and at least in principle to particularize it through
engendering a third person. Persons reproduce other unique, never-to--be
repeated persons. Persons incarnate their engendering love. Thus the
sexual union of men and women is never a matter of simple reproductic n
or recreation; it is always an evidence, when it is authentic, of a
loving relationship between them. Babies, naw beings like themselves,,
are procreated in the midst of their lovo for each other.
THU CASE FOR AIH :
%
When one considers the loftiness of the parental
vocation as an cssentialpart of marriage, ana the
immense joy of the' spouses who for yoars have desired' children and who,
through this manipulation, are able to receive their own child in an
atmosphere of genuine love, then zixji
aIH van
can bo
w juuuxxuuv
justi-fija.ns to the methqjci
of obtaining the semen of the husband (whether it be by aspiration from
the epididymus or testicles, or
b;. "aspiration
from ti-)sn riunva^ina"
immedlate~
»7 i « n 1
r* v»z-\ o v>
m
r > 11 a m
+ ; i v.K n r
r- i"! ' \
ly after coition, or by a cervical
spoon, or
even Kir
by ‘masturbation
1)
nona is morally wrong in principle. Voluntary ejaculation for justifi ed.
iagnostic aims doesnot constitlie masturbation nor doos it induce any
idrome of mastubatory attitudes.
THE CASE FOR alD:
Justification for a1H cannot be unilaterally applied
to AID. 2iID separates procreation from lovo in the
measure to wmeh neither donor nor recepient posits his or her act
within the sphere of a lo\e which unites them, In AID each functions, as
it wore, from "outside" the other, thereby putting asundsr”what God
G-od joined together*” when
v/hen he made love procreative. However,
Hovzever, to speak
this way about AID is not to label it adultery, though it is thus con
diderod by many courts of law.
*./e shall now consider the implications of AIL from
various points of view - medical, legal, social and philosophical before
arriving at a moral judgement on the justification or otherwise of AID.
(Incidentally, this discussion must show us how careful we must be before
we pass moral judgements,“and that in taking a moral decision affecting
his patient or a medical procedure, a doctor should not rely on his own
medical wisdom, but has need to seek insights from other soecialtios.)
-
.. . j/-
A
r
*
a)
a
MedSt .2
Medical implications:
Several meoical conditions are required in
tho donor. (1) He should, be in good health,
free from transmittable diseases, venereal or otherwise; (2) he should
be studied from the point of view of heredity (malformation, psychoses
in forbears or collaterals); (5) it is desirable that he should resemble
husband in physical and racial qualities; (4) if possible, his intellect
ual and moral qualities should be superior or equal to that of husoand.
as a purely medical procedure, AIL1 raises
sorbous moral questions. It is wall known that Al rarely succeeds the
first time, and that it is necessary to. repeat the operation over sev
eral consecutive months. For this the sperm must be frozen and preserved.
Now, are the parents justified in exposing "their" child to unknown
hazards because of possible genetic mutation9 Would abortion be tho
Justified ’next step", in case of a defective offspring? FUKTHAK, to
consider AID as a stop towards "progressive eugenics" is simplistic,
to say the least. It has been calculated that through random fertili
zation the e is a possibility of 70 trillion genotypes of offspring,
which amounts to 2300 generations of tho entire present population of
the entire world (figures given by Bentley Glass,DCIJDCF ax^L FTHICaL
VALUES quoted in ETHICS aND THE MEW MEDICINE, by Harmon L. Smith, p 8?).
Consider,further,that of the approximately 500 defects that are suspected
to be controlled by tho genes, wo have more or less effective tests for
fewer than 4 percent, and one wonders whether aID, purely from the medi
cal point of view, is going to give us superior individuals of the sort
areamed of in A. Huxley’s BRAVE NEW WORLD.
b) • .Le^al. implications: In certain countries, AID constitutes adultery,
and tho offspring is considered illegitimate •
Besides, many difficulties arise in the matter of property rights and
rights to succession. AID further-gives rise to possible falsification
of certificates becauso of the secrecy involved with regard to the
anonymity of the donor etc.
bocial implications: Several psycho-social conditions most bo fal
con so quc-nfilled in order to avoid unpleasant conso
ces. The® are: (I) The donor must riot_ toow/who
tho XTcduple
arc.
.
-_
. (ii) The
couple must not know who the donor :is.(iii)No
r
third party not bound by
the medical secret should be told about
bout the operation
operabion, (iv) There must
be a certainty about the deep and persistent desire of the- couple and
the stability of their home.
A number of questions naturally arise. Who
decides that the donor is the ’’ideal" man? On what does he base his
judgement? Is. ho . a man of superior moral qualities who for* a sum of
money calmly enter a doctor’s ejaculate semen into a beaker? Who would
without a sense of responsibility be a father to a child or children
whom ho would never see now have a duty towards? Further, what of the
social dangers of marrying first-cousins without Knowing it?
d) Philosophical implications: Gabriel Marcel, not^c French philosopher
has characterised tho whole procedure of
AID by two words : grotesque and burlesque. Another commentator- has sug
gested the Same when he says that we could cast a slur at an AID chile
by calling him a "son of a test-tube". The fact is that AIL supporters:
(i) forget that AID is not a simple operation like a blood rransfuslon;
and forgets further that it has psychological overtones for the hus
band. To tho husband- the child is a stopchild, a constant reminder ■
of his own sterility. The AID child will have an extramo offset on
the marriage itself by signifying achievement of motherhood for the
wife and failure of fatherhood for the husband. ( In this connection,
adoption is a far better solution.)
(ii) deny tho value of marriage as love particularized in procreation.
The AID child is the fruit of a process not of love.
(iii) base their reasoning on a false philosophy of life: "every man
has a right to be happy and thsreferre to do as he pleases". The
view is sometimes put forward that every woman has a right to
maternal fulfillment. Why, it has been asked, no one thought of
the right of the husband to paternity, and suggested an anonymaus
#egg and womb" donor xnx to receive his semen in case his wife
is sterile?’
c)
f
4
ARTIFICIAL
INSEMINATION
Med.Eth. 2
The point is that, by definition, personal fulfullment can
not bo a private affair in trie context of love and marriage, nor can
it be achieved outside, the sharing, involvement r.nd participation of
the other. Through love and . marriage a man ana a woman become husband
and wife - and husband and wife t ru’
mutual love want not a child
but our child. Paul Ramsey puts it as follows: Men and women have
no unqualified’ right to have chilaren. It is simply not the business
of medical practice to- enable every marriage to produce a child by
any moans. ”■ ;(efr. LINAGRE QU/iRTERAY, 1971, p- 19)
3 51 Vfc#* J’'
5
Moroov6:f',: in view of the population explosion and a growing
number of homo loss and otherwise disadvantaged cnildrcn, it i.s at least
nrguable- that AID is socially irrssponsible and that adoption, which
allevlates.the needs of both childless couples ana parentless children,
offers a prof rablo' alternative to involuntary childlessness. The argu
ment that ■AI.i gives, the wife th/ satisfactions of maternity may bo
countered by • he. fact" that fecundity moans more that breeding, and
that the seri. ,js throat -to marital harmony and love caused oy the radi
cal asymmetry whereby the wife has achieved motherhood but the husband
has failed ijo achieve fatherhood, should weigh very heavily against nID.
of
A MOKiiL JUDGE fid NT: (The formulation/this moral 'judgement is ,chiefly in the
words of Harmon L. Smith in his book ETHICS AND TEE
MEDICINE p. 8j ff.)For the present, and in view of (1) the way we
have understood sox and marriage, (2) what wo know about Al, and O)other
social and psychological factors which impinge upon this action, the most
responsible (not to say the only) response appears to be a qualified ’’yes”
to AIH and.a qualified "no” to AID.
Id the case of/iIH, there is no moral question of
adultery in. asmuch as the unitive and procreative dimensions of human
sexuality are preserved. Moreover, a child thus conceived and' born ie in
every Sense truly the ;fruit of the union between this husbano. ana wife
who are parents both biologically and
.nd pe
personally,
r so nal ly . ns for the morality of
the methods foi" securing the husband's
ana’s semen, ora
ncnj, r_:t
__ L
not even masturbation,
is morally wrqng in principle.
A ;
! AID, bowsver cannot be similarly ’ justified. nlD sepa
rates/procreation from love in the measure in which neither aonor nor
recep’ient posits his or her act within the sphere of a love which unites
them.’ilhis' is not to..-.say that AID is adultery in the conventional sense,
nor dyen in the. sense of carnal lust. But it is lust in the sense of
ivy, or co vet ou sne ss that best characterizes the moraJ. failure of alD, for
is‘argued that, d woman should nut be depriv js of the self-fulfillment
of maternity just because she loves ana is marxi/d to a man who happens
to be sterile. Further, parenthood is not a natural right and in the
light of the population explosion and the growing number of homeless
children one can at least argue that AID is socially irresponsible,
because adoption would satisfy the needs of parenthood and parentless
children at the same time.
Finally, in view of the fact that it is estimated
that up to 150,000 living ixmoricans owe their births to -il (TIMS, 196b 9
Feb. 25, p.48), and thdt about lOpOC pregnancies per year are being- :
achieved through Al, ;one could go /ith the statement made by the' author
elsewhere (p. 167) arid in another context, that ” medical science and
technology have- developed many possibilities for which we have not yet
developed the ethical wisdom and moral stamina necessary for exercising
humanely responsible -control.”
•: '•
-M- * * -M- -M- 4$
Topics deaIt with in the
IK’-
I.
resent course of Medical Ethics
—TURES :
mat la Medical Bt6lc.7 (v».
etiquette)
1. Basic principles of Medical Ethics.
total perspective,
2. The Concept of Health - a
and social justice.
3. Health care priorities
4. The Doctor -patient relationship
-medical-oibility to the
individual and community.
- the doctor vis-a-vis social legisltat ion
- the medical secret.
PROBLEMS CONNECTED ^ITH THE BEGINNING OF L1FE
II.
Artificial Insemination
Genetic engineering
Abortion
5.
6.
7.
III.
PROBLEMS CejmPICTED
Meaning of human s exuality
Contraception
a) Motives and methods
8.
9.
10.
11.
12.
IV.
V.
h) Morality
Abnormality sexuality (e.g.
hoaosexuality)
Masturbation
nomas. oouMOlling ( e.g. TO
patient and
obligations to partner; sterility; i: mp. o t en c e)
tntecrity of ths BODY and
PRO BL ElViS CONNECTED ffITH THE
OF THE PERSON.
13.
14.
Mutilitation, sterilisation
psychosurgery, psychotherapy } narcoanalysis and
hypnotism.
15.
Experimentation on human heings
PROBLEMS CONNECTED
16.
17.
18.
VI.
S EXUALITY A?-'U MARRIAGE
fflTH, THS END OF LIFE.,
The meaning of Death
Telling the truth to the patient
of Euthanasia.
prolongation of life and the problem
SPEC IM^^ECJTION.
19.
20.
Alcoholism and drug addiction
haemodialysis)
Transplantation ( Bloofl transfusion &
**********
A
*■
>.
. . ___ Off Tm mwtng er izfe
( -^tracts from THE DOCTOR AND THE
THE SOUL
SOUL
1.
by Dr. Viktor Frankl.M.D^
PvTtv 1u'?t'OpS cMracterize human existence as such- man's snirU.,
f°£^utydT*fSPlr3-t“alltr of U
i. 4 thing-to-duft:
■'
is irredycible. Freedom means freedom in the fare r ?wU6 nOt sPiritual; H
instincts; (2) iHhur-ited disposition X
three thinSS: (1) the
no ftieaiis merely a«eroduct of here-'itv
• nvilon®ent- Thus man is by
element; decision.-' ^ult?L?efv deoid^
ihere is a third *
his conscience and-to God.a
i S f°-r himself Kespohsibllity - to
sot ‘
,.2.
unbiased
“F“ »
ESJ^
we may
^61 inn*
c
as a
we-feed the nihilism tcv
S^rS“ if
being free.
the will, is for the
xu ^xPeriG'rtcs of himself
r
oi- the will must either be
or {suffering from a para-’
his- will■ as having been
as rwe. r£Bp't!rso-“iL'r'a°f/S°Ur‘‘: to h',S an
i»PpiUs.irb-«j™L“%a
able to
(P-
Jhete
and guilt stands and falls' on our belief ri?"
' -----accepting a3 fated limitations th- „
1 niiU G tru&e capacity for not simply
character; on his ''eaoaci fv tv r.
. OOI1&tr>aintb impose, by race, class or
him shape-his destiny ar.d^lifo. ^fpr 1fl)'taOm iaSt'Qad a6
challenges bidding him
falsely becIu8e“itt5efer?iiXely1to'3''lif8»UUi't1
13 to Put the question
general toxmis -is
-■
' son's own" existence. We must’ IL tw
concrete!v- t.„
..„;.?ue.&Hoa
a" and not concretely
to "eachSerk> CJ
m
A rt V, 4
- . _
entirely new twist. To wit^ It^is^ltr0 question of the
meaning
ofn • life
----- ) an
the last resort, man shoSd not Lx
qSk3
of ra.an. In. ■
■'«
rasponsiolu; he c^ ^y answer tp by
■
bottom alwaysKpro8enta.and%haS.t'^ accomplish in lifQ is at
powers...The individual mgft' comprehend Pff1G1Plu 16 always within the man’^
I ^h of^his tasks. The tore be
his^sponsibiiity to accomplis?
af<iHi^fUi hiS -!-ifs"“will appear'’"to him While'th?3,
L iii’c, the more
of his responsibility simplv takes Tif« h 1 th nan'"who is not conscious
bLmX'lZ10 tO SeQ lifG'aG
sssiXint; SFL^Jol! SXiStBntlal ^ysis
nfea?LafebT.LSiLn%gLa rp
;
the task comes. They, experience the taskStJ^Sauthority from which
them. In, our opinion we have hers an estL ?
L .has a-eslgded the task to
ss*®«
the taskmaster, (p. 58-^9? The r • n j-iaSkS’
also as being rfesppngihif- +o “
For th .ana ^hat?s-is';alco aware of the tlskm^stlr +LtaSir’ but as a mission..
L A^sands of years that source’has been Ln a ’ LA5 e°urce of his mission.
nLhLrLLnr^r^0-with —of^^-;uCrsLLc-LSs
5. CONCLUSION :
endure almost any mode
is just this: to find his wL t
uniqueness and singularity of his about learning
ean reP17 th?-t his primary task
T'ropor task, ■ to advance -towards the
what he ought to be frL
szrbjh“ Mi" gt >>
^or^» how a man is to so .
■
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Living. ( ftnISv •ilu.ati.oxi opy othuis-," says Kogdrs, Ras not a mjlcm. 101 ms»’’-) •
Hl.pl-.-'nag .t.p ■po.camr ix, moagi >1.: for him-suif ■-.( "f.. rm tho one who cheosss'.
.-...who i...; tcfmi'rjs s' to., v Ih-mof hn^c xpe-r ioncL lor me."')
:5-
111 iomaas.'t'?' 11 > - his iif.. ... . .? .1 - L'.ap ant . in a LLu.l ;, on-goinr pioc-sss.
'• ! in. pwhi.ch K. A s covLinualiyp msoovpriop now as;,-...pt g/.of h± list if in thb
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iyya’ cotol-oxity of procLes ( "J ’ban’pt . i^lw '^y o ' unuc r st
>-■ 3s’ to ois’-H c^pa anar-ionecs (fuolings
of • t1- . ■
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: -i,,.
r;.'■- : .op.?£i to th; b.:^ OTIC.; with al Infinite striving.. c:;
c/ - -p.
-P/V -ig t-V ;t">" i<V ouojopr, ("V'S is a tbihkiag i^odT' -"rascal) .' ■
- ? a--. -I ! it-, i plgO.’ .blTitr-y - atii sb apas- M's awa cijstr'iny
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TfiO BLANCHES OF ANUWLFDG-b
Does science have all the answers? Can science give all the answers to the problems that a man
faces,
putting to himself? As persons 00^^outD'HfT '
good to place it in its
-- pioper perspective, and be conscious of its limits. :
Any moral judgement implies knowledge of facts ( soi ent i fi r.
\
and an insight APAo_Zaluu^_£_a phi lo so phi c intu i t ion) .
mowleuge./
He needs to^kS^whtt i^th-iuatt-?th^hW
^owledSe ofl facts,
there"), how his condition cpm
patient ( what is going on
what is right and wrong he ?ten nec-IFfa’ lmPr2ved- In o^aer to know
Xt p
2.
The question
the- imoaning of man is a b.isic question today.
Question of t.hn
Jt is the
basic question of philosophy'
'philosophers' (positivists,
Cdphiloso hGie?hS i*Q* °°
amPirical,* oSeSvationLrkLSdge^^iJrgoes
meaningless"
poilosophy, they say, is either camouflaged science, poor poetry* or lust
Pihitn°n1Senr; Hence’ tbey ^vo.only a place for science, and science c^
J sPe^k of facts, of possibilities, of 'usefulness". (NOTE: One can
With
thQy are. faced. Thus, Bertrand Russell
..dmitu^d that he hao never been able to resolve the problem of how to in
tegrate into his philosophy the groat moral sentiments which he felt.)
.
B. Other philosophers ( the Existentialists ) recognise the
ruaiungiulness of the question. They believe in philosophy. Science Ld
xjhxlooopby, they realise, are two different ways of approaching reality.
, 4_,
Thou,gh_ philosophy and science are both efforts to know anal underWc find ourS'STves, the philosophical approach
(method,
(i-^Lnou., aut±uuat) dixfurs oasically from the scientific approach.
Science is observational. The scientist deals with observable
facts concerning man and the world in which be lives. His approach is that
of the onlooker, the observer. In describing the’nature of things’ he
actually describes what he ’finds to be the case-’-, ’what is happening there’
what may be expected to happen in this or that situation’.
Philosophy is reflective. It is man’s reflection on his own
being, his being conscious - free, his
]
‘
being
in the world, his being [with
others. His reflection is a search for the meaning of human existence,, for
‘.-1 1 i 1
G
b . T'n::.
V ■. • • 4 : ’ • .
-i .•.
v. I
4- 4 ,,
L,
the uPue nature of man, for •f-.h
ther \Tvalues
to be realised
in
man
’s ...actions
and attitudes. His question is not: what is going on there?.how
there?..how explkin
explain
those facts? BUT: what does it mean to exist through and in these facts?
What is man? What doos it mean ’to bo human’? What does it mean ’to be’.
TWO SCHOOLS OF EXISTENTIALISTS :
a) Questioning the meaning of life, some existentialists (Sartre) conclude
that life has no meaning. Though there is much that can be done, there
is nothing that should bo done. Our being free has no purpose, no meaning.
’Living meaningfully’ can only moan: to live according to'what you are,
that is; free’. ( "Remain free", " exercise your freedom, redeemed from the
slavery of established traditions and convictions, rejecting the ’masks’
society holds out to you." ). To them ’living meaningfully’ means: being
oneself, ^ny committment should be a free choice. ( Ono can understand
why life is meaningless, an absurdity - because this life, society, laws,
God, impose so many curbs on our freedom i.e the absolute freedom the
existentialist dreams of.)
b) Other existentialists recognise that life has a meaning. Man’s being
free is meaningful. There is something to be done. ■Lhere is a task
which makes ’being-free’ meaningful.
QUESTIONS: Can science answer the fundamental questions on man, his nature,
the meaning oi Ine, ooa, creation, destiny? Can we expect it to?
MEDITATION
FCR THE MINISTRY OF HEALING
FROM THE PARABLE OF THE GOOD SAMARITAN
’A man was going down from Jerusalem to Jericho and he fell among robbers,
who stripped him and beat him, and departed, leaving him half dead...1
Let us Pray:
For all who start the day in health but end it in pain,
Hear us, 0 Lord.
For all who suffer injury at the hands of others,
Heap us, 0 Lord.
For all who reveal their sickness by placing material things before human
values or moral principles,
Hear us, 0 Lord.
For all who reveal their sickness by being insensitive to the pain and
distress of others,
Hear us, 0 Lord.
And for all who reveal their sickness by brutality and greed,
Hear us, 0 Lord.
’Now by chance a priest was going down the road; and when he saw him he
passed by on the other side. So likewise a Levite, when he came to the
place and saw him, passed by on the other side,’
Let us pray:
For all whose lives are dominated by hypocrisy or ignorance,
We pray, Good Lord,
For those who practise their piety only before men to be seen by them,
We pray good Lord.
For those who say ’Lord, Lord’ but do not the will of the Father in
heaven
We pray, good Lord,
For those who are in need but are neglected because they have no voice
to cry for help,
We pray, good Lord,
For those who are in need but are neglected because those who can help
avoid responsibility,
We pray, good Lord.
’But a Samaritan, as he journeyed, came to where he was, and when he
saw him, he had compassion, and went to him... 1
Let us pray:
That we may be blind to race or caste,
Open our minds, 0 Lord of Truth.
That we may be led to those in need,
We ask your guidance, 0 Lord, Good Shepherd.
That we may see the needy, wherever they are.
Give us eyes, 0 Lord our light,
That we may have compassion,
Live in our hearts, 0 Lord our life.
That we may goto those who need us,
Order our footsteps, 0 Lord our way,
•And bound up his wounds, pouring on oil and wine, then he set him on
his own beast, and brought him to an inn and took care of him.• • • 1
1
1. PRAYER OF A DOCTCP
Thy eternal providence has chosen me
to guard the life and health of thy creatures.
May the love of ray art inspire me always.
Do not let my spirit be confused by greed or thirst for fame
and distinction,
For they are the enemies of truth and of love.
They might easily divert me from my great purpose:
to look after thy creatures .
Let me always in the sufferer see the man.
Give me strength, time, and energy
to improve and extend my knowledge.
The field of science is great,
but we do not know the limits of human reason;
it penetrates further and further;
today it discovers many errors in what I yesterday
thought I knew,
and my knowledge of today may tomorrow appear to be
full of defects.
God, thou hast chosen me
to guard the life and death of thy creatures.
Here I am, ready to follow my vocation.
2. PRAYER OF A TEACHER:
Lord God, merciful and patient, grant us grace, we beseech
thee,
ever to teach in a teachable spirit,
learning along with those, we teach,
and learning from them whenever thou so pleasest.
Word of God, speak to us, speak by us, what thou wilt.
Wisdom of God, instruct us, instruct by us, if and whom
thou wilt.
Eternal truth, reveal thyself to us,reveal thyself by us,
in whatsoever measure tho wilt;
that we and they may all be taught of God.
A
-2-
Let us pray:
For understanding and skills which are useful for healing, and for
those who employ them,
Receive our Thanks, 0 Lord, Great Physician.
For medicines and salves and drugs, and those who develop and
prescribe them,
Receive our thanks, 0 Lord, Great Physician.
For beasts and carts, for petrol(gasoline) and ambulances, for
stretchers and bearers, for drivers and attendants,
Receive our thanks, 0 Lord, Great Physician.
For homes and hostels, clinics and hospitals, rest houses and
shelters of any kind, and for those who welcome strangers in
their midst.
Receive our Thanks, 0 Lord, Great Physician,
For those who attend the sick with loving care, nurses and aides,
orderlies and therapists, housekeepers and cooks, physicians and
all other healers,
Receive our thanks, 0 Lord Great Physician.
’And the next day he took out two denarii and gave them to the innkeeper,
saying, 11 Take care of him, and whatever more you spend, I will repay you
when I come back J” 1
Let us pray:
For all who are concerned for the welfare of others,
We praise Your Name, 0 God for we can love only because You
first loved us.
For all who support the work of the ministry of healing and care
throughout the world, through the Churches, through the government,
through volunteer groups•..
We praise your Name, 0 God giver of every good and perfect gift.
For all who administer the gifts of others as good managers of your
work,
We praise your Name, 0 Lord, who is the same Yesterday, today,
and forever.
For the ability to see, to serve and to share, and thus to become
neighbour to those who arc in need,
We praise your Name, 0 Lord, Who not only has commanded, but
has enabled us to ’go and do likewise’.
I
LI; ibioLi-^nte of
■ft fWHHt 4f- # ->
1.
MAN IS FREEDOM:
•, ’i'h^istlo Philotwpny
of Lille
Philoof
Liio1‘ - Hi. nxiotential^cm
4$
J-* -iHr -W- 4i-
-ft
-if-
-ft 4J- -Jr -JH*- * # #45-* 4Hr44- 4'r4f- -k4t- 4(- 4<- 4<- 45- 4(-4HI- 46-4i 4;-4F *
Man is a conscious-frue-bein^ (’’has intellect and will).
’Consciousness’ refers to man’s ability to ’recognise1
- ’identify’ - what he perceives ( basis of science) and to ^reflect’ on his
being-in -the-world-with-others ( basis of philosophy ).
Consciousness implies freedom•
When you become conscious of your being here in the
classroom, together with others you somehow 1distantiate’ yourself from all
this; you find it all ’before you’. In ’stepping back’ you ’free yourself’
from this world to which you belong; you ’transcend the world of facts’; you
become ’free1.
This ’becoming free1 (from the class, yourself, the others
implies the ability to ’take a stand1 with regard to this ’world-before-you1,
that is, the ability to-‘respond1 to accept or reject, to act (to admire a - '
dress, to hate or love a-person,- to open or close a book).
This’being-conscious-free’ constitutes the essence of
man: Man is freedom.
Freedom does not mean:
a)
b)
c)
freedom from physical force ( even in a concentration camp, man can remain
truly human i.e. free ).
freedom from moral obligation ( a doctor doing what he knows to be his outy
remains truly human, i.e. free ).
that you could have done something else too ( the mother rescuing her
child from fire is tryly human, 1*0. free in her action, even
though ishe could not have acted otherwise. )
If you would say ’i’ll love you for two weeks’ you
either talk nonsense or you speak of something else than true love. The moment
you become deeply aware of the other, of his needs (e.g. like Christ did )
you cannot but respond to the other, to bis needs. Still, this loving concern
remains truly human, Le. truly free.
Lt •
We exercise oui’ freedom necessarily as this or
that person ( man, woman, teenager, talented
etc. ) in this or that situation ( in Bangalore,1970,studying at the College,
etc. ). We can change our Situation; we cannot act independently of it. We
can change; but we cannot act xoutside history’ • Our freedom is incarnate’;
it is the freedom of this particular creature in this particular settling.
2< MAN IS11NCARNATE1 FREEDOM:
At every moment of our lives we are ’what we have de
come1; someone who can be described, identified, recognised. (And we want to
not merely as something.abstract: 1 fellow-men’
be accepted as what we are;
■...
classified’
-'-/we
At the same Time, however,
we rightly refuse to be^identifled1 , rcla*sifie
(
consider
the
painful
experience
of
someone
who
is caught
is ’that fellow’
Key-hole,
in
the
eyes
of
others,
he
is
reduced
to
a, "peeppeeping through a
’
who
is
free 1;
,
that
is,
as
one
’
Lng-tom”.) We want to be accepted as persons,
with an open horizon of possibilities; who is able to free himself even from
himself; able to be ever new.
3.
MAN’S DESTINY: LOVE AS THE REALTSnTIQN OF FREEDOM.
Man is not born to ’have things’(only the onei who is
a slave of his desires will place his hope.on1having things’; a civilisation
civil
dominated by material things and by machines leaves man unfulfilled).
Man is not born to ’become something’ ( only +•the slave
of his ambitions will place his hope on being something, e.g. a big manager;
uanmgJ-e bt>; .•
he will discover that, just being this or that is meaningless)
to free himself from the
Man is born to love, i.e., tv
tyranny of pride ano. concupiscence in the
thu encounteruncountei’ with the other (|man,God);
(man,God) , 9
in the acceptance of the other of which the emorace is the expression(having
place foi" the other which is not the same as ’having use for the otl/r
other’ ).
at-the-world
To bo truly human means:: to be ’’at-the
—world 1 (recogni- *
belng-with-the-other’ (acceptance
tion of the world as ’object for action’) in 1 bof the other as person). It means: to become-of the true reality ana to respend in truth,free from distorting slavery of pride and concupiscence. It
relationship;creating
moans: to encounter the other; entering into an ’I-Thou’ r^
the Me’ (in family, church,factory,etc.) building up the Kingaom of God:the
Kingdom of love; the true society of men.
EMERGENCE OF GOD. The universe,which
finds CTrtrt
its oafulfillment
in man,
4. "rTHE
X-------------------- - --- ----------------- zrtr------------ • -O
A - ... n r-,
on onaw^f Kq ^,^10*rldO17---blem'
/to
love
God
except
through
the
medium
of our
It is impossible to seek God,
_
’
this
same
medium. ii
•
I cannot r< nlise myself except thru
I
j
Wed. Apr.5,‘72
SYMPOSIUM ON MABTUKBATION.AND HOMOSEXUALITY
A brief summary of the,main paints.
A.
MASTURBATION:
1.
In adolescents:
In adults:
It is a normal manifestat ion of adolescence
- due to the adolescent’s inability to resolve, satis
factorily, the conflict ho/sh: experiences between
tho demands of the child and that of the adult- It
bespeaks lack of control of the emotions d of the will.
- may be due to unusual conditions (periodic masturbation)
- si^n o$6n-completed adolescence (tinged with narcissism)
2.
Effects:
- recurrence in a durable fashion can be
(a) duo to intellectual weaKnoss (senility, cerebral
atrophy, alcoholism)
(b) a sign of schizophrenic dissociation.
It is not the cause of physical or mental illness, but it may
be a manifestation of psycho-neurotic imbalance, as sulch,
indulgence in mastubatory activity only rc-inforces tho
imbalance. (Dr. Viktor Frankl speaks of a ’’mastubatory hangover"
- a sort of guilt because the act is not ”goal-dir ct ed”)
HOWEVER, masturbation is an act of infantile .i /eois
‘ sm^m,
sexual immaturity, and is not altruistic* Thus, it
may make Intel personal relationship, .•specially with
the spouse in marriage, difficult.
5.
Treatment;
Education about true moaning of human sexuality. Ecujcation
of the will to self-control; inculpating s^lf-confid.cncc;
setting ^ high idcals^to break ogo-cetitricism.
Masturbation is not always a sin, but is always a disorder.
Doctor/counsello!’ should allay excessive ^uilt or fears,
but should not condone it, much less recommend it.
B.
HOMOSEXUALITY
1.
Homosexuality has many causes and is of several typos.
A distinction should be made between:
Homosexuality: cases of long-standing overt sexual Activity
with prcfercnco foi the same sox.
Homophilia:
marginal erotic friendship with a member of the
sam sex without indecent behaviour.
2.
It is not an illness in the strict sense, but a defoctivc jfunctioninr-;
that calls for medical and other help.
3.
Ethical homosexuality, or homosexuality by choice is sinful.
Homosexual perversion of the young is also considered a crinc.
4.
Treatment: There is no HEAL treatment, but through sublimation and
anagjnctic methods some cases of overt homosexuality can
be reduced to a latent form. This should bo consiaerca
a therapeutic success.
3
Undue moralism■(and labelling a person ’homosexual’)
can load to further phobic anxiety. Doctor should help
patient to find mouning of human sexuality. While he /
cannot encourage what is against the principles of
morality, he should neither obstruct the proccs^ of
healthy transformation by unduly insisting on a moralism
of principles.
...
v
<
.
’■
,
b
i
|
HUi,AN GUINEA pigs
by D. ■. M. H. Pa ,opwoi' th
(Penguin Books)
THE PROBLEM: For several years a few sectors in this <
arc3 in
y..r.iiCd hove been trying to bring to the country
attention
of their
practices Vptu2?bln9 aspect of what have becor.-“ commonc
experiments mPtchirfly‘ St -The£S
concern
di St IJT'hi nr
1. •
Z-
b L P^l-l^nuS, Land the aspect which is
of medical knowledge, many °linvrian^aor ZGa+ tc,ext?!?ci tbG frontiers
of the fact that
Be
tt3nlP^arily to have’
lost sight
individuals with common rinh^t ’ S " experiments are in all ebses
be cured. As a resul? J
m°St C"SeS Sick PeoPle h'’ 'ping
’
to
“riSir'1 to taite ri;‘s''bb
■°™onGNGrenco
fOT thk
ose patients are
J
CO'V-'int1Tfr''+P'e’ °r 001 aWare 9t all> and to whir'
they would not
distr-ss Which Yi”efn awar&; t0 sub^ct -hem to
■
nt
a
+ hXCr''S a.Wn
lo. ln no Wsy necessitated bv ana baa' 1 and physical
no connexion with,
21 - rhfi ’'■’-sease from which they are
cas_~ deliberately to rotate the reewverv
+i Stiff ering
■-----J’;and in some
investigation of -1 n-ir+i
->»> ' i'PV"'T>
The i diseasea sc that
_
J
1 'J Pai titular condition can be extended.
(
(p.15;
on,but thereIm-j'f,t 'be’^^wl^ged1^^ 4 I™11 )CIiriiCe 1 research must oo
must go
2) SrSoStJ of^gcs'^Inr"
moral integrity,but an expanding
Pati^s*
-a]4y.^exKt^t!^5
P■ e?rch acpwith ths ni9ilG^
illegal practices. 3) Unless
- me-'"--! re'S-.x'r'
un9'tb.icsl and probably
unethical practices of this mino-itv th^nnh?-665100 ltself stcPS tne
such as to cause cppcs:-Hon +0 °n ri’^h6 Pybllc outcry will eventually be
"It behoves the nedlc-’T
/ • 1 cUuical research (p. 18)
y
The primary st.p
‘rscofnidlf?l^Gpljbli? lnt° lts b^i«nce.
the morel dilemma - do exist fir «lMrt. h»b
'!°-aI pro''lens ~
from many sources, "in the^nd'we haj^tn^ "22 2^riCe c?n'b" W*
do exist to the search for knowledge." (Prof u'a FrtS
’
UnV£
WHAT CONSTITHES A JU3T1?'TABLF EXP^HT? •'"h
^wyer) ((p.2G)
P.2O)
mdicme is something new and siniste^^ i + \ science of experimental
experimental
m our minds the old faith. tbaTTv^ tt ’u
( ?S..C6??fcle of destroying
patients whom we have unriertaken^A^X??^"!"^.?1?? servants _3f the
11
be violated. "(Dr.S.S.Ketty)
or the lives
■■ ■05Uvl?:^“n,
experiments only after due
(p'pi)^ safety of the subject mest ^ever
ifHgnedNIouAX'’torirelieveOor cCre^1^ sen-^<BEverY act of a diefor
of an easily justifiable kind^ TbA
?„pablent 15 experimentation
doctor's hands is evidence of
''"ti -' S fldCei!ient cf himself in the
one wnen the acts of trie physician vAA J*® pcobiem becomes a knett
V
of the patient present but toward'^ rT+i ?1+°C.teu not ■t°'"ard +he benefit
requires the exnlicit consent
1 ln 9eneral- Such action
more than this ;it requires Prof;unri"t^^^ga?enh Italsb requires
part of the physician
? Tght ?nd consideration on the
cases so great it 1
not r^-oA-rp-?1‘jles 0' IBa^icine are in some
adequately informed a-' P the <T1i1‘'"P01eXp2?:' tn'^ the Patient car be
His trust in the physician muv V-p1^1^^1005.hat his conse- t me ms.
"We should,! think for
° CaSlly to Sdy
(Dr.Beecher)
patient which is net ’ geAeraIP ac?^?^65’1'69010 anVthin9 done to the
therapeutic benefit or as loXil 2+^2^
feei2? 'for his direct
as constituting an e. perimrn+"nP c ?f •+'rj
diagnosis of his disease,
Of the term.ex^rlmJn?^
(p"?
t*hin thP scti“
.ujic^.m . UProf.McCance-Prof .of Exp 11 .Med.)
?
'
‘ f11 ’ -■
:
■ i
-v
• it
1 & s'
/ yXu^.Wff>» n., rniMWjl ■• one hunsan btaina is in dlsty.^s ,in rr ed c-vfno^or
being is concerned and
to'assist him The
R Theirs1’’e^h^rp!
rende’ it precipitate their relationship.
~ friends nun?'l ^?flon®hlP between two I.'s, like between two lovers,
‘
c
CaUed S“Ch 3 -l^ionshlp .the’
^r^IAN:~1NVESTI^TQ^;;:The.Physician-patient relationship of cns who
4c\-l "S exP2-1,llents. of no immediate value to the person uncidr- observation
s impersonal and objective because of ths- character of th"Research
'
hFHFbe SwecFiFttFo1? ■ 'SF °? "!,iCh ,th0> “set- BW even
' '■'n suoject in’ the
ho iOepXFilF
no+ th-^ suMoc-fF i iFFFf
,?v-grammatical
rY
»»sense.
"^eho
nF ain
nS -^ha
* ®
to eliminate every subjective factor, invoked by the drive fo"
outl^tS^toSogrFpSr10"’ cbj=t’lvitv is the password*tteo^h.
FhhFFF1
mto
‘f1"5
Fts T a Fr9a
£i4,F? “FSFtFr"1"5'
P0Sltj-0n ls entirely different if there is no
b^-kjtlihooo of ;he patient himself benefittinn.
men+o^can^Sodufi "v+r^133^ feiatiYelY innocous to the hardened experiSF?? SUb’Gfed .t toothing he'dpf 'net unFrFf J
"
recorded’ in ^dief rub 1’tr
Y
subjGc.ts of GXperiments i.. rarel
Fid F f B f
s-o"a-" - FFSSiF
vFE FFSni«£°' ferFpF?edyFl$
Md
of’the liv-'r -hould b- F
•
imental purposes. E.g."Needle bioosy
-hould be regarded as potentially fatal. Five hundred ‘
firPt~to b^Y’bm ?errorms,d without incident,only the fiv- hundred and
iFdFtFn.FSK-F/f
?r!
V
f
3
3
“
"'
f 3 --- aa a°'b“ -
3ndThEsFo?nFeUdFLrrP°iSOuaFFtn9 riSl<; ■’"tVi9"ta of tba ?aU“rt
be ^-ard th~t pvpn^v-ii lit
- everyone will agree, the viw should
ir> *^ n4-: V’1^J1119 ano ln-ormed patient may not bo morally
IFFaS Fs FSF"9 FF?inhFakb n «" be "lalntaineFtF? -y
own health or lif- ' "Th™ t-i
’’f1 ~ tC rUn undue risks •vith his
Physical or n^Ocht Jt
then,has no ri^ht to involve his
they entail serious destrSitlontut^ft eXpG;rirnent or research when
Pius XII Sent
+ T fuctl°I?>mUl'ilation,wounos or perils," (Pope
H1US All,Sept.1952,to International Medical Congress) (P.41)
^toLcarry^tU^;tDofLfnHAlnT7f:/v+2Y exP,?rimerits are defended by
tc thl D-fiYn?t; n+h 1
grounds that while admittedly of no heire-nts.^nmft n., t0 KlftnHnF F'eoSFFf F/F .”4"^
p™lent3"notFFFr1?™e?1"ant-a’en?*JClally ^"sFous’ofsFn’unFspectlna
hope of makLgtcitnt^icCditoletS3tS%hin9 lnVy sti9aty5d ’ so1g1y in th®
emd the pursuit ot now er- \ X •> •
S’t "'51GnCe 1S no^
ultimate qood,
precedence ov^r morS y-knowl^9e should not be allowed to t. ke
Which is.notluncXonlv ibi/tere dhe tw !re in conflict. The statement
inter.--^nn it
h ?
amonp resea®ch workers,'It woulF
" 9 ' know »though natural and,doubtless,frequently true,is
wlw (fatWir jiMediral gulktm
OStGAN OF THE CATHOLIC MEDICAL GUILD OF ST. LUKE, BOMBAY
Editorial Board
Dr. A. C. Duarte-Monteiro
Mgr. Anthony Cordeiro
No. 86
Dr. Juliet D’Sa Souza
Dr. C. J. Vas
SUPPLEMENT TO THE EXAMINER
May 13, 1972
IN SEARCH OF A CHRISTIAN MEDICAL ETHOS
'By Fr. Denis G. Pereira
Chaplain, St. John's Medical College, Bangalore
We must now explain the word ethos. An ethos is
A T a time when codes seem outmoded and almost
/“^inoperable, and ethics seems to be little more different from a medical code, or from medical ethics.
than a convenient way of doing business, jwhcn Whereas a medical code provides the framework for the
secularism is making inroads into faith, and religious acceptable form of behaviour that would safeguard the
indifferentism is gnawing away at the entrails ol reli doctor, the profession and the rights of the patient ;
gious fervour and practice, it is an awkward question to and medical ethics would represent the systematisation
ask : “Is there a Christian Medical Ethos ?” But, of moral judgements involved in making medical
in an age of searching — inexorable, rigorous, incisive decisions ; an ethos is the value-system that influences
and honest — this question must be asked by every the formulation of both code and ethics. The ethos is
sincere Christian doctor, if he is to find meaning in his the way a man experiences, sees, and relates himself
being both a doctor who is a Christian and a Christian to, the world and to his fellowmen—is his fellow-man
a thing, an object, to be manipulated and used for
/ho is a doctor.
j
,
o
_
j
an
international
meeting
of
self-aggrandisement
; or, a rival over whom he must
About 20 years ago, at
Christian doctors at°Tubingen, Germany, the question gain ascendancy, exercise control or wield power ; or,
was posed : “Is there a place for continuing to run a neighbour, his neighbour, one who makes an impeChristian hospitals?” Whereas some, among them
------ rious demand on his love and respect, one for fwhom
L„.„. ‘' Chris- he must' care in his need, and for whose benefit he must
clergymen, challenged the propriety of; having
tian’ hospitals, the assembly came to
t_ quite
Z the opposite strive to ameliorate the social and ecological conditions
conclusion at the end of the meeting. The assembly of living ?
of Christian doctors felt that there are problems,
It seems obvious that in arriving at an ethos parti
mysteries, perplexities connected with healing, living cular to his profession, the doctor should consider not
and
and dying,
dying, to which
which secular
secular medicine has no
no answers,
answers, only the existing code, but also the convictions and
and upon which the Christian Gospel of the death and ethical behaviour of conscientious colleagues. But,
resurrection of Christ does throw light.
we may well ask, is this ‘medical ethos’ to be restricted
Is not this the perennial question we keep posing to to a lowest common denominator ol accepted values?
ourselves : What difference does it make that one is Can a doctor be satisfied with an ethos based on a
a Christian? Does his Christian faith make him a moral values (if one could truly speak of such), on
better, or different sort of, doctor than his non-Christian values determined by the utility-,, or, efficiency-, ov,
colleagues, leaving aside their respective technical profit-, principles that so regulate a materialistic
competency or diagnostic skills? A Christian doctor society? Can an “everybody-does-it”^principle form
must answer this question if he is to find the meaning the basis of a justifiable medical ethos ? Is there not
and relevance of his faith in his professional life, and room for a Christian medical ethos ?
accept courageously and cheerfully the challenges that
an increasingly secular climate of opinion and attitude DIMENSIONS OF A CHRIST. IAN MEDICAL
/ill inevitably pose to his Christian conscience.
ETHOS
When speaking of ‘difference,’ we must beware not
A Christian medical ethos must spring from the
to think in terms of ‘better’ or ‘worse’. The question, Christian faith. It must spring from the understanding
as C. S. Lewis rightly suggests in his book MERE the Christian doctor has of his vocation in the light of
CHRISTIANITY, is not whether being a Christian his faith. A Christian physician who models himself
makes you a better man than someone else who is not, on Christ—whom Christian tradition has given the
but. rather, whether being a Christian has made you singular title :
The
Great
Physician — would
a better person than you were not a Christian. To obviously have a set of values which he would not have,
use a commonplace medical analogy : to ask whether were he bereft of this faith.
To a great degree, the
Miss Buxom is healthier or not than Mr. Pehlvan
1. The Concept of healing :
because she takes Multivits and he does not, is a mean- formation of a Christian ethos would dependIon whether
ingless question. The real question is whether there is a Christian concept of healing. It is to be
Miss Buxom is healthier because of the Multivits than noted that a very specific
,
sign
\ ofrthe
-1 Kingdo:
^’ - ^m of God,
she would be without them. T
Hence,
T
we should
1
11 1
be- mentioned1 in the
1
Gospels, is the healing of the sick.
asking ourselves whether the right understanding and Even the forgiveness of" si
sins is linked with the healing
Go, sin no more. Your faith has made you
living of Christianity makes better persons of us or not. process. “Gi
c
i
i
s
r
... i
ii il ____
In the same way, would it make a difference to the whole” (where ‘wholeness’ refers to total well-being,
adequate
definition
of
health).
Is
it too
doctor’s understanding of his role and mission in life which is an
that he has accepted the challenge of the Gospel,
"
much of a surprise, then, to note that the ultimate
through a personal commitment to serve his ailing injustice
‘ J
is
' described,
1
*’ 1 among
others, in terms of refusal
neighbour after the example of Jesus Christ ? Obvi- of health-care : “I was ill and you did not come to
ously, we are speaking not of the nominally Chris- my help” (Mt. 25, 43) ? A Christian doctor through
tian doctor but of one whose vision of Jesus, the his work of healing shares in the mission of Christ ;
Great Physician, brings him to see his calling to be a he proclaims the Good News through his ministry of
doctor as a mission ; of one who takes seriously such- healing, thus extending the frontiers of the Kingdom of
like sayings of Jesus to his disciples (among whom he God, or, if one dislikes the triumphalistic overtones,
counts himself) : “You are the salt of the earth. . . makes the kingdom more present among men. In
you are the light of the world.” Such a doctor would this ministry, he is God’s instrument, doing God’s
legitimately be expected to ask : Ts there a Christian work of redemption. Both his personal life, then, and
medical ethos ?’
his dedication to his healing function, must proclaim
70
SUPPLEMENT TO THE
EXAMINER
May 13, 1972
the presence of God.
Besides, he will accept the the right spots, and on responsible persons in public
obligation, before God, for the health of the individual office, to ensure that health-justice is provided for those
for his total health as a person, and, through him, for all who, in his Christian conscience he feels, must be
those who need his care. He is, in a word responsible cared for, and when such care can only be provided
to God, and responsible for his fellow-man’s health, by public agencies. To give an example : concern
and is bound to provide the best ministration he can in for the rights of the unborn, in the face of liberal abor
tion legislation, must make Christian doctors want to
the situation.
This last phrase may sound like a pious cliche, but, do something about getting a different sort of social
as a Christian, a physician must ask : “Before God, legislation (that would, for instance remove social
what is the best ministration in this situation ?” In stigmas like illegitimacy) passed, and about working
other words, can one rest content with the status quo for the setting up of counselling services for distraught
of current medical practice and accept the ‘non-choice’ women seeking abortion and Homes where, they may
approach that characterizes so much of today’s medical be helped to have their babies with dignity and without
services? Is the Christian doctor — and, by extension, “fears.”
The Christian vision of man, as it is worked out in
the Christian medical institution and the Church(es)—
to view his medical mission as meaning ‘to provide the the community of believers, must further influence the
best care to those who come to him,’ or, must he go development of a Christian doctor’s ethos. This
further and assume responsibility for those, too, who understanding of man will bring special light to bear on
do not come because they are either ignorant, or can’t some problem-situations, such as those which come up
afford the fees, but are in fact most in need of his care ? in genetics and human reproduction, medical experi
Our Christian concern must determine the way we mentation and the dying-event. Further, it will affect
fix our priorities. A pediatric Mission-hospital in one’s dealings with one’s patient, and the respect due
Africa had an excellent record of service and of care to him coupled with the obligation of not taking ad_1„1______________ r___ 3________ ______ 1
provided to every child that was brought to it. At the vantage ofr this 1helplessness
to feed one’s greed. T<.
It ...:q
will
same time, during the 50 years of its existence, the determine the nature of the medical secret, the obliga
infant mortality rate in the area served by the hospital tion to respect the conscience of the patient, and his
remained at around 282 per thousand births. While right to know the truth about his illness.
2. Other dimensions : One could bring within the
providing excellent care to the children, brought to the
hospital, its authorities had failed to provide basic, scope of his Christian ethos the doctor’s obligatior
life-saving care to the numerous children that were to, and relationships with, his colleagues, especially
dying of ‘neglect’ in the surrounding area. It’s excel the junior doctors who have to set themselves up. Too
lent doctors were too busy saving a few at the expense many doctors enter into> a rat-race for patients, and
of the many. In terms of costs, one could say that the bigger practice, at all costs! Not merely professional
cost of saving one child on whom, say, the equivalent decency, but effective charity — really caring enough
of Rs. 500 was spent, whereas, if the same amount was for one’s colleagues, and their welfare, as to want to do
diverted towards providing even basic medical care, something about it — should determine right relaten children instead of one could have been saved, tionships. Is “group practice” a Christian answer ?
was, infact, Rs. 500 plus 9 deaths. We need specialised Or, entrusting part of one’s burgeoning practiceJ to a
hospitals and specialist doctors and excellent care; junior colleague? Each Christian doctor must find
but we also need to think in terms of the greatest good his Christian answer to the demands of love in his own
for the greatest number. It is a case, therefore, not of life situation.
“either-or” but of “both-and.” Incidentally, in the
Still another dimension is the Christian doctor’s
above mentioned case, the infant mortality rate was relationship with his own family. Elis absorption in
brought down to 78 per 1,000, within five years, through his work, whatever the motive he professes, may make
the action of a concerned pediatrician, newly arrived, him not care enough for those for whom he is obliged
who requisitioned the services of 15-year old girls, to care.
Further, living as he does in an underfrom the local mission school, to provide the basis of developed country, the Indian Christian doctor cannot
health education and health care. (This is a line of absolve himself of the obligation of thinking in terms of
thought and action that GPs., with a 1large and com- the needs of the country and the community, in fixing
fortable practice, could fruitfully consider). We need whether he is going to specialise or be a G.P., whether
constantly to re-evaluate our concept of “service” in he will practise in the town or in the mofussil, whether
the light of the Christian imperative of “caring.” he will serve in the country or go abroad (to get job
Perhaps we would find plenty of which to be ashamed satisfaction, or to ensure the security of himself and hL
family).
This is an ethical decision from which the
in our “service.”
The Christian’s one guiding law is that of love, which doctor cannot escape, for, in fixing his “priority,” he
someone has paraphrased as meaning : “to care is determining the measure and quality of his service
To be, in India, an U.S.-qualified
enough about others as to want to do something about and charity.
it.” How does one “care enough” in a Christian way neurosurgeon, may mean that one restricts one’s service
especially when we know that needs will always exceed to a microscopic minority, composed in the main part
resources ? There are no ready answers, but we must of those who live in the larger metropolitan centres,
keep asking ourselves the question, often an agonising and who can afford the fees. Of course, the country
one. One suggested criterion for helping us fix our needs specialists — but the decision to be a specialist,
priorities is that of the “Poor.” The “poor” are not or not, must be taken in accordance with his Christian
necessarily the poor in any simple economic sense, but vision of the demands of love in his life-situation.
Finally, his Christian ethos must make him care
rather the neglected, the ignored, the rejected,'the drop
outs of society, those who are not cared for and to whose enough for himself, giving himself the time to relax
care no prestige is attached. Where there is a pioneer and to pray, to build up the resources of his faith, so
ing need to do this, because nobody else will give that the frustrations of growing in age may not make
.attention to it, then it is a Christian calling. As Chris- him a cause of ennui to others.
Conclusion : The Christian doctor, indeed, must
rtians our particular, though not exclusive, concern is
ito care for those who are not cared for ! Each Chris keep searching for a ''specifically Christian medical
His, faith, which he must ever strive to keep
tian doctor must listen for this specific call of God, in ethos.
•the secrecy of his heart, to such service within the alive, must make him view his task not merely as a
profession but as a calling, a mission, i.e., a ‘being sent
Framework of existing situations.
Another aspect to this ‘service’ must be considered. forth’ to carry out, in its total sense, the healing work
Tt is not always, nor only, a question of what a Christian of Jesus. While loyally giving ear to the teachings of
•.doctor should do in terms of individual service. Prac the Church’s Magisterium, he must remember that he
tically speaking, much, in a developing country, has too is a partner in listening, and active sharing, in the
lo be undertaken by Governmental agencies. The process involved in making moral decisions relative to
medico-ethical problems. He must be .preChristian responsibility of the doctor, then, would also complex
x
.•consist in exerting himself to bring pressure to bear on pared to, and, in fact, conscientiously ask, the daring,
SUPPLEMENT
May 13, 1972
TO
THE
EXAMINER
71
if upsetting, question : ‘‘What more does God expect That is the risk involved in the search ! But the search,
from me?” “Am I really caring enough so as to fix the in Christian tension, must go on and the Christian
right priorities according to the mind of Christ whose doctor must be prepared to act according to his Christian
minister of healing I am, and to the promotion of whose insights. A medical ethos based on such Christian
kingdom I must dedicate myself?” Many questions Searching will certainly make a difference—hopefully,
are unanswerable, or are not immediately answerable, for the better !
THE FAMILY DOCTOR
(An Eulogy)
By Dr. Fred Noronha
J T is perhaps no exaggeration to say that no greater the family he treats, he often can and does detect the
I honour responsibility or obligation can fall'to the presence of an unwholesome environment or unhealthy
lot of a medical practitioner than to become a Family trait or attitude on the part of one or other merriber of
Doctor. For such an assignment, he needs not only ^e family. It is not uncommon for an alert family
the scientific skills of his profession, but also human Doctor to avert or nip in the bud, by his timelylinterunderstanding, courage, wisdom born of experience and vention, an abnormal situation. Many a consciencmotional maturity if he is to provide this unique service
Family Doctor has saved an emotionally insecure
t”his fellow-men. The Family Doctor is not a mere child from future tragedy, effectively diverted a floundehealer of disease, he is also a friend, confidante and "ng adolescent from the path of delinquency, success
counsellor to the family he treats. He is, in fact, a fully advised against a hazardous marriage, averted
pXfieged person.
In his traditional role, he not only suicide in a depressive, restored an alcoholic o sobriety,
-endeavours to prevent and cure disease, whether of helped an elderly patient to lead a happier life despite
ciiucuvMtA
r
o
nprsnnal his disabilities and performed a hundred and one in-
srxYrars
"“'iv" "“’ue "“ip wi,h
him each of them is a person and, he attempts not only
family made possible.
to consider the physical and psychological problems of
The Family Doctor is often faced with the sadder
his patients, but^Jo to view each of them in his correct aspects of medical practice^ Few problems are more
erspective in relation to his environment, occupation, distressing than those presented by the patient with an
sodal milieu and genetic constitution, all of which may incurable or fatal disease. With tact and deep underhave a bearing on the health of his patient and, through standing of human nature the Family Doctor knows
hhn on the health of his family. He gives them intelli- when, what and how much to say about the illness,
iiiiii, on
j
cvmnnthv and nnrlrr- to his doomed patient. The dedicated Doctor has
gent and humane care with tact, sympathy and under
succeeded in brinmne- warmth and cheer to the
standino- For him, the patient is not a mere collection oltc.n succeeded in bringing waimth and cheer to the
atanuuij,.
r
avlelno- frnm dk- patient and his family in such situations. He has to
of interesting signs
■> P'
J . . . emotions draw heavily on his humanity, mature judgment and
ordered func ion, ic .
bodv mind and intuitive talent on such occasions and be careful to avoid
be. F—y
>» - -.jasyta-g-"
might be a n lan lag ■ solemn bedside conference or an ominous frown For
A dedicated Family Doctor brings to the ailing patient Examples could each of them cause untold harm to
and his anxious family a feeling of confidence and
anxious patient of his relatives. Yet he, owes a duty
security. Illness often creates problems foi the patient tQ
patient to encourage him to prepare himself for
and members of his family such as, interruption of daily
bQth in the material as well as in the spiritual
domestic or occupational activities, financial embarrass- pjane \vfien death occurs, there are the survivors stricment, fear, anxiety or depression. Moreover, i Iness kcn witfi grief who also need his attention. Often, he
sometimes profoundly alters personality or constitutes need not do or say much jn sucfi a situation, His mere
a threat not only to the patients bodily integiily, ut presence and a few consoling words may help lighten
also to his status in society. A person m such situations tjie|r sorrow and feelings of helplessness.
often seeks the help of another on whoni he can re y
essential difference between the family Doctor
as a trustworthy friend. 1 he family Doctor ulhls and his other colleagues lies in the former’s professional
he need admirably.
attachment to the family he treats . He is above all.
The Family Doctor’s grasp of the patient’s personality, a personal physician to the members of the house-holds,
background, hereditary traits, environment etc.,, places and jjig service is personalized.
From this relationship
him in the unique position of being able to know his there flows a two-way traffic between the Family, and
patient in his totality, a fact which enables him to the doctor. Genuine affection, mutual respect, loyalty,
evaluate symptoms more accurately and intelligently, confidence and trust in the doctor on the one hand, and
and often to diagnose an illness early. An early diag- concern, sympathy, professional integrity on the other,
nosis generally implies less suffering, speedier cure and Such is the foundation on which a most fruitful doctor
less expense to the patient.
patient relationship thrives.
Strange are the psychological attitudes which some
Some people, unaccustomed to the ministrations of a
patients adopt when ill. Some appear to take a secret Family Doctor, might conclude that such an entity does
delight in illness and resent anything that threatens not exist save as a figment of one’s imagination. The
their invalidism ; others refuse to face facts or bellittle fact is that changing patterns of society and a variety
their symptoms ; others again, try to adjust their dis- of other circumstances are creating an atmosphere in
torted personalities to the environment by one or other which the Family Doctor can no longer function qua
of those devices known to psychologists as “mental Family Doctor and may soon face extinction. On the
mechanisms,” and so on. These phenomena are not other hand, since no other system of medical care can
susceptible of solution by the use of precise scientific fully and satisfactorily replace this unique institution
methods, but require profound experience of human it seems reasonable to expect a resurgence of the Family
nature, and some degree of maturity to probe beyond Doctor in future albeit in a new garb.
The family
surface motivation and behaviour, see accurately and Doctor of the future will, like his predecessor be a nondeeply the problems of another human being and tackle specialist and very human General Practitioner who will
them satisfactorily.
care for his patients and not merely treat them. He
One often hears of tragedy stalking unnoticed, in will of necessity, be equipped with superior training and
certain families, merely because its roots were not knowledge, and adapt himself to an entirely new pattern
detected early enough or not at all. The Family of society. He will steer clear of all those influences
Doctor has a grave responsibility in such situations, which tend to turn him into a superb technician fit only
Fitted for the task by training and practical experience for the practice of a soulless medicine and preserve the
as well as his intimate association with the members of truly humane character of his noble profession.
72
SUPPLEMENT
TO
THE
EXAMINER
May 13, 1972
and associab°n with the activities of the Guild. She
vJU 11^17
l^lLLVv o
a]so referred to dedicated work of Dr. Menino De
Our column ‘Guild News’ was held over for want of Souza in several spheres, civic, academic socio-cultural,
space in the past three issues. A brief account of some and political, particularly in “fund-raising” for several
of our activities during the last quarter is given here:— charitable and educational causes. His Eminence, ini a
very eloquent reply, thanked the Guild for their greet
Annual Mass
■
ings, and good wishes. Tracing his associations with
The annual Thanksgiving Mass to celebrate the feast the Guild from 1938, he congratulated the Members
of St. Luke was held at the St. Xavier’s College Chapel for maintaining a high standard which was due in large
on Sunday, 17th, October. The Rt. Rev. Dr. Simon measure to the Presidents and the Committees. He
Pimenta, Auxiliary Bishop of Bombay was the celebrant said he was particularly happy to read the Guild
and preached a very impressive homily. The frater Bulletin regularly since 1949 ; Stressing that the bul
nal repast followed at the college cafeteria. Welcom letin was indeed ‘an accomplishment,’ he exhorted
ing Bishop Pimenta, Dr. A. C. Duarte-Monteiro, our members to see that it appeared uninterruptedly. Dr.
President said that in keeping with the past tradition Menino thanked the President and Members of the
the Guild took the first opportunity to invite c’—• Guild for their felicitations and good wishes. He said
new Auxiliary—representative of our Patron—as Chief he followed very keenly the activities of the Guild and
Guest. His Lordship then spoke in glowing terms of congratulated the Committee for the progress they
the good work Bombay Catholic doctors were doing; he had made in recent years. He said Dr. Duarte-Mon
said he was happy to be admidst them and offer teiro, who was Guild President for four long years
prayers for the living and the deceased members at the was greatly responsible to give it a ‘new look’ and a
Thanksgiving Mass. Dr. C. J. Vas, Hon. Secretary “good shape.” Dr. C. J. Vas, the Secretary then pro
proposed the vote of thanks.
posed a vote of thanks.
The function—punctuated by recorded music re
Biennial Meeting
After breakfast, Members assembled at the College freshments, and variety of games for young and old—
retiring President
was'in **•'
the
to be quite
an enjoyable
one due primarily
council room • The
aav* * ***
. * >*-******<**■**■*
*>*■ Chair,
*-?*.*y*‘*— ■ "proved
_
~
~
,
* to
The Biennial report printed for the occasion reviewed ^he efforts of the ofiice-bearers, and assistance, of
the activities of the Guild for the two years April 1969 Drs
D1'S-- Terence Fonseca, Miss Carole Duarte-Monteiro,
—"4 Duarte-Monteiro,
Duarte-Monteiro, and
anJ young
--------- Fonseca
17 ------to March 1971. The audited 2
Statement of Accounts, Denzy!
ay henceforth
as well as the Report were duly approved and adopted. This rn
may
henceforth turn
turn out
out to
to be a regular featui
At the elections that followed, following Members eons- of the Guild, to enable members with their famihes
meet at a get-to-gether
tituted the new Executive Committee:—
- — during X’mas Season, and orgaDr. Juliet De Sa Souza, and Dr. Eustace J. nise sports, games,; or X’mas-tree for children.
De Souza were elected President and Vice-President
respectively; Drs. C. J. Vas,• (Mrs.) F. de Gouvea Pinto,
FIFTH ASIAN CONGRESS FOR CATHOLIC
(Mrs.) J. N. F. Mathias and Terence Fonseca, were
DOCTORS
re-elected while Drs. Olaf Dias, Miss Charlotte de
(Bangkok—1972)
Quadros, Miss A.C. Duarte-Monteiro, and F. Pinto de
Fifth Asian Congress of Catholic Doctors will
Menezes were elected as new Members. Messrs. C. N.
de'sr & K?wereTc^ppo7nt^“audito^
A.’£ take place in Bangkok, early in December this year.
Duarte-Monteiro thereafter thanked the retiring comwill be reca led that on the occasion of the IV Asian
mittee for their assistance, and dedicated service Congress held in October 1968,, the assembly^ had
authorised the Catholic Physicians Guild
rendered during the two years that elapsed. He xunanimously
recal
President
for
foui
ye^rsf'and
he
felt
"f
Thailand
to
organise and play host for the V Asian
led that he was T
- - - to -his
• successor in a
Congress.
happy to hand over the Guild
very
An unique feature of the Fifth Congress is that plans
good shape, judging from the activities undertaken,
financial stability, solidarity as also relationship with are formulated to include it in the First Ecumenical
the Junior Guild. Fie then vacated the Chair in favour Conference of the Catholic Organization and the
President Dr. ~Juliet ~
De Sa Souza, who thank- Christian Medical Associations in Asia, jointly sponof the new f
•
sored
ed all members for electing her *unanimously,
andby
asthe Asian Regional Executive Committee oi
sured them that she would maintain the high tradtions the FIAMC (International Federation of Catholic
established by her predecessors. She referred to the Medical Organisations) and the EACC (East Asian
dedicated service rendered by Dr. Duarte-Monteiro Christian Conference), although with a separate pre
life, full of vigour and colour to St.
who gave a fresh
f
A Tentative Agenda of the Fifth Asian Congress is
Luke’s Guild. The meeting terminated with a prayer
outlined
here. Further particulars of the First Ecume
and vote of thanks to the Chairs.
nical Conference, as well as of the Asian Congress of
Cardina! Gracias and Dr. Menino de Souza Catholic Doctors will be given in our subsequent issues.
Tentative Agenda.
Felicitated
A special function—Tea-party—was held in the Subjects for discussion
Junior Gymnasium Hall, St. Mary’s High SchoolI
1. F.I.A.M.C. Status and Bylaws (as amended and
Patron, His Emi- approved by the Convention 1970).
Mazagon to
felicitate
our
T
(a) Membership problems (National Organization
nencc, Valerian Cardinal Gracias, on his Episcopal
Silver Jubilee, an also Dr. Menino De Souza on his and Fees).
being the recipient of Papal Knighthood. This
(/>) Regional Executive Committee problems (Meet
function was fixed for the 23rd October last, the 71st ings, cost for travelling, duties and obligations).
birthday of His Eminence. Unfortunately he was not
2. (a) How does the work of your organisation
in town, as he had to attend all Sessions at the Synod benefit from F.I.A.M.C.
of Bishops from 30th September to 6th November.
(Z>) How can Catholic Medical Organisations in
On his return after five weeks he was caught—to put Asia benefit from one another.
(c) Closer relationship between Doctors, Nurses, and
it in his words—“in the stream of deep anxiety for the
r* .
M
1
1
fl * . .
.1
•
x
1
future,
” The TIndo-Pak
conflict
and
circumstances
that Para-medical workers.
followed. Despite the fact that, 2nd of January hap3. Closer relationship among Chirstian Medical
paned to be a day when there were fseveral other func- Organisations in Asia.
(a) Joint Regional Conference ?
tions in the city, St. Luke’s Medical fraternity mustered
(/>) Joint National Conference ?
quite a good strength with their families and children,
(r) Joint National Committee ?
in the nature of a large Family Gathering. The Presi
(rf) Joint Activities of National Level ?
dent Dr. Juliet De Sa Souza, gave expression of the
feelings of joy of Members, and offered felicitations on 4. (a) Election of Regional Executive Committee
behalf of the Guild to the Cardinal and chevalier for Asia.
(Z>) VI Asian Congress—Where ? When ?
De Souza. She referred to our Patron’s keen interest
• 1
. •
•
T'M
•
1
•
. 1
Z^l
‘TRANSPLANTATION - THE MORAL ISS'US.
our
INTRODUCTION:
?ave5bLTJop?PaUvc or helped to liye
p
?o ns.oot of V6SU8, ol lOkOf
for the present, is precisely ths etmeax x-su-o
1. M5DICAL APPLIANCES:
a) Prosthosea:
Those arc mainly of two kinds;
i) Removeable o.ge dentures
11) Built-in o.g. fnVW^crplaC3K10
’
b) Artificial organs;
i I ^onroorarv OeX- hoart-lun^ u.achino, a.^ti
i) ^mpor-uy
a flcial ^iJnoys, etc.
11} Built-in;
so far none arc available
fox* human beings, though
an animal has boon fittol
with an artificial heart.
of
S
-®e S s;
hold in .all medical practice -
2. TRANSPLANTS:
The sc arc of three sorts:
that taka place within the
a) Auto-transplants: We those
skin,
I-Lbody of the person himself o.g. l
cartilogOj; bone.
b) Homo -t ransp 1 ant s
i -a . those that take place from the
------- - t0 that of another.
body of one person
include*
organ
These
- blood transfusion,
kidney,
llvdr^i
grafting o.g. of cornea,
heart, etc
otc0o
j that taiic place from the
;: ioGo thoseanimal to that of a human
c ) Hetoro-1ransp1antsbody
of an a
parson c eg. sex-glands, organs (incidentally- the first heart transplant
ov^r pot
performed,
was that of a chimpanzee ’ s
over
----- heart to a 64-ycar old man, in 1964
in the U.S.n.)
*d-'
aom Shloh would likely follow. Tho loWrlty o porsonal 11^
-*-t other
and oersonal identity prevail over prolonging li±o er any
nJssiblo advantage afforded by such a transplant
transplant.• Finally
Finally,,
homo-transplants present more serious problems, ana wo munow consider these separately.
5. HOMO-TRANSPLxAITS :
«) aadayorlo
The ethical situation changes with the
source for obtaining the organ to be transplanted,
and organs removed
Seopt^bX"!
2
for one’s neighbour. In the case of a person who has not so
bequeathed his body, the doctor must obtain the consent oi
his relatives to the use of any part thereof*.The practice
of presuming such consent, or acting without it (e.g. as
happens in some teaching hospitals and research centres), is
a violation both of the law and of the rights of the relatives.
Since cadaveric transplants present fewer ethical problems,
doctors should work towards making their use increasingly
feasible, medically. There arc indications of better prospects
in this respect, especially with regards to the use of cada
veric lungs and livers.
This refers to tissues and organs removed
in the course of ordinary surgical opera
tions e.g. when kidneys are removed in the case of urethral
canccr or the creation oi a subarachnoici urethral shunt* With
our present scientific know-how, these present an advantage
over cadaveric transplants because of the contractile nature
of the organ, while,at the same time, they do not involve the
ethical complications which are present in living cionor trans
plants” (see below)*
b) ’’■Free transplants” :
This refers to tissues and organs
provided by living volunteer donors.
Cardinal ethical issues are involved here since it touches upon
two individuals, the donor and- the^recipientt. Ono has to consider
the risks both to the
•— donor
-------- as
- well as to the recipient.
c) Living donor transplants:
TWO SPECIFIC xLREAS THAT AROUSE STHICAL
REFLECTION.
a) Blood transfusion; This procedure has literally saved thousands
-----------of lives, has prolonged others and maae pos
sible major surgical operations. It provides one of the best
ways in which a man can be a good neighbour. Barring serious
accidents of typing, sterilizing and labelling,.reactions are
rarely serious and they occur in not more than in about b/o oi
transfusions. Th e overall mortality rate is probably not
higher than 3 in a 1000. However, it is hard to be sure oi.
avoiding the transmission of hepatitis, syphilis and malaria
(in some parts of the world). Moreover, as we learn more about
individuality in bloou groups, the development of a dangerous
sensitization is a risk always to be kept in mind, finally,
there is the danger of taking the procedure far too lightly:
’’topping it off” or ’’giving a pint more just to be on the safe
side” has sometimes, ironically, resulted in death.
4. HOMO -TRANSPLANTS
How does one act when the patient refuses
to accept transfusion for religious or rather reasons whio.1.*
are not medical (o.g. Jehovah's Witnesses, or racial bigots
racos or castes)
who refuse to have blood from inferior
Should the doctor resopct the prejudices of parents, when
saving the life of the child is involved; or, of an aault who
refuses to be transfused?
i) Many feel that the parents’ or patient’s wishes should be
respected, because they are consio.ering not merely their
physical welfare but their spiritual welfare and future
life - and, therefore, this takes one out of the realm
of medicine* No doubt one regrets being thus constrained.
11)
Others feel that the refusal of the parents make it a
police matter, just as a proposed human sacrifice- would be,
and they would consequently seek a court injunction to
carry on a transfusion- Strangely, the Courts of Law oo
not speak with one voice on this matter. Among the various
reasons for authorizing a transfusion of a chilu respite
the objections of the parents, is that- the chil^ is not
yet free enough to choose its religious convictions, ana,
therefore, must bo given a chance to live in order to
choose its convictions. In the case of a motne-r w,-o nc-ouso.
j
-
a transfusion and refused iu, the court ordered it to be
done, because the mothex1 had no right to sacrifice herself
and leave her seven-month child without her services. In
the case of adults, one x'eason for upholding transfusion
is that , since an adult has come for medical treatment, and
insists on it, he must accept the treatment advised and
recommendedo in any event, in the case of anyone who refuses
Ct U1UUU
U XCUIGI U OXOlJi,
Ui.x«
---------- --------nO t
a blood transfusion,
the
doctor who feels that he --should
respect the wish of his patient (cuafthe parent of his child
-patient) should seek a court order to do so*
b) Organs from living donors: Two questions have to do posed end
answered:
1. Is the procedure justifiable medically?
2. Has the donor the right to mutilate himself?
In reply to the first quostion,the major consideration revolves
around the immunologic compatibility of the recipient with the
available donor^organ® Oucis are presently about 100 to 1 that a
recipient will get a tissue type that exactly matches his own
tience,tho doctor who would lime to do all he can for his pat iont
because he has a’deep and irrepressible concern for his patidnt s
needs, should be careful to also consider more the immunologic compatibility of the available organ than the need of the patient
in itself. This would sometimes moan that a surgeon would be con
strained not to transplant, since the well-being of a person is
to be understood to be more than a mere prolongation of life.
It is interesting to note that for kidney transplants, except,
in the case of identical twins, probably no more than 15 patients
i,v*v’r vnci m
v»n t.hdn
vee.rs. ’’The procedure is
in the world ihotto
have «
survived
more
than p years
of unknown value in terms of the f:ivo-year or ten-year prognosis''
(cfr. STHICS IN MEDICAL PROGRESS, p^ 67)
,In reply to the second question,two points must be considered:
a) The risk to the patientc It has been calculated that the ?isk
of nephrectomy to the donor is as follows: 0.05^ as .a post
operative accidental risk, and 0.07% as the risk of any kind
occuring later to affect the remaining kidney. However, this
statistic must nou oe lightly interpreted,and physicians must
have a conscientious concern for the better procurement of
organs which will obviate the necessity of risking a healtcy
donoPc
b) The consent of the patient* Especially in this area when the
donation by a close relative, or tvzin, affects the saving
of a life, it is difficult to assess the genuineness of
consent* The donor can be pressurised both by otiior members
of his family, who might oven consider him expendable(1) and
by an inner oressuro exerted by his own social and religious
education concerning the value of self-sacrifice,^etc. The
specially
freedom of consento
doctor should be s
‘
\ sensitive to
,
Sometimes the help of a psychiatrist is<
While it remains true that doctors should work towards P^ocuring organs from cadavers, the question remains: within our
present limited options,, can a healthy person donate one of his
healthy organs to save 'the
— life of another? The answer would
.
seem to bo in the affirmative. ^ox-,^ if we could accept that a
lay down his life for his
man can, in self-sacrificing love,
friend” when this is an act c.f service to the other , we could
also accept that he boo premlttea to give) a healthy organ to
save the life of his friend* However, in
: ■ arriving at this
decision the following must bo considered:
1} Is there a proportionately good reason?
11) Is there a reasonabl ‘ hope* of success?
ill). Will the ’‘damage- caused to t^e donor be such as to
prevent him from leading, a normal human exisuoncer
,iv)/ Has his consent been duly obtained?
4
5, TRANSPLANTS IN THE "TWILIGHT ZONE" - LIVING PERSONS OR LEAD BODIaSp
Wo said,above, that tho procuromsnt of organs grom cadavors
would obviate many an-ethical difficulty. The question about the
momant of death has become a thorny, one in view of now procoduies
that can koep up certain physiological functions (heart beat,
respiration) even though irreversible brain damage has occured.
Physicians, lawyers, philosophers and theologians must apply
their minds to a ro-defining of "the moment of doath .(See notes
on EUTHANASIA for details about the criteria for actormining tho
moment of doath).Thia will affect the detormination of the con
dition of the donor - is he-alive or dead? But the central problems
of organ transplantation will remain, and will have to be sottleo.
by different and independent norms (see below).
Once again in this question, as in so many
others which we have considered in our course
of Medica-1 Ethics, we realize that there are disturbing cases in
which tho doctor cannot hope to find ready-made solutions y os alished standards. Tho dotor should guide himself by tho basic pri ciplo of concern for the person of the other. On the one hand, then,
he should beware lest " zeal for research is carried to the point,
which violates the basic rights and immunities of a human Person ,
on the other, he must work out together with experts from other
SoSalS'□“cornea with man (o.K. lawyorB, phUoBopberB, Bocral
scientists, theologians),some moral guidelines to assist him as
ho treads tho paths of progress in medicine which ho hope8 will bo
to the benefit of man. Below is given, by way of example, a set ot
suidelinos drawn up by two doctors with regard to transplantatio
S orgm (S™ Ha?mon L. Smith, ETHICS AND THS NEW MEDIOBNE.p 121)
6. FINAL CONCLUSION:
L2-. Compassionato concern for tho patient as a total person is
Organ transplantation should have some reasonable possibi
lity of clinical success.
The
transplant must be undertaken only with an acceptable
3^
therapeutic goal as its purpose.
4. Risk to tho hoalthy donor of an ofSa-njnnst^oc^kopt luw,
to the.
but such risk should not be a contra-indication
cin"-''
l
informed
donor,
voluntary offer of an organ by an
honesty with the patient and his
5. There must bo complete
<
—
t
family, including every benefit of available general
specific information concerning
medical knowledge and of
.
transplantation.
6. Each transplantation should be conducted under a protocol
which ensures the maximum possible addition to scientific
knowledge.
7. Careful, intensive, c,xx^
and objective evaluation of results
of independent- observers
--- - is mandatory.
8. A careful, accurate, conservative approach^to^the
dissemination of information to public nows media
is do sirable.
( Dr s. J .R . Elkinton and Eugene D.Robin)
Medical progress is going to throw up many questions to
oFLiodical
ethics can provide
which’ no preliminary systemi c.
’'
.
I
’
hs
ethical
training
immediate and certain answirs.
---- ~ of a doctor,
"
henceforth
to
ths
teaching
oi a low
then, cannot bo limited
roaciy-mado rulos» LTo quote Dr. J. Hamburger once again:
.ux
”Too produce
doctors who --arei strong mon, who are not only
honest and just in thought, but efficient in action;
to develops in them an awareness of the value of human
life* to convince them that their vocation is an ex
tensive obligation to the individual and to gthe group :
such, it would seem are the best means of facing ths
over increasing difficulties oi medical 0^q^s_i
\
(efr.ETHICS IN MEDICAL PKOGK&SS,p•137}
ORGAN OF THE CATHOLIC MEDICAL GUILD OF ST. LUKE, BOMBAY
Editorial Board
No. 83
Dr. A. C. Duarte-Monteiro
Dr. Thomas C. da Silva
Fr. Anthony Cordeiro
Dr. C. J. Vas
SUPPLEMENT TO THE EXAMINER
October 16, 1971
EDITORIAL
that “the Hippocratic oath prohibits euthanasia, I the
Our attention was drawn to the following comments
in favour of ‘mercy-killing’ in ‘The Times of India’ belief being that as long as there is a spark of life a
under the heading “Human vegetables” (Current man must be kept alive,” he concludes that ther s is
Topics, May 4th): “Thinking and talking about the certainly another side to the problem, and that the
j
' to be openly debated in a calm manner.
unconventional may be distasteful to most people but issue needs
this is an essential activity for man, the social and It will not be out of place to reproduce here what “The
intellectual animal. Twenty years ago free and open Himmat” writes in an editorial entitled “Of life and
discussions about sex or abortions were taboo, but Death,” wherein it compliments Pope Paul’s firm stand
thanks to the efforts of trend-setters such of the hypo on abortion and mercy killing
crisy surrounding them has been stripped away. Eu
“The Vatican is to be complimented for its c ear
thanasia (or mercy-killing) is another subject which is enunciation on abortion and euthanasia. In a letter
still considered by conformists to be unmentionable.” to the International Federation of Catholic Medical
In support of his plea, the critic lays stress on the Associations’ meeting in Washington, the Pope said :
.ews of Lord Ritchie-Calder, the noted British science ‘Abortion has been considered homicide since the first
centuries of the Church and nothing permits it to be
populariser and professor :—
“As a result of mental illness or degenerative diseases considered otherwise to-day.’
such as multiple sclerosis some unfortunate people turn
As for putting those who suffer from incurable or
into zombies; when advanced age compounds their painful diseases to death, His Holiness says
‘With
disabilities, they become little better than human vege out the consent of the sick person, euthanasia is mur
tables ...”
der. His consent would make it suicide.’
The learned professor poses the following question :—
Indeed a society where one satisfies one’s desires
“How merciful is it to keep them alive with all the
without any responsibility for the consequences,>.and
resources at the command of the modern medical prac
where the 1laws are created to encourage this irrestitioner ?”
Obviously
critic 1AO.O
has considered man only from 1ponsibility, cannot be considered a mature and civilised
’DVlUUSiy the
L11V V1XU1V
socio-intellectual
viewpoint,
disregarding the ethico- society.
the t
As an answer to the above question posed by the
' rational
*
’ one.. The Catholic view
moral, and_ even the
point ’ considered from the latter angle, teaches us to Professor, above referred to, we publish in this issue a
respect human life, which is the basis for civilisation. talk given by the Chaplain of St. John’s Medical
Fortunately, in the same comments, while pointing out College, Bangalore.
EUTHANASIA *
By Fr. Denis Pereira, Chaplain, St. John’s Medical College, Bangalore
r^EATH in America,” says a recent article in NEWSU WEEK, April 6, “is no longer a metaphysical mys
tery or a summons from the divine. Rather it is an
engineering problem of death’s managers—the physi
cians, the morticians and statisticians in charge of
supervising nature’s planned obsolescence. To the
nation that devised the disposable diaper, the dead are
only a bit more troublesome than other forms of human
waste.” And a little later, quoting an^ American
psychologist, the article goes on to say : ‘‘The dying
no longer know what role to play. Most of them are
already old and therefore worthless by our standards.
There’s simply no place for a human death when the
dying person is regarded as a machine coming to a
stop?” (Kastenbaum)
It would seem clear from the above that any dis
cussion of euthanasia must necessarily be preceded by
agreement on a proper philosophy or theology of
death. What does death mean to us ? Is it a machine
coming to a stop?’ Does it merely provide ‘a bit more
troublesome form of human waste?’ or is it
in the
eyes of us doctors, the great enemy against which we
must fight with all our resources, backed by patiently
acquired knowledge,” and if so “is it reasonable that we
should be indignant, that we should indulge m barren
irritation, before this inescapable condition of human
existence ?”
♦ Talk to St. Luke’s Medical Guild, Bangalore, on April
22, 1970.
“Death” says Francois Mauriac, “is that terrible
thing that happens to other people.” In a world
frenzied with the pursuit of pleasure and comfort,] ob
sessed with its egotism, “death is an affront to every
citizens’ inalienable right to life, liberty and the pur
suit of happiness.” (A. Toynbee speaking of ‘Death as
being un-American’). But for the Christian, and the
man of faith, death is not the end but a stage in living—
the process of dying is in reality the art of living rdeaningfully in and through the process of dying. Death
is the gateway of eternal life. It is the moment at
which we ratify the fundamental options we make in
life. If ‘to live is to choose,’ then to die—if that death
is human and meaningful—is also an act of choice in
simple words, a truly human death is one in whichl one
ACCEPTS to die. This is what Dr. Elizabeth KublerRoss, in her book ON DEATH AND DYING hints
at when she quotes one woman, who finally bowed to
the sentence of death after steadfastly refusing to ac
cept the fact of her impending death, as saying: “I
think this is the miracle. I am ready now and not
even afraid any more.” She died the following ’ day.
It is to be noted, however, that the acceptance of death
is not to be taken to mean that the person has the right
to impose death on himself, to ask another to shorten
his life, or to place in another the power to end it I We
have no right ovei' life, even though we may haye at
tim
tion of euthanasia.
Etymologically, the word EU-THANASIA means
58
SUPPLEMENT TO THE
EXAMINER
October 16, 1971
“dying well” But that is not what it has come to mean patient, in the doctor, in the lawyer, in the priest, in all
in legal or medical parlance. From its original mean who share a responsibility for life.
ing of “dying well,” a perfectly innocuous and healthy
2. Man has a right to his own dignity as a person
philosophical value, it has come to mean “easy dying,” even in approaching death. Therefore, once the rea
which is not the same thing, for this implies medical sonable means to keep him in life have been exhausted,
intervention to cut short the process of living in order he is not bound to destroy his dignity by expecting to
to accelerate or rather induce death. Other words be kept alive without being able to live, io think, and
used to describe it are “mercy-killing,” “merciful to feel as person. No one is bound to ask for medica
release,” “voluntary euthanasia” or “easy death” tion that would prolong the agony of death. The same
(which, incidentally, is the name of a society started in principle is valid for the community; its .members
.
3 are
England in 1935 to push euthanasia legislation through not' 'bound to prolong
’
’ agony for a human being.
the
Parliament), and “the termination .of life by painless
3. There will always be complex situations and
means for the purpose of avoiding unnecessary suffer borderline cases where a clear moral judgment can
ing.” It is easy to see how ‘mercy killing’ can turn not be formed within the short time available . In this
into ‘convenient killing’—but let me not anticipate.
case we have to respect those who, animated by the
A. EUTHANASIA in the strict sense means : “to first two principles, make a genuine effort to bring
cause death (or to assist in causing death) to a conscious, about the best decision even though they may fail to
certainly incurable patient who requests that his agony find it there and then. Yet the effort itself was good
(physical or psychical suffering) be terminated by a and the resulting situation should be accepted as the
calm and painless death.” Here we can distinguish
only reasonable
’’i one in the circumstances.” (L.
between ‘direct euthanasia’, i.e. where the assistance is Orsey, S.J.) '
rendered intending death. This is murder, or coI Iwould
’ idea of bene
4.4. ““
wouldurge
urgethat
thatwe
wej promote the
operating assisting in suicide, or both, and is never mori)
mori, a dignified
death,
There is
’_
\ in the dying patient.
'
allowed. And we can speak of indirect euthanasia’ no
process, nor
no need
need to
to prolong
prolong the
the dying
dying process,
nor is
is there
there any
any
or the administration of treatment {e.g. to ;alleviating
” ’ '
moral or medical justification for doing so. Eutha
pain) with as a side effect, the acceleration of deatk nasia, that is the employment of direct measures to
This last would better not be called ‘euthanasia’ at all. shorten life is never justified. ‘Bene mori’ that is,
J. Fletcher calls this antidysthamasia
’ (not
.
.
.prolonging allowing
v the xpatient
. i to die peaceably and in dignity '
the process of dying). “Tt
It is not euthanasia to give 1 always 'justified.
'r' ’ ”” '(J. R. Cavanagh)
a dying person sedatives merely for the alleviation of
[N.B.—This conclusion presupposes (1). that all conpain even to the extent of depriving the patient of sense cerned act in accordance with the will of the patient; (2).
and reason, when this extreme measure is judged
that the patient is dying. The dying process is the time
sary. fSuch sedatives should not be given before the in the course of an irreversible illness when treatment
patient is properly prepared for death, nor should they willI no longer influence it. Death is inevitable.]
be given to patients who are able and willing to endure
B. EUTHANASIA IN A WIDER SENSE: Eutha
suffering for spiritual motives.” (Directives Catholic inasia in a wider sense is less complicated to deal with
Hospital Association, U.S. and Canada). It is ob- ethically,
”z. It includes:
vious from this directive that the person must be helped
' ' ~
(a)
To cause death, at the instigation of pity, to an
to live meaningfully through the process of dying. unconscious dying person, to monsters, the seriously
The real problem is: to what extent must a doctor/pa- insane, etc.
tient prolong life? Always and at any cost ? We
(£) To cause death, for the sake of society, to a so
could perhaps be helped if we distinguish between cially dangerous person, to persons, in general, who
‘Prolonging life’ and ‘prolonging the biological process ccannot live a moral life within society (the so-called
of dying’; or to put it in other words, we could visualise ‘‘.eugenic deaths’). This causing death for the sake of
cases in which the prolongation of biological life may, society may go to the extent of disposing of “useless”
not ireally be ‘living meaningfully,’ whereas acceptance persons, the aged, etc.
of death may be ‘living
moment as a human "being’
ixMnnr this
+
Qne can easj]y see, especially jn the light of the Nazi
biologicaMife isjhortened (of course with- atrocities of World War II, how fraught with terrible
even though
t
out being directly terminated, which is plain murder consequences the admission of such a principle would
even if done with the consent of the patient.)
be ! “From a purely medical point of view shortening
Take the case of a dying person who is ready to die or taking the life of a patient for the relief of pain i
and wants to die. He is suffering. He is surrounded unnecessary. Moreover, it is a confession of professional
by medical apparatus. He has hardly any contact failure oi' ignorance” (Dr. Graham). Further, “the
with his environment, his friends, his family. His practice of euthanasia would lessen the confidence of
children are kept away, and visitors not allowed. patients in their physicians, for the patient who was
Would not a doctor be justified in instructing the gravely ill might readily fear that his physician would
nurse to take away the instruments and allow the chil judge his case incurable and so administer poison to
dren to be with the father even if this may well mean end his life” (Healy). One could imagine the con
an earlier death? Indeed, this may well be the best fidence one would have in confessional practice if the
way to help a person to live—through the process of priests were sometimes justified in betraying the con
dying meaningfully, even though the duration of the fessional secret. And lastly, as B. BonhoefTer who was
himself executed
in a German xprison camp,
process is shorter. Keeping a person alive is not neces- {t
.
* put it:
sarily helping him to live, for living means more than
wc cannot ignore the fact that precisely the supposedly
biological survival. And in this case the duty of living worthless life of the incurable evokes from the healthy,
becomes the duty of dying well. (The question as to horn doctois, nurses and relatives, the very highest
whether a patient is bound to accept, and the doctor measure of social self-sacrifice and even genuine hebound to prescribe, extraordinary means to prolong roism, and, we may add, has been the inspiration for
life could be discussed in this context—but this would much leal icscaich and advance in medical knowledge
take us far out of the scope of this talk.)
and practice (efr the heart transplant surgery by
1 .
. t -ii
i
doctors who would not give up”). Truly, euthanasia
To summarise this part, I will now read out some is bad medicai practice.
norms with regard to indirect euthanasia.
Conclusion : In the course of the last few months,
1. “A human person owes it to himself and to his two of the Associate Professors of Medicine of our Colcommunity (to his family, to the society in which he lege, both excellent Hindu gentlemen, addressed our
lives) to keep his life intact and not to destroy the pre-professional class students. One of them, when
value that it represents. Human life lived in a per- asked about euthanasia said he would never practice it,
sonal way is the best that we can find in this world, because it was a doctor’s duty to protect life, and he
Nothing else comes anywhere near it, in the hierarchy would work to the end to prolong it ; the other, with
of values. It follows that both the individual and the touching candour, said : ‘There are times when I can’t
community has a duty to do what can be reasonably help my patient to live longer. At those times I must
done to preserve human life. This duty exists in the know how to assist my patient to die well, saying the
October 16, 1971
SUPPLEMENT
TO
right word of encouragement and helping him to ac
cept his sufferings.’ In the face of death, this is exactly
what a doctor should do. “We have helped our pa
tient” writes a Catholic Doctor in an article in GA
THERS LAENNEC, December 1946, “in his suffering;
we now help him to die, to die well, or more truly to be
born again into eternal life.” And he adds in the same
article : “do not let us change by a merely spectacular
attempt at medical intervention this last and precious
contact between the living {i.e. the patient and his
family), and tlris final possibility of colloquy with God
on which eternity depends .... Shall we by a gesture
aimed at the entourage, rather than the patient, and
which does not even hide our human medical impotence,
shall we run the risk of obstructing the light of this
last vision of God, and thus prevent an adherence
which often remains . . . the assurance of a happy
eternity for the patient ?”
Notice, the emphasis on
the patient’s right to die a human, meaningful death.
And he concludes, and with this so do I, “in the appre
hension of these serious realities, let us, on the contrary,
pursue to the end our true role as doctors—our role of
respect for life—towards all and inspite of all. . . The
tranquil death which we desire for our patients, as for
ourselves, is not necessarily the unconscious death
which drugs, even prudently administered, can pro
cure. We ask above all, a peaceful death with the soul
t peace and abandoned to goodness and mercy which
opens to it the gates of eternal life. The sweetness of
death is in that vision of light and life.”
THE
EXAMINER
59
the government mostly through the individual S ate
Governments. The government spent a great deal
by way of shelter, food rations, immunisation and
sanitation programmes in most of the camps. On an
average the government spent Rs. 3 a day on e|ach
refugee and at present we have nine million ! Jhe
Indian , Catholic Charities—Caritas was also doing
y a
tremendous amount of work in looking after about
70 refugee camps,
A number of other organisations
such as CARE, CASA, OXFAM, Medico Interna
tional, S.C.I., Red Cross, Hindustan Steel, Ramakris ma
Mission were also very active. It provided, medical
aid, shelter, clothes and food to the refugees. Salt
Lake which was one of its biggest camps, was nearest
to Calcutta and supplies were therefore brought in
more easily and regularly. Transport to the cajjnps
further north was difficult and made worse by (the
floods. In addition, those camps also dealt with a Con
tinuous influx of fresh refugees under a persistent fear
of military attack.
My first visit to the Camp created lasting impressions
on me. I still remember walking through the sajnds
of Salt Lake towards the camp. There stretched beiore
us miles of endless barren sandy land with not a tree to
be seen except for a few on the distant horizon, But
this very land was teaming with two hundred thousand
refugees trying pathetically to adapt themselves to
hostile
conditions.
We could see hundreds of
little tents huddled closely together and endless
rows of barrack-like sheds built of bamboo-matting
covering the shed completely except for the mhny
little doors. Each door led into a dark damp area
of about 20-30 sq. feet. One could see a few sad faces
By. Dr. Henrietta Moraes
of the inmates peeping through and viewing us with
"T"HE poor intern is considered neither a student an air of aloofness ; women garbed in tattered clothes
I nor a doctor. His budding potentialities are and burdened with naked hungry-looking children,
underestimated, and though he himself may overesti- spiritlessly trying to lightt a fire with a few damp twigs
■’
’
Or C------------------------------------------unj x
coaxing a listless child to eat what little food they had.
mate them
a’ weeP bit, few realise the enthusiasm
and
the children, with the starvation and 2hardship
dedication with which he could perform perhaps a Some of.....
few small wonders in any medical situation—if only they had gone through, wore the brooding expression
of the old on their sunken faces. One hardly saw little
he were given a chance.
When I heard of the urgent medical need of the children playing together. There was no tract of
Refugees, I was drawn by sympathy and also by the curiosity or cheerfulness in their expressions.
Fresh arrival of refugees brought a wave of depres
challenge it offered I was full of enthusiasm, prepared
to fight against the diseases of the refugees and to make sion upon us. But it was something we were always
myself feel worthy of being a member of the medical to see. They had treked wearily with their bare feet
blistered and swollen and with hardly any clothes.
profession.
The Bombay University was preparing to send a When it rained, their meagre flimsy clothes clung to
few male interns but with its usual fatherly and dogma- their skins as they walked along at the same weary
‘•’’cally conservative attitude, it refused to send interns pace, in no hurry to seek shelter. There was hardly
/ the weaker sex (though after a lot of consideration, a day that a complete family arrived at the camp.
it has just sent a few lady doctors too).
Everyone We would often see a woman alone with her children
at home, supported by a host of friends and relatives, and perhaps an old helpless relative. Many of the
decided that I would not return in one piece if I left, men folk had been killed, some had stayed behind to
Finally after a lot of persuasion and many promises fight. Occasionally, a woman would tell us thatt her
child
that literally bound me to spend more time safeguard- c
u;1'q or parent had died on the way, of exhaustion
ing myself, I was allowed to go. I am very grateful and starvation, or that she was not sure of the existence
to the Indian Catholic Charities—Caritas, for it was of
-p her
1-— husband
K--1
J or older
1-1-- sons. And
A“-1 then
-- some would
11
beat their heads to the ground and cry helplessly.
through them that I left.
I travelled to Calcutta with two compounders who The refugees were so reconciled to their fate that it
had also volunteered. At Calcutta, where Caritas was really heartening when one saw a youngster helping
has its headquarters for its Refugee Relief Work, it an old disabled man to the dispensary, or a few little
was decided that we work at the Salt Lake Camp. There boys fighting to get into a puddle of water or a group
were many volunteers who had come through Caritas of young girls peacefully singing a few songs.
The future held no promise and they were so bereft
from all over India and abroad to help in the relief
work. It was wonderful meeting these people who of emotion that one rarely saw one refugee volunta
had come with an abundance of enthusiasm, cheer rily helping another.
Of the refugees, ninety per cent were helpless women
fulness and selflessness to volunteer in the service of
the refugees. I would love to mention them here, but and children and the same percentage of them were
perhaps I dare not, for I could never forgive myself Hindus,. Most of the refugees at our camp were
if in my thoughtlessness I mentioned some and forgot illiterate. Most were landless farmers by occupation
and very few had an occupation or trade.
a few.
Our greatest problems were nutrition, unemploy
It was truly this spirit of dedication, co-operation and
thoughtfulness on the part of the volunteers towards ment, sanitation and the continuous arrival of more
the refugees and to each other, that got us so involved refugees. Conditions were such that men worked
in the relief work. One realised that however vast for no payment. Every morning there were crowds
and urgent a situation, nothing could be achieved of men waiting to be employed but so many had to be
turned down. They were not permitted to go into
without some organisation and co-operation.
There were over 900 camps all along the eastern the city to beg or work as there was so much unemborders of West Bengal, Tripura, Assam, Meghalaya ployment among the local people themselves. To
and Bihar. Most of the camps were organised by keep the refugees occupied arrangements were under-
AMONG THE REFUGEES
60
SUPPLEMENT
TO
THE
EXAMINER
October 16, 1971
way to start schools for the children with the few educa
ted refugees as teachers. Parts of the camp were cleared
up for play fields for football, etc. There were sewing
We offer our congratulations to the following students who have
classes for the young girls and women. The men
passed the University of Bombay Examinations held in April
would soon be employed in bamboo matting.
1971
Endless hours were spent by the refugees in patiently
standing in unending queues, often in the scorching
Third
sun or heavy rains, for bread, rations, medicines or
Miss Premila Robert D’Silva
water. Caritas was supplying 20,000 loaves of nutri
Miss Philomena Faustine Lewis
fied bread daily. Even though one loaf was given
Mr. Eric Joseph Francis Pinto
to every four persons, there were many who went
Mr. Vernon Patrick De Sa
Mr. John Austin D’Souza
without bread and waited their turn the next day or
the day after that. Each time they received the bread
it was ticked off on their ration card.
Second M.B.,B.S.
We had a well supplied dispensary with a separate
Miss Mary Margaret Carrasco
shed for minor surgery, bandages and injections.
Miss Maria Prisca Colaco
We examined about 600-700 patients a day.
Miss Sandra Frank De Souza
We would go out every few hours among the queues
Mr. Ghipriano Scrafinho Fernandes
Mr. Gregory Michael Fernandes
and bring in the serious patients who often without
Miss Aruna M. Fernandes
murmur would patiently wait their turn. These
Mr. Christopher Joseph Lobo
patients would be admitted to our hospital. It gave
Mr. Gilbert Dominic Lopes
us such joy when we were able to save many of them
Miss Alzira Francisca Mascarenhas
Miss Sarita Joan Noronha
with the wonderful drugs and other medical aids that
Mr. Arun Charles Pinto
had been donated so generously by countries all over
Miss Lorena Siqueira
the world. We had a simple but fairly efficient num
bered card system for the out-patients and we even
No Candidates appeared for the First M.B.,B.S.
kept an out-door and in-door patients register.
We realised how a few friendly words and a little
attention could go a long way to make these lonely
Our 20th Annual Social Gathering
sick people feel better. This was brought home to us
Members of the Senior and the Junior Guilds, are hereby inform
even more strikingly by a middle-aged man sufterthat the St. Luke’s Annual Re-union will be held at the Bombay
ing from cirrhosis of the liver. It was a chronic ed
Presidency Radio Club, Colaba on the 4th December, with Nelly
illness and there was not much that we could do for and her Orchestra in attendance. For further particulars kindly
him. As he had no one, to care for him, we let him contact the Chairman of the Entertainment Committee, Dr. (Mrs.)
remain in the hospital. When he made a nuisance Francisca de Gouvea Pinto (Phone No. 371630), or any of the
—Dr. F. Pinto de Menezes, Colaba (No. 213010);
of himself, we did not hesitate to shift him to a following:
Dr. Terence Fonseca, Byculla (No. 377264); Dr. (Mrs.) G. Silveira,
small empty tent. That night he hanged himself. Mazagon (No. 372958) ; Dr. John Fonseca, Mahim (No. 455623) ;
This had such an impact on all of us that it made us Dr. (Miss) Charlotte De Quadros, Bandra (No. 533103) ; Dr. John
feel guilty. Frustration may have driven him but if V. Ribeiro, Santa-Cruz (No. 538877) and Dr. A. A. Soares, Chemwe had been a little more friendly and attentive we bur (No. 521352). Students may please contact representatives in
the respective Medical Colleges.
could have saved him. We immediately decided to
reserve two big tents for those old and chronically ill
patients who had no one to care for them.
Our hospital housed two hundred patients in a few
sheds and tents. We had two tents for maternity
cases ; two tents for the old refugees ; two sheds for AN APPEAL FOR HELP TO THE REFUGEES
children; one shed for adults and one for patients
11 will be recalled that at a Meeting of various organi
with diarrhoea. With the admission of many of the
zations
of Bombay’s Medical Practitioners held on the
patients we had the rest of the family in the hospital
too—living round the patient. If the mother accom 9th April, 1971, a Committee known as the ‘Bombay
panied the sick child there was often no one else to Medico Bangla Desh Aid Committee’ was formed, an*4
care for her other little children. Most of the patients it was also decided that medicines and money be coj
were admitted for pneumonia, typhoid, cholera, dysen- lected to help the refugees.
try, nutritional deficiencies, measles,
chicken-pox
At another meeting of the representatives of St. Luke’s
and infective Hepatitis. Diarrhoea in children was Medical Guild, the Catholic Nurses Guild, the Catholic
quite the most persistent problem and would remain Relief Services and Caritas India, held at Archbishop’s
so with poor sanitation and nutrition. We had House on June 22, it was decided to appeal to Catholic
transport at our disposal throughout the day to Doctors including Interns, as also to the nurses and
transfer patients with acute surgical problems to the compounders to work as volunteers among these refugees
city hospital. If it was not for the dedicated work in Bengal. It is heartening to note that a batch left
of the Sisters of Charity, the volunteer nurses and Bombay on the 12th July, 1971 in response to this
helpers (among them many were refugees) it would appeal. However, the need for volunteers continues
not have been possible to run the hospital.
more so because replacements will be required for those
The dead bodies from the hospital and camp were who are due to return on the completion of their period
kept in a tent among sacks of sulfur and bleaching of service. While appreciating the generous efforts of
powder till they were disposed off. The refugees our members and their families to alleviate the suffering
had been deprived of their Motherland and later their of these refugees, we urge them to continue their activi
dear ones. It was only death that emotionally moved ties in the collection of drugs, surgical dressings, clothing,
these people—but only into a deeper and unapproacha coverings (particularly blankets), mats, sheets, sarees
ble gloom.
and the like, and deposit the collected articles at any
One cannot say what the future holds out for the one of the centres given below. For the convenience
refugees—but with the blood, sweat and tears that of members there are three different localities, North,
these people have shed, we with them pray that Bangla South and Central :—■
Desh will be a reality.
1. St. Peter’s Parish (Bandra), for the suburban
I had spent one month with the refugees and though
there was heaps of hard work we had our moments of members.
happiness too. Caritas had provided all its volunteers
2. Sodality House (Seva Niketan), central areas.
with homely and comfortable quarters. Returning
back after a heavy day’s work or a strenuous night
3. Nirmala Niketan (School of Social Work), 38,
duty we were always sure to have waiting for us just New Marine Lines.
the things we desired most. Our experiences at Salt
A. G. Duarte-Monteiro.
Lake will remain as vivid memories never to be forgotten.
OUR FELICITATIONS
I
nf Medical Ethics
Topics dealt with in. the present course
'^'rr LECTURES :
What is Medlosl Ethics, (vs. -.««« etiquette)
Basic principles of Medical Ethics.
The Concept of Health - a total perspective.
Health care priorities and social justice.
T^Tr •
I.
/W^
1.
2.
3.
4.
Tlie Doc kor — patient rolntionsnip
-medical
-ibility to the
individual and comaunity.
- the doctor vis-a-vis social legislation
- the aedical secret.
PROBLEMS CONNBCTEHjnTlQHE BEGINNING OF LIFE
II .
Artificial Insemination
Genetic engineering
5.
6.
7.
Abortion
PROBLEMS CCNNECTED gITH
III.
SEXUALITY A?;D MARRIAGE
Meaning of human s exuality
Contraception
a) Motives and methods
8.
9.
10.
11.
12.
b) Morality
Ahnornal-irty sexuality (e.g.
honosexuality)
Masturbation
Marriage counselling ( e.g. VD of patient and
obligations to partner; sterility; iupotenco)
tRITY of the body and
PRQBLWS CONNECTED ifITH THE TNTEC
OF THE PERSON^
13.
14.
Mutilitation, sterilisation
f.y.^W.ry, psyototMr.'.py,
15.
Experimentation on huuan beings
PROBLEMS CONNECTED
16.
17.
18.
VtlTH THE END OF LlEE^
The meaning of Death
Telling the truth to the patient
of Euthanasia.
Prolongation o-f life and the problem
SPEC IAX_Sj^QTION.
VI.
19 .
20.
Alcc.holisn and drug addiction
Transplantation ( Blood transfusion & ha e lio 3 ia 1 y s i s)
**********
l
nJ
1
4
• The principle of valid consent:
(see first five clauses of Nurem
berg Code) To obtain the consent
of the patient to a proposed investigation is not in itself enough,
owing to the special relationship of trust which exists between a p
patient and his doctor, 510st patients will consent to any proposals
hhat are made. Further the considerations .*»..( see text)
I
• ■
nUv
-•
r!
'
.
'I-
■
.
,
••'
h
j(;
•.$•
■!
actenja S|,"‘ ceAAbf jW’th Wbll? ftlf tfe"
r-U
> ‘ ' i
whai
physician
is justified, m
in placing
piling science or public welfare
.vexidie ifirst andNo histbliqation to the individual, who is his patient or subject
suijec t, pocond * No doctor,
As Claude
Bernard
-AdJ^nder °V!0Gern.experiment31 medicine put it:"The
principle
**
'
of
medical morality consists then in never performing
r— --- ’
principle
on
ihah
an.
experiment
±t‘J!“-=thS:ilt0?lr" in a"y ?e9rea '•'■’s'tsiever JhoOT'hnM
result
health of
nssl™
-edioal ethit-s; as enun=lated
of
?l‘X
orlne.
.42-43)
co mon good
justified
life,
persons and not simply as mSns^VS FstiS XlTpif"^'515 as.
Vanderbilt Univ. .Nashville ) An Ameri mh SK’Ptil f P^osopny,
e^en more strongly: "Any cla^sifi^-iti rn o^iSnClan ^aS
the matter
'for the ciood of CcCll
n ' •
°f W™30 experimentation a s
Undoubtedly,a 11 sound work has thiltt^J with distaste, even alatm.
f• PV;pCtPLES: Morality rests on what is right in itself ■'
towards
-.^even
An experiment is’
---- post hoc ethical
distinction
between?
ends ano means. (Dr.H.K. Beecher)
(p 225)
JhoU S?’
:3iXl
8
ES™
if;.-!..
»•» 4'.™
it would
ustify the'vil^necs of wh^t uWachieved
e’^le 'G rV
woljio not even have be^un to
nave weighed m the batafee agafnft fie
«5C
i^fol!;wiSethiiU|im an" £hft the? i9n°-e? JhTsuffSng Xe^calsed
at thfelsoi:!’den?LrpfUon?SddSforth(p^g?fUre’ bUt iS SuWei:ted f° ib
^..CODE , CONCERNING iUMAN EXPERLMEjN LITION would be concerned with the
i o r 1 owing principles :
----------
pBieg*o^d^f
ch?if ’’Er?6111 ? stauld be_ contemplat
in circumstances ident leal
to sSbmiChimsl4nt&ndetSUbjeSti> ’were
exP^iment^ZwoGid
-1 even hesitate
co suomit hinuelf or members of his own familv or
<
anybody for whom he
mo?eathanethpCt
apf?ction- Tb-e idea that theo experimenter is worth
more than the subject is ruinous.
(p. 230)
4
■
■
•
•
1,
t. .
. u, ..j I. .
•/...’A
(JUil. .-Ij
Udis chat are made. Further,the considerations involved ar.'
~C’ technical as to prevent their being adequately understood by one who
not riimself an ’expert. Two essential pieces of information are
Ox: uen neliborately withheld from the 'consenting volunteers’ namely
y2cj Procedure is experimental and that its consequences are unpi ..w.ic^aule. Moreover,in keeping a subject in the dark as to what
is
ing cone to him so as to •avoid a refus. ,the experimenter is, '
m tact,guilty of a fraud.' (p. 232)
X’--A.,P,Tincir iy. of prohibited subjects: Experiments should under no
circumstances be performed on mentally sick patients,whatever may be
the technical designation of their particular illness. Nor should
experiments ever be performed on the aged or the dying. This fo-Aows
from taking the above two principles seriously. (Especially wish
regard to The dying and the testing out of new drugs,where the patient
cannot be saved it is common humanity that he should be allowed to die
m peace. ) (p. 235)
• -i-he principle of previous animal experimentation: This is suggested
by every code. (p. 238)
Thu_..principls of the
experimenter
’s
_________
. . competence
: The parts played
by people who are actually unqualified ledically should be limited
//4C)
to what they can do with complete safety.
(p, 240)
6. The principle of proper records: Zf
If ~a patient consents to be subject
of an experiment,what has been done to him is virtually
~ y ,parts of his
medical history. A
n
1 ’ against a patient’s
Neglect
of proper records is thinterests,against those cf the doctors and againi- . the interests of
medicine.
•Ll the above, I am opposed to inhuman clinical research and
T2’- ^i"S
placement by humane research. (Notice hotv,when speaking
Ox. mishaps , experimental physicians relate the mishaps to themselves
rand not the patients.) Every human being has the right to be treated
di decency,and that right belongs to each and every individual and
snou^u superced- every.consideration of what may benefit mankind,what
mny ccrisribijte to public welfare,what may advance medical science.
-’0^C4u?^°r1
'L;stified in placing science or the public welfare first
ano his obligation to his patient second. Any claim to act for
vh^ good oi society should be regarded with extreme distaste and even
c:'Lai J? S 1’9 a
lown expression to cloak outrageous acts.
h worthy end does not justify unworthy means.
(ibid, suppl.)
*****%*
)
k
4-
r'
“ 3 -
?£ iolfare1ff'atheBsibje?tiSuBt°Jls?A^ experiments of whatever klJd.
SLDject must, also ano. always be taken into account.
thisArie:htmawh?nhn?ab?'S-ith?-ri?ht to ’0G treated- with a eertain dejncyw^at Pa’-S’mAo??+Cba1^ inaiviaual> supercedes every consideration of
nhvsictan ?a
°r ^^te to the public welfare. No
his obllRation tJ f’
■ lPAaC1,;S soiQnQS
Public welfare fi'rst and
obligation to t... ioodiviaual,
i^diviciualj who is his patient or subject, second.
i
Dr. Guttentag defined as ’experiments in medicine’ “experiments
on the sick which are of no immediate value to them, hut which are
made to confirm or dispute some doubtful or suggestive biological
generalization. Recently this type of experiment has become more
and more extensive." (p.22-2J)
PHYSICIAN-FRISSED: Ono human being is in distress, in need, crying
7
, for.help; and another human being is concerned
and wants.to assist him. The cry for help and the desire to render
it precipitate their relationship. Theirs is the relationship bots ween two I s, like between two lovers, friends, pupil and teacher.
U TI have called,
called such a relationship ‘the mutual obligation of two
5 equals1.
*>
i.
1
I
1
V '•
•i;.
;
( ♦
i
*
UO
Mt v'vhtidm
”Purely t*wt ?Y b^'* '^
1 Ki y
very profitable: to all doctors and students who read it.) be
HUi^AN GUINEA PIGS
by Dr .M. n. Pappworth
(Penguin Books)
PROBLEM: For several years a few doctors in this country and *in
America have been trying to bring to the attention tf their
fellows a disturbing aspect of what have become commonc
practices in medical research. These practices concern
hosPTttal Patents, and ?he aSct^hC":
:.ch is
-x. uUi^bing io the ethical one. In their zeal to extend the fronriP-rc
of th?fictnthatd+b’ mabY cJinicians appear temporarily to have Y
ost sight
inGvG.Gie
th 3U,-'J?CJS of their experiments are in all cases
be Ju-ed
As a rfilttPh eh
m°St CaSGS Sick people hccin9 to
lk cu ea.
as a result it has become a common occurrence for the'
investigator to take risks with patients of which those patients ere
^ohfnthf^hop °r nOt awsr! 3t aU’ and
and to
t0 which
which :hsy P°ulc! ™t
consent 11 they.were aware; to subject them
to
--- _j mental' and physical
+ h»t+^S-uWni+h -S-un G way
v''ay necessitated
llfc!<-essitaced by,
by,ano
ano has
has no
no connexion
connexion with
,
the ^eatment of the disease from which they' are
suf
ferino
•
and
in
rr--~’
■ suff
ering;and
in some
cases deliberately to retard the recovery fkn.areth.'
/di^
so ihat"
‘"“
investigation of a particular condition can be extended. (p.15)
'
'
Sy?^.iARY OF.VIEW-C Oh MXDICAL EXPERIMENTATION: iJCllnical
~
n '. -■ - -----■'■ - --------iu.ux 4. research must go
on.but there must be acknowledged
and observed safeguards for the patients.
2) ThaS2joSw off??U3rd1'SO are
aMN
lrtuallV non-fexisteht
non-Wlntent:.
virtually
>.hose engaged in clinical research act with ths highest
an expanding minority resort to unethical and probably
3) Unless the medical i
7
the
.—u minority,the public outcry'will
•Pz-v
-1
u.•.
v-C4xv,i■
(y
^8)
•'It behoves the medical profession^to take.the ofcfc
t1b1/ into its confidence.
public
--ctMipTM ^id^jrUTbe-^?1
’knoXdof”
from many sources. In the end we have'to c' r’
limits
do exist to, the search for knowledge." (Prof ?P*.A.Freund
j—
gjAr c0NS11
CONSTlTOTES
A Jl 'STIFIABLE EXPERIMENT
EXPERIMENT?? "The
"
^ -'g A_JbSriFIABLE
science of experimental
medicine is something .new and sinisterjfor
sinister if or it
i+ is
iqV'nnbia
rAn^hia of' destroying
e1
=■
lithe
tqe
lives
regard tortheOseSibilitJOwelff°rni iJ1 hfman e^ime^s only°after
due
be violated."(Dr.S.S^KettyJ 1(prll)nd Safety of the subJect nrafet nSver
^-Every act of a dooL
of an easily justifiable 'kinH Th
\qi,Ve? Pa'tien't is experimentation
doctor’s hands i eildence of’cSLo? S S placement of himself in the
one when the -ct^- nf th\
consent. The problem^ becomes a knotty
Of the paH^n? oretenJ H,? YnYC1Hn "G ■dlrected not toward the benefit
squire? I'e ^Lu^onL^ GrPr^2 ? 9^erG1-
Such actiori
more than this;it require! orofLndPatlenP
^o requires
part of the physic-: n fo-^ +hGGUn? thought qnd consideration cn th3
cases so great it i
°f medicine
in some
adequatelf infnrpHPd'ae to the n,vt-WieXG- t!‘G the Patisnt can be
His trust in the" ohvGr n
GW^cations of what his consent mens.
"We shoulri t G? ’
may itad niln t0° easily to say ’y5- ' <(Dr •Beecher)
patient which is'nSt’a^j^G^ purPc3es>re'3ard anything done t o the
therapeuticTenefi?
G+GG? f°r his direct
as constituting an e- pe^imrnJ- TG Gif •
'^egno.sis of his disease,
Of the
• \ kriui .i/icojiice-Frot .ot Expel.Med.
. . .2
t
<
'
Ar
B
!
Ji
j. ,
i
: ■ i"1:W"+ lcna^J-
Theirs is th^ rel -H -'nd- 7
•Si'nds pupil W
oSShton ofMt»
v
e
.
Precipitate their relationship.
'
“Ued SUCh a -l=«onshlp !the’
°rrGn tWV S’Uke bGtween two lov^s,
S75§fS5SSS3Sf7h?-PhVHd‘:ian'P?tient ^iationBhlp of one *0
ic +he Sbi2r+ ^h?h° ly 5S:S °? Whlch theV mset* But *ven though
“C ' su?Ject ln grammatical sense,he is not the ^ub^rt -in
to ol'Sn0?"1
,EV"rV rftort is
“ d«.’"rsotoItocWin /nS '
every subjective factor. Invoked by the driv« for
objecUvity Is the totototo throuoh-
aain if the^xoeriment t- hT hi'® PatleF1* has Personally something to
1 1: \
L er, Wp?flrncnt.directly concerned with the reli -f A-f hi 1
iTv-'i'T"U -&y PPG position is entirely different if there”is no
likelihood of the patient himself benefittino.
~
men+oJrCIan Sroduce
felativelY innoScus to the hardened exp
expert-
patient XPtodEi„WtoWtod toS-;i?tidi"? ’to°od deal of feaz.,11
.
—
--
~
~ x.5 -U. J
4 }
a
something he does not understand
properly. Such distress,endured by the^subjects of experiments,is rarely
recorded in medical publications and often appears to be of small concern
to the experimenters who have <caused it. (is. g .Mas si vs ^laemtorragihg
liver,causing
trivial 'cr-idnnt'-imr
-J1 s u---e s to the paticrit,may be zecordpd as a
• pvrn\ + k
immediately corrected by blood transfusion.) (A.25-^6)
exoXrt 'houSniTbVVhlCTC^n be
saf. ly in the hanSToka tkUled
of +17 liv-r koulriTo d f°? experimental purposes. E.g."Needle biopsy
bioosik ^5 u
T9S-k-d as. Potentially , fatal. Five hundred
first to beYcoZoH^?eri h Wlth°Ut ^J^nt.unly the five hundred and
immediak treltSik ?h?Y ?-ST9 lnt”Peritonea 1 haemorrage demandirfe
anS r^fl Sic!?ion forP?hruk +“St therforI be careful^ selected3
(n-p cj,. 14'1 i "
.!
it
must be present before a biopsy is nc-rfo^mpH ”
(Dr.ohe±lock,a noted medical researcher But what i- a ’real indican
incication'? ibis is the cere of the matter.and ?feSeSo?ntheU5oetorPOiS
’F5 risks and riS>h*s »f
P^lent
be ’--td thto Wen
Tilt
1 — evJbVoni3 “i11 !>9toe,toe view should
justiHed iTaknhtr U 29-Snd.iPR)rmed Patient may not be morally
ovVvnn h 2 acco!jbl?y certain risks. It can be maintained that
~ Y - “"'or'2-' iff t^hmc,1’cl obligation not to run undue risks with his .
own health
patient,then,has no right to involve his
physical or ^^?nlc ^tegrity
thpv
in medical experiment or research when
Pius x!ktJeTQ^tdeTStfUCtion’mu$ilationAoundS or perils "(Pope
.ius XII,Sept.1952,to International Medical Congress) (n 41)
"^r^.x.ny exputoiments are def ;nded by
to the oa+ion-TkX
b °n 9rounds- that while admittedly o+' no help
meSS it il?ibmafT-?Tn bT™ 'T° T th9 sufcj^t,the aimw i such Sperlpaukh Tot^TiT6-1^^’0^019117
^fes-,on’untuspjcting
hop-- of mekinq''sci'entifi7TT'“e dl?oaSe..V?ln9 investigated, solely in the
and thtf nkBT fCrer^S’V4ience is' not
ultimate good,
precedence t7-r
'!ntlu1C kn°wled9e should not be allowed to tc.ke
which is not urrorr-enlv'\UfcS ’ d®re
^W° are in .conflict. The statement
intorectina to
Xn u J
research workers,'It would be
ri--- j...g .o know ,though natural ano,doubtless,frequently true,is
3
=4
medical
EXPERIMENTATION
( Bolow are given excerpts from an cxcollont book by an English
doctor who spent years ’studying this subject and kept a bulging
dossier on th© same. Many moral principles are highlighted
which have relevance to the whole field- of
’n^fitabU
S be hoped that the reading of these notes will be profitable
to all doctors and medical students. )
!
V— ■*
ON
DEATH AND
PYILD
The Doctor face to face with death : Death is a frightful,
fearful happening, which, we are convinced, "happens to other
people", (Franceis Mauriac). Yet it is something the doctor has
to face routinaly in the course of his practice. He must fac®
not only the dying patient but also his relatives to whom he has
to break the news of the impending end. The patient expects his
doctor to stand by him till the end, and in an existential way
will ask the doctor about the odds for his life or demise. And,
inescapably, the queries of the patient will become the question
the doctor must ask himself: 'what is death'? If death is a big
problem in the life of the doctor himself, if it is viewed as a
frightening, horrible, taboo topic, he will never be able to face
it helpfully with his patients. He might hope they will £
bringit up, and would probably talk about other trivial things.
1.
The Physician stands always on the side of life. He must
wage
the
battle against death with all the strength of his
~
wage
must
inspire
in
his
patient
the
competence and commitment. Ho i----- .
■ ~ health, ; But
will to live and encourage the hope of recovering
point of personal
if to live is to- be free, then the highest
] ~
freedom is the courage to face peacefully, the prospect of
imminant death. If the doctor considers the patient s death as
the enemy to his profession, death as a professional battle lost,
then in his desperate struggle against death he will not help
the patient to serenity and balance, strength and effective
personal freedom in the face of death. As a famous physician
writes: "Not only for the dying patient but also forthe doctor,
does a strong faith generate an intensification of freedom.
It allows the physician a full commitment to life without that
obsession which considers death as the greatest of evils, since
we consider death as belonging to the fulness of
free acceptance of death is the only real chance to get out of
that death which seems to destroy all
opportunity to assert our freedom." It should therefore be
the doctor's endeavour to assist the patient in achieving,
peaceful death. Pain should be relieved as much as possibl ,
tat with the'main objective of ensuring freedom and
fear of death, it's greatest terror, should be defeatod. Only
then can freedom mature.
2-
The Moaning of Death :
In acquiring correct attitudes,
as
guidelines.
(a) Death is something which happens to a persog.. Whereas
death can be considered from different angles .
cytological, physiological, philosophical, theological each person apprehends his/her death as an unique y
expressive event. It is not 'a machine coming to a
stop1, nor 'a bit more troublesome form of human
waste' nor 'an affront to our inalienable right to
life, liberty and the pursuit of happiness (Toynb e),
but an intensely personal thing - a stage in living.
The process of dying is in reality the art of living
meaningfully in and through the process of dying,
"heath belongs to life as birth does; the walk is
n
in the raising of the foot as in the laying it down.
(Tagore).
...2/-
- : 2 :
(b) Death is a rcql factor in tho meaningfulness of life•
In the face of death, says Viktor Frankl, as absolute
finis to our future and boundary to our possibilities,
we are under the imperative of utilizing our lifetimes
to the utmost, not letting tho singular opportunities whoso ’finite'1 sum constitutes the whole of life pass by unused.
(c) Death, for the believer, is also a significant religious
event : It is, as it were, tho occasion on-which wo
ratify .the fundamental options we make in life. Those
who, for exanple, believe in Jesus Christ, and in his
passion, death and resurrection, as a salvific event,
gain a new vision of death. Christ transforms death
into the greatest manifestation of trust in the
Father and love for all mankind, For tho Ghristicn,
death opens on to life eternal. Every doctor should
try to bo cognizant of the hope and faith of his
believing patients, the better to help them to face
the prospect <f death with equanimity.
3.
The Monont, of Death : In view of organ transplantation, this
question has acquired special significance. After all> a person
dying is still a person living, and he keeps his elimtntaiy
hunan rights up to the monent vten life becomes extinct.
In short, the principle that brain death is synonymous
with the death of the patient (or death of the person) has
found universal agreement. A Halyard University team that
studied this question in depth give the following criteria:
"It stated that in order for brain death to bo designated tho
subject should be in deep’ and irreversible coma; manifest a
total un-awaroness to external painfuj. stimuli; have no
spontaneous muscular movements or responses to external stimuli;
have no respirations when not in resuscitator; have no- olicitablo
rcflexos; have pupils fixed, dilated, and unresponsive to light;
and have an isollectric KED (flat EEG) , with the foregoing
characteristics having been main tainod over a period of 24 hours."
(Archives of Internal Medicine, 124 - August 1969 - p. 226-227)
4.
TUE PROBLEM OF THE PROLONGATION OF LIFE' AND EUTHA^IA> "
Tho right to live humanly implies tho right to die humanly , i.o.
with dignity and in freedom. Does this mean that the patient has
tho right to end his life or the doctor to assist him in doing
so? In a recent document, the American Hospital Association
approved a 12-point Declaration of Rights of Hospital Patients,
which grants to the patient the right,. among others, "to refuse
treatment, to the extent permitted by law, and to be informed
of the medical consequences of his action". This implies that
an adult patient with no prognosis for recovery has a right to
die without medical therapy. The point is: would this "right
to die" justify the patient in asking the doctor to end his
life, or justify the doctor in presuming this consent and
acting in such a way as to cause death ?
THREE POSSIBILITIES : In the management of terminally ill
patients, or patients whose brain has suffered massive
destruction to the extent of being irremediably non-function!ng,
there are throe major options :
(1) withdrawal of artificial and/or mechanical life-support
systems (i.e. non-interference with death);
...3/-
I’ I
-:3s-
(2) administration of pain-relieving drugs whicli wil! have
( }
effect, among other effects of accelerating the
death process (i.e..hastening of death)
Administration of death-inducing or life-terminating
(3) ^5 (K deliberate action calculated to cause death).
death) .
I think it is arguable, says L- H™ Snith (ETHICS AND THE NEW
MEDICINE o. 167) that options 1 and 2 are now morally licit
“u. th’, m^g-ht of
Jatl.ht., hut that option 5
stend and apply the dispensability v
of both extraordinary and ordinary moans which are n
■rpmnrHes
The line between options 2 and 3 is a fi
>
I know; but it is reinforced, by the awnreness
science and technology have developed many possibili
Which we^ave not yet developed the ethical wisdom and moral
sSna necessary for exercising humanely responsible control.
SOME NORMS ; In arriving at a morally discriminating decision,
the following norms should be kept in mind.
(1) "A human person owes it to himself and to his community
(to his family, to the society m which he lives)
kip hL So Intat
hot to destroy the r* that
it represents. Human life lived in a personal way is the
teslXt1 can rind In this world. »ethl»S else
arywhore near it, in the hierarchy of values. It
follows that both the individual and the cousminity has
a duty to do what can be reasonably done to preserve
human life. This duty exists in the patient, in th
doctor. In the lewyej 1» the priest, In dl who shm-o
a responsibility for life*
(2) Man has a right to his own dignity as a person even in
approaching death. Therefore, once the r0^able
Xis to keep him in life have been exhausted, he is not
bound to destroy his dignity by exPQC^^kt0£^
alive without being able to live^ to think, and
Sei ." person. Ro one Is bomd to ask for nedxcntxon
that would prolong the agony of death.. The so
principle is valid for the community; its membors arc
not bound to prolong the agory for a human being.
(3) There will always be complex situations and borderline
cases where a cloar moral judgment cannot be formed
within the short time available. In this case w
have to respect those who, animated by the first two
principles, make a genuine effort to bring gout the
best decision even though they may fell to find
there and then. Yet the effort itself was good
and the resulting situation should be accepted as
the only reasonable one in the circumstances.
(4)
"I would urge that we promote the idea of benemori,
a dignified death, in the dying patient, There is
no need to prolong the dying process, nor. is there
ary moral or medicgl justification for omg s
Euthanasia, that is the enployment of direct
measures to shorten life is nover justified.
■Bene mori1 that is, allowing the patient to die
peaceably and in dignity is always justified.
...4/-
- : 4 : EUTHANASIA : Etymologically the word means ’’dying well”. But the word
has now come to mean ’’easy dying”, for it implies medical
intervention to cut short life by causing death. We must .
distinguish between euthanasia which is claimed as a legal
right, and euthanasia as a moral option.
(a) Legal euthanasia: Advocates'of euthanasia as a
legal right of every citizen can be understood
to speak of euthanasia in two senses:
(i) in the-strict sense : i.e., ”to cause
death (or to assist in causing death)
to a conscious, certainly incurable
patient who requests that his agony
(physical or psychical suffering) be
terminated by a calm and painless death”.
(ii) Ina wider sense : This would include:
(a) to cause death, at the instigation
of pity, to an unconscious dying person,
to monsters, the seriously insane, etc.;
(b) to cause death, for the sake of
society, to a socially dangerous person,
and in general to persons who cannot
live morally useful lives within
society (the so-called ’eugenic deaths’,
and disposal of useless persons e.g.
the aged, mentally retarded etc.)
The judgement on this has been succinctly formulated by
Pope Paul VI when he wrote to the International
Federation of Catholic Medical Associations: ’’Without
the consent of the person, euthanasia is murder. His
consent would make it suicide.”
x
(b) Euthanasia as a moral option : Hero it is
customary to distinguish between (i) Direct or
positive euthanasia: i.e. the rendering of
assistance in order to- cause death, This can
never be allowed, (ii) Indirect.or^egatiye
euthanasia: i.e. the administration of
treatment, e.g. for the alleviation of pain, which
has.as a side effect the acceleration of death.
Here, we could also include the stopping of those
procedures which only prolong the process of
dying, while they hold out no hope for life.
This should better not be called euthanasia at
all, and in fact is morally licit.
FINAL
SUMABY
We can summarize all that ha~s been said above, in an organized
way, by quoting extensively from a lecture given by Dr. G.B. Giertz
at a Giba Foundation Symposium on ETHICS IN MEDICAL PHDGRESS: with
special reference to transplantation. Ho writes; ’’The subject of
euthanasia poses now problems in medical ethics. Tho central point
is whether we can establish the moment when life ceases to have any
human value; this is essentially the same central problem as in
abortion, although it is then a question of deciding the time when
life begins to have human value. Both problems force us to face up
to the question of whether man can draw such a boundary that he can
disregard the obligation to protect life. There are essentially two
possibilities. Ono is to leave the duty to protect and preserve
human life umohditional. .Such a view implies that man lacks the
...5/-
I
- : 5 : -
ST»°a S"1—
individuals ana sending th.rr
^cfh+ or daorived of the power
grave changes in personal! y, wi
P °
t f tho vaiuo of human
of locomotion, actually a gain from the asp®t of tho vax
life"’ In this connexion tho economic factor has boon nonui
Uto
/»
»’“ :>■»
SSil8 aooiae
ZMtSS «h«t is not, «na direct our reoouroos to tho
former?
+T , » +Mvrl factor has entered this discussion, namely
More recently a third factor h
attitude is that in
the question of the dignity of life ™dJ^\r7 to ^t so that the
the treatment of the hopeless case we shoul ^ry^t &
p0SSible
patient, in spite of everything, - *
Much of our me(3ical effort
and is freed from pain as f<J as P9ssib
hoose the path that appears
is concerned with achieving these ends.
® Pfe
thus
to us to be tho wisest from the human amwhen
do „t Itall our consideration
“ kmcult to
ft’hs »” - ”l°"e“dX:»i.g“:
S i.’X
teSish»d
XdX^td
should take this into eccoun :L^1^UF C flowed to run its course. The
is a natural phenomenon and ^d be allowed to ™
to
a
thought that we physicians should be obliged, forin
patient alive with a respirator w^n there is no possibly
,g &
recovery, solely to try to pro ong
terrifying one. It must beyarded
m^dic^l B'iom that one should
-^.^rolong life,
not be obliged m every situation
untenable situation and
Such an obligation would rapidly
point is that these
spell disaster to our hospital organization, ^ho^oin^^
considerations are purely me
refrain from treatment because
object of killing the patient. ^ ^^Tt is not in the patient's
it does not serve any purpos
'
medical means I death has
interest. I cannot regard this as killi o
accept thQ
already won, despite the figh we -P can’enable us to solve
fact. Only the recognition of this lin.
^onizing One 2:
XX of life when it has already been
bereft of all its potentialities .
”o*O^O*O^O*OX)*O*O*O*On
DP:e£
5
ON
DEATH AND
PWEi
The Doctor face to face with death : Death is a frightful,
fearful happenli, vhieh, ve
dootor h»
1.
»E “S Sea
doctor to stand ty him till the end
will ask the doctor about £he °dds Jor Ms
inescapably, the queries of ho P
aeath’^
the doctor must ask himself; 'what is death ?
SSnSgXSble ' X0joplc
Zd,
quQStion
If death is a big
If
ag /
fa0°
The Physician stands always on the side of life. He must
wage the battle f.-gainst death
pj^^^his patient the
““X t£ Fr
llasat loath.
If tte doctor oohsxdors th^patxout
It allows the physiolan a
of S, sines
obsession which considers death a
ilnoss of life. The
« consider death as
teJJto get out of
S Xl&lSV astro, ^1 our
^XCnS^to
patient In —
fear of death, it’s greatest terror, should
then can freedom mature.
2.
acquiring
Tte Heonto st math . In ?
q«in« com ait
and
answer S
l----toto
Swtlon.
few points
points «=
nWhat is the moaning of deathf rseiow eu. &
guidelines •
(a) Doath is something which happens to a persog.. Whereas
death can toe considered from diiier^nL angles rv+olosi-al physiological, philosophical, theological
OeX£=»’«PP~“ hls/hsr death ss »
’
expressive event. It is not -a machine caning to a
stop1 nor 'a bit more troublesome form of human
unqte’ nor ’an affront to our inalienable right to
life liberty and the pursuit of happiness’ (Toynbee),
t^an^intensely personal thing - a ^age in li-ng.
The process of dying is in reality the art of livi g
meaningfully in and through the process of dying"heath belongs to life as birth does, the walk
in S raising of the foot as in the laying it down. n
(Tagore) .
...2/-
(b) Death is a real factor in the mcaningfulness of life*
In the face of death,: says Viktor Frankl, as absolute
finis to our future and boundary to our possibilities,
we are under the imperative of utilizing our lifetimes
to the utmost, not lotting the singular opportunities whose ’finite’ sum constitutes the whole of life pass by unused.
(c) Death, for the believer, is also, a significant religious
event : It is, as it were, the occasion on which wo
ratify the fundamental options we make in life. Those
who, for example, believe in Jesus Christ, and in his
passion, death and resurrection, as a salvific event,
gain a now vision of death. Christ transforms death
into; the greatest manifestation of trust in the
Father and love for all mankind. For the Christian,
death opens on to life eternal. Every doctor should
try to be cognizant of the hope and faith of his
believing patients, the better to help them to face
the prospect si death with equanimity.
3.
The Moment of Death : In view of organ transplantation, this
question has acquired special significanceAfter all, a person
dying is still a person living, and ho keeps his elimimtary
human rights up to the moment when life becomes extinct.
In short, the principle that brain death is synonymous
with the death of the patient (or death of the person) has
found universal agreement. A Halyard University team that
studied this question in depth give the following criteria:
s,It stated that in order for brain death to be designated the
subject should bo in deep and irreversible coma; manifest a
total un-awareness to external painfuf stimuli; have no
spontaneous muscular movements or responses to external stimuli;
have no respirations when hot in resuscitator; havo no elicitablo
reflexes; havo pupils fixed, dilated, and unresponsivo: to light;
and have an isollectric ESI (flat EEG), with the foregoing
characteristics having been maintained over a poxiod of 24 hours.t!
(Archives of Internal Medicine, 124 - August 1969 - p. 226-227)
4.
THS PROBLEM OF THE PROLOIGATION OF LIFE AND EUTHANASIA.
The right to live humanly implies the right
__o_ to. die
. _ humanly
/ , i*e.
with dignity and in freedom, Deos this mean that the patient has
the right to end his lifei or the doctor to assist him in doing
the American Hospital Association
so? LIn a recent document,
_
approved a 12-point Declaration of Rights of Hospital Patients,
which grants to the patient the right, among others, "to refuse
treaiznent, to the extent permitted by law, and to be informed
of the medical consequences of his action". This implies that
an adult patient with no prognosis for recovery has a right to
die without medical therapy. The point is: would this "right
to die" justify the patient in asking the doctor to ond his
life, or justify the doctor in presuming this consent and
acting in such a way as 'bo cause death *
THREE POSSIBILITIES : In the management of terminally ill
patients, or patients whoso brain has suffered massive
destruction to the extent of being irremediably non-function!ng,
there are throe major options :
(1) withdrawal of artificial and/or mechanical life-support
with death) ;
systems (i.e.■interference
non-'-...3/-
I
I' I
- : 3 : administration of pain-rolloving drugs which will have
(2) tte oftet, among other effects of sooelorating the
death process (i.e, hastening of death)
(3)
says L. Harmon
proeeduros’h ths management of tomlnJ- or ^“-^"X^den.
Is a
remecao
■
n-forae^ by the awareness that medical
SOME NORMS : In arriving at a morally discriminating decision,
the following norms should be kept in mind.
(1) ”A human person owes it to himself and to his communi y
.i which
he lives) to
(to his family, to the society in
...
destroy
the value that
keep his life intact and not. to d.
■
*
l a personal way is the
it represents. Human life lived in
unc w we can find
in this world. Nothing else comes
bestu that
:---------• •• IX^hore^near it, in the hierarchy of values.
IMt toti the inaivxduel «>d
=
a duty to do what can be reasonably done to presorvo
human life. This duty exists in.the
J
doctor, in the lawyer, in the pnest, in all who shar
a responsibility for life*
(2)
(3)
(4)
Man has a right to his own dignity as a person even in
approaching death. Therefore, once the ^^ona
Sins to keep him in life have been exhausted, he is not
bound to destroy his dignity, by expecting to be kept
alive without being able to live, to think, ^.to
XE as person. No one is bound to .ask for medication
that would prolong the agony of death. The seme
principle is valid for the community; its members ar
not bound to prolong the agony for a human being.
There will always be complex situations and borderline
cases where a clear moral judgment cannot be formed
within the short time available.
this case we
have to respect those who, animated by the first two
principles, make a genuine effort to bnng about the
best decision even though they may fail to find
there and then, lot the effort itself was good
and the resulting situation should be
a3
the only reasonable one in the circumstanc .
"I would urge that wo promote.the idea of
a dignified death, in the dying pationt. There is
no need to prolong the dying process, noris there
ary moral or medical justification for doing s .
Euthanasia, that is the employment of direct
measures to shorten life is never justified.
’Bene mori1 that is, allowing the patient to die
peaceably and in dignity is always justified.
...4/-
- ; 4 s -
EUTHANASIA : Etymologically the word means "dying well". But the word
”
has now come to mean "easy dying", for it implies medical
intervention to cut short life by causing death. We must
distinguish between euthanasia which is claimed as a legal
right, and euthanasia as a moral option.
Legal euthanasia: Advocates of euthanasia as a
legal-right of every citizen can be understood
•to .speak of euthanasia in two senses:
(i) in the strict sense : i.e., ”to cause
death (or to assist in causing death)
to a conscious, certainly incurable
patient who requests that his agony
(physical or psychical suffering) be
terminated by a calm and painless death’1.
(11) in a wider sense : This would include:
(a) to cause death, at the instigation
of pity, to an unconscious dying person,
to monsters, the seriously insane, etc.;
(b) to cause death, for the sake of
society, to a socially dangerous person,
and in general to persons who cannot
live morally useful lives within
society (the so-called ’eugenic deaths’,
and disposal of useless persons e.g*
the aged, mentally retarded etc.)
The judgement on this has been succinctly formulated by
Popo Paul VI when he wrote to the International
Federation of Catholic Medical Associations: ’”Without
„
the consent of the person, euthanasia is murder, His
consent would make it suicide.”
(b) Euthanasia as a moral option : Hero it is
customary to distinguish betwoen (i) Direct,or
positive euthanasia; i.e. the rendering of
assistarce in order to cause deathj This can
never be allowed. (H) Indirect or negative
euthanasia: i.e. the administration of
treatment, e.g» for the alleviation of pain, which
has as a side effect the acceleration of death.
Here, we could also include the stopping of those
procedures whidh only prolong the process of
•dying, while they hold out no hope for life.
This should better not be called euthanasia at
all, and in fact is morally licit.
FI NAL
SLW1ARY
Wo con sunmafize all that has been said above, in an organized
wav. bv quoting extensively from a lecture given by Dr. G.B. Giertz
at a Giba Foundation Symposium on ETHICS IN MEDICAL PHOGRESSs with
special reference to transplantation. He writes: "The subject of
euthanasia poses new problems in medical ethics. The central poin
is whether we can establish the moment when life ceases to have any
human value; this is essentially the same central problem as in
abortion, although it is then a question of deciding the time when
life begins*to have human value. Both problems force us to face up
to the question of whether man can draw such a boundary that he can
disregard the obligation to protect life. There are essentially two
possibilities. One is to leave the duty to protect and preserve
locks the
h,iro,n life unconditional. Such a view implies that man lacks
...5/-
- : 5 : •
4-v^ t
nf life and "to iudge what is a valueless
right to deteroine the length of life is outhanasia, for
life and what a valuable one. The second P03^^sOT of pr£cticai
which there aro strong advocates in S
J P
repairing damaged
philosopy asks: "Is the physic:ian ^^cXd Se' blind or deaf, with
individuals and sending them
denrived
the
power
deprived of
of of
"thehwan
power
grave changes in personality, with poor S1J^.^/^Xe
!f locomotion, actually a gain from the aspect of ^J^oned. Is
life”9 In this connexion the economic fac
with
who might qualify tor it,
^oospt that man shall docile
f°’BSo Si what is hit, - direct our resources to th.
former?
More recently a third factor tas ohterod
the question of the dignity of life and Jeath.
y
the treatment of the hopeless case we shoul
ry
la
ec
possible
ss x
-
do not limit our considera ion op
qps .? + is not difficult to
Shall „ giro up «
gon. »
? ght »th all-. m.r. at our
Butwh.n
is a natural phenom™ and should be allowed to run
thought that we physicians should be obliged
“™UV of
patient alive with a respirator when te 1= »»
g
13 „
reaver,, solely to
to prolong his life by P
one should
terrifying one.. It must be ^gareuG
to prolong life•
not be obliged in OTe^/ltu.aJ^n1^dU^ *n untenable situation and
Such an obligation would rapidly
noint is that these
spell disaster to our hospital
“'stop Is Sen with the
considerations are pureiy me ice
treatment because
object of killing the patrent. ^nXit is not in the patient's
it does not serve any PufP°^’
kililng by medical means: death has
interest. I cannot
have put 3, and we must accept the
already won, despite the fig
P
enable us to solve
fact. Only the recognition °fs i
ht of doath
agonizing one
S SX "ftoS?
S Sf. «h« li has elroady >»«
bereft of all its potentialities.
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I
course of Medical Ethics
T' >pics c1 ealt Fith in the present
- LEOTUHES:
I.
v/hat is Medicel Ethics? (vs. medical etiquette)
Basic principles of Medical Ethics.
The Concept of Health - a total perspective,
Health care priorities ant? social justice.
The Dec jOX —patient relationship
medical
-ihili- 7 to the
indiviaua- and community.
- the doctor vis-a-vis social legislation
1.
2.
3.
4.
- the medical secret.
II.
PROBLEMS CONWCl?ITH._THg_JgCTNNING OF LIFE
Artificial Insemination
Gonotic engineering
Abortion
5.
6.
7.
III.
FTOLWS. CONNECTED. WITH SFpJALI^^D MAKRIAGE
Moaning of human sexuality
Contraception
a) Motives and methods
b) Morality
8.
9.
10.
11.
12.
IV.
V.
ly.i' lui
homosexuality)
jICE
mrrto*. counselling ( e.g. TO of patient and
oSUge-tlons to partner, sterility, inpotenoo)
INTEGRITY OF THE 30BY AND
PkOBLEfaS CONNECTED gITH THE '" '"OF THE __ggB.S0N7^
13.
14.
Mutilitation, sterilisation
and
p s yc he s ur g e r y, p s y cho the rap y , narcoanalysis
hypnotise#
15.
Experimentation on human beings
PROBLEMS COKNgCTED,^g.ITH TgEJjND .OF LIFE.
16.
17.
18.
VI.
lirt-y sexual _ty (o.g.
The meaning of Death
Telling the truth to the patient
of Euthanasia.
Prolongation f life and the problem
SPECIAL SECTION.
19.
20.
Alcoholism and drug addiction
haemodialysis)
+
( Blood transfusion &
**********
O'
J. .
I
>
—
MEDICAL TECHNOLOGY - _ETHTC AL^IgS
TY* health
'JATFir.tHooriSc
bangalohe- Anil Pilgaokar -
CELL
The practice of medicine by it- very' nature (a) invades the privacy
of individuals (patients) and <o) is vulnerable towhat may be
best termed "rationalized misuse/illuse potential.
lu is m this
context that ethical facets of Medical Practice become very
important.
"Technology" (described as the "science of indus ri
arts" - Consise Oxford Dictionary) by its very genesis lends
itself to commercial exploitation.
It is m this light that
ethical issues of'.medical technology become of ^paramount impor anoe
but alas this is a neglected subjec : m the meoical circles.
It
is with this at the back of the mine that we felt tnat it would
be of pertinence that there is at least some sort of debate anc
discussion on the subject ar.d hence this
must be
■clarified at the outset that we are alive to the rather dismal
prospects of putting before you a comprehensive paper before
you but then that is neither our claim nor our aim to do soo. >
There are limitations of data and more importantly our own.limi
tations which prevent us from taking any firm positionin
respect of many topics covered in the paper, but then it is ou
hope that vigourous (rigourous) deliberations at the MFC moe^i .g
would be helpful in (a) clarifying the grey areas on tne one
hand and (b) taking up some position (s) in respect of many aspecuo
discussed in the paper; (which primarily is concerned witn
raising some questions for discussion) .
r
Admittedly medical technology is a broad term and it would be
purposeless to dwelve on every technology concerned wita
-e
practice of medicine; for that matter even commonplace injection,
could be concieved as ' technology, _ and it would be 3u:Lte Jpoint j.es
it Is
to discuss the ethical aspects of injections 1here*. Rather
.
sophisticated
and/
our intention to restrict ours' Ives to newer :
or pervasive medical technologies «>
In very crude te^ms, for t. he
purpose of this paper we shall ignore the "first generation
like ,say
technologies" (to burrow the current 'in* expression)
.
X-ray machines, and devote the discussion to ‘higher generau. on
technologies" like CAT-scan or PET-scan«
Gr ouping/Catagor ization of Tech no 1ogles. ?
In our sarrvoy
surrvey of literature we have act come across any group ing
of the various technologies harnessed in
or lcatagorization
_
medical practice: but for the purposes of? :nis paper it is
t the
important to device one and so even a_
... risk of being challenged
we have resorted to the following classification
(i) Function replacement medical cechnologies eg0 Heart-Lung
machines or say renal dialysis units; cardiac- pace-maker etc.
i
(ii) Investigational-aid medical?. technologies like CAT-scans
sonography; echo—cardiography; and its sub-class (ii—a)
"Investigational-aid extendable (in some cases) to curative
medical technologies like some endoscopic insurumentso
(iii)
"Control technologies" like contraceptives, vaccines, and.
artificial life-support technologies, and of course genetic
engineering and sex-preselection techno..-.ogies•
Each as a class would have its own ethical considerations in
addition to general ethical considerations■ o zA priori, the above
for -increasing stringency in
classification suggests a need
n-- -ethical considerations with each class of the medical technology.,
Whereas the benifits risk as also the costs benefit evaluations
vis-a-vis respective populations must form a case for assessing
the relevence (in ethical terms) in all the three classes or
technologies but it is evident taat in the first class, the
.2. .
-
2
ethical considerations would mainly relate to ‘operational’ part
i.e. use; mis-use; denial of use as also the fees for services
etc. The ethical questions in this class mostly relate to the
individual patient and the'institution (investigating centre)
policies. In the next class (ii)z the ethical questions -- all
ethical questions relevent to the previous class are indeed
pertinent but in addition, because of the enormous costs of
some of the instruments involved ethical considerations in
National priorities also must form important facets as many of
the instruments lock up and siphon significant monetory
resources, and thereby quite often affect (adversely) other
medical facilities by depriving funds for these..In
I*. the
-L- last
classt, even more wider questions relating to demographic,
individual rights vs rights of societies, right (?) to manipulate
human systems and forms etc. could figure-r
(i)
Function replacement technologies:
Admittedly most of
these technologies are indeed ’life-saving' in critical
conditions. But when the question such as whose life?
become appearent (as in many cases in our setting do).then
ethical issues do arise and these need to be debated in
full measure. We shall take just two illustrations to
initiate the debate.
(a) It is well-known that in a renal dialysis unit
priority for dialysis service is given to acute cases
rather than chronic renal failures. Again there is a
long waiting list for routine dialysis of chronic renal
failure patients (who have to be placed in a queue system
because of the paucity of dialysis units.
Even so when
”J.P.” needed dialysis (Jaslog Hospital) he got precedence
over others. With all regards for the noble man, the
question of whether life of other citizen is worth anyless
needs to be taken up.
Again, the dialysis serves as a temparory respite until
the organ teransplant arrangements are available, and.
it is at this juncture that further ethical issues ariose..
Should kindney of a young person be transfered to older
person? The obvious answer is No.
Yet one finds that
kindney from a young woman (16) being transplanted on
to MGR - knowing that, the leader was close to his grave.
The "organ trade" racket with the conivance of the medical
profession has been highlighted in lay press and yet the
ethical questions have not been raised in relevant
bodies
It must be conceled that the examples quoted above, are
not strictly ethical issues of medical technology,
rather they are issues related to 'medical practice'.
All the same these are so intimately connected with the
technology usage that the mention made here would not
be totally out of place.
(b) Cardiac pace - makers are fairly widely used in
our country. And for harnessing this technology
Intensive Cardiac Care Units (ICCU) are essential.
The usefulness of these units is widely known and
ac?<nowledged. What is not generally appreciated is
that in our settings is that a proliferation ofsuch
units could actually impede the quality of service
(medical service) in other faculties of the hospital/
institution. A bed in ICCU could cost (to the institution)
.,3..
A
3
some 100 times more than the bed in say a general ward
(of a public hospital). With relative crunches on the
budget of the hospital, the pinch for resources is felt
by other facilities. A..y keen observer, who has observ
the "progress" of some of our premier public hospital
in last two decades, could not have failed to notice
that with the advent of super-specialities (like ICCU,
Artificial Kindly Units and the like), there is a steady
Sp
degradation in the facilities in other departments,
we have a situation where the best of the facilities
would be available in these highly specialized units and
at the same time there would be acute dearth of common
requirements like cotton, lint and linen in the general
wards of the same hospital.
Even at the cost of increasing the length of the paper
let us labour over this point a little more. It would
not require statistical figures to state that the
incedence of tuberculosis in the city of Bombay far, far
exceeds that of CVDs. Dr. Amar Jesani ( Economic
Political Weekly, Se.pt. 24, 1988) has pointed out that the
deaths due to TB in1the city have increased over the years
thus emphasising the increased requirement of hospital
beds for TB in the city, but these have in fact been
reduced by Bombay Municipal Corporation (paucity of funds)
in the only hospital for tuberculosis in the city of
Bombay; whereas there is a spurt in the ICCU beds in the
— ’beds
(And mind you the ICCU
cost• somej 100 times
city.
of
ICCU
beds
in
the
city(in both public
The number c_--more)
are
some
30 to 35% that
and private hospitals together)
of the beds in the TB hospital
Is this due to class biases ? CVD is a rich man’s diseIs it 'ethical’
ases and TB is a poor man’s diseases»,
At
the
cost of TB beds ?
to permit spurt in ICCU beds ?.
~
■
(ii)
i
»
■■
■
.
Investigational-aid medical technolociess- In this group
there are technologies that ’affordable’ only to insti
tutions as for example CAT-scan instrument and there the
ones like sonography (ultrasound) which can be found with
individuals too. What is peculiar, atleast as far as
Bombay is considered is that none of the public hospitals
have these as of today. And this brings out two possible
reasons for this viz(a) the aquisition of these instru
ments is primarily for ’marketing’ reasons - marketing of
’image’ of the institution and(b) the law of diminishing
returns impedes the aquisition of these instruments in
public hospital i.e. the additional benefit in invest!gations with the aquisition of these instruments is not
commensurate with the hugh cost of aquisition, operation
and maintenance of the instrument□
It is true that public hospitals have little access to
recovery of costs from the patients (even when these h^ve
resorted to collecting partial fees from the patients (in
Maharashtra).
-.But in private hospitals fees are.
be unthinkable
to operate
levied for services, it would
---- --these instruments (CAT-scan) if these are to be used s alely
used in well selected cases only. This is because.the
capital investment (around Rs.30 lacs) and allocation for
operation and maintenence (another Rs.30 lacs) would work
out in annual interest of Rs.10 to 12 lacs, which would
have to be acrued from the patients, (i.e.Rs.l lac per
month)« And considering that the time required for 'processing* a patient is 2 hrs and an 8 hr working period. i_t
.4
4
would mean to break even this Rs» 1 lac would have to
be recovered from 120 patients or Rs o 833/- per patient <>
The question that one needs to consider is that would
there be 120 truely well selected cases for such scan,
in a month, every month, every year ? If the answer is ■
NO then it follows that patients who do not require such
an investigation would also be enlisted for such investi
gation - which seems to be the case indeed. How does
this stand on ethical grounds ? How does one ensure that
such trend is checked ? reversed ? Could there be a
Could there
well laid down norms for selecting cases
be an audit of such investigations ? Who would conduct
such an audit ? These and many other questions will need
to be answered.
Sonography s2 Ultrasound technology ; This has been the
domain of obstetricians and many obstetricians perhaps
aquire this instrument for 'image’ purposes. The.pre
mise that the technology is ’safe' (is it conclusively
proved ?) has led to rampant ill-use or mis-use. Wides
pread (though unconfirmed) reports have indicated that
this technology is used to detect pregnancy when cheaper,
more accurate and non-invasive pregnancy tests are freely
available.
One reason behind this is to enable to charge
fees (ususally exhorbitant) for the investigation. How
ethical is this ? What does one do to prevent this ?
What are the situations when use of this technology is
rational ? Can there be an audit?
(iii)
Control technologies 2- These are perhaps the most^
‘impactful* and controversial technologies, and ethical
as also philosophical must be discussed.
Contraceptives technology s There has been a shift?, in
4-r> '«
technology (ies) ‘progressing’ "user-safety'*•I to
"contrace
ptive duration of action" (from condoms & diapharms to
‘implants’); there is a shift from "user-control *
(condoms & diaphrams) to "doctor-control" (implants).
The shift has been from birth control to- population
control.
Is this ethical ?
In the case of doctor-control (and therefore state
control) contraceptive if there is a contraception
failure should it not merit compensation ? Is consent
necessary ? imminent ? Is it sought to ?
The question also arises of ‘doctored* results of field
trials ? Should there be a third party audit of the
field trials, particularly since there is an obsession
to pushing these technologies.
Vaccines 2 These technologies being a part of Preventive
Medicine are state mediated and at general population
level some questions need to be raised.
Is consent a
necessary pre-requisit before vaccination ? In the event
patient not be compensated ?
of vaccine failure tshould
--- — the
.
Can vaccination be forced in epidemics ?
■
"foeticide
' ’ ■* j 2 Sex-determination
Sex-preselection /
/ selective
and Sex-preselection technologies
and selective foeticide
:
. ..5
i
5
are the ones which have discriminitory and demographic^
upset potential of the worst kind and yet these techno
logies are vigourously persued. In extremely small
number of cases where a particular sex foetus could
jeopardize the life of the pregnant woman can these be
justified if at all.
Even so there are no laid down
ethical codes in respect of these at all.. Apart from
catering to individual passion for a particular sex of
• spring, scientific’ ego of achieving control over life
processes, and' a- political handle to manipulate sex
comoosition of a population, these technologies.have
little to offer to mankind. The basic premise m medical
research is to improve the quality of human sustenance
These technologies have very little to offer in
direction (except perhaps cases:mentioned above.)
But
they do have an enormously large adverse potential.
i
Should such technologies be* allowed to be harnessed in
medical comunity decrey
the country ? Should not the
u.
these technologies on ethical grounds ?
Genetic
Genetic Engineering
Engineering ; These technologies'can have extre
mely widespread manifestations and carry with them die
otomous repurcussions.
It is with this at t e ac o
mind that there needs to be an extensive debate on the
merits and demerits of these technologies to work out
rigid code of procedures.
The justifiable purpose of genetic engineering (wej are
aspects of genetic
restricting ourselves only toj medical
i---rectify
genetic
aberrations
engineering only) can be to ------.
' l can
(note the avoidence of the word abnormality) which
and
nothing
have disasterous or agonizing consequence
more.
However as things stand today the commonly per sued
(and commonly percieved) goal of the technology is to
rectify genetic abnormalities and improve the quality
( of genes ? )» Just what is abnormal? What is improvement in quality of genes ? On this there is no final
word. What is more it is unlikely that there could be
any final word on this, Allow us to elaborate this
further.
i
Genetic aberrations like Down's syndrome; inborn errors
of metabolism; juvenile diabetes (?).can have disas
terous consequences and genetic rectification coy
possibly avoid these con-sequences and perhaps this
technology could have credence in these areas.
say,
if a person has six fingers on his/her hand, there is no
reason to label him/her as ABNORMAL just because he/she
does not conform to the commonly percieved frame of
reference, since there is no physiological/physical^agcj>ny
This line of argument can be
or distress emanating.
extended to ridiculous but effective extent thus.
Blond hair, blue eyes and £-1fair skin is normal to certain
;
la dark skinned/ dark eyed and black hatred
peS^i^thi^populatioWwould be ABNORMAL would generic
in this population would be ABNORMAL would genetic
engineering experts like to 'improve'’ (?) this individual
to fair skin, blue eyed and blond haired person. Decades
. . ,6
6
earlier an ’engineer1 attempted to do a similar exercise?
his name was Hitler and his goal was called Fascism.
Can genetic engineering lead to camouflaged^Fascism ?
What are the ethical and philosophical positions one
takes on genetic engineering ?
Life support technologies employed in lengthing ’vegitative* forms of human (inhuman) existence ? Prolonging
'life* with total disregard to QUALITY of life is not
uncommon these days Is this ethical ? Is it ethical to
perpetuate incapacitation ? ^Tiat is the position one
takes on this issue ?
Research What are (should be) the priorities in research for
developing technologies ? Who takes the decisions ? Miose
needs (what needs) are given importance ? These are the.crucial
guestions that need to be answered. The situation existing today
is not one where ’independent' medical scientists engaged them
selves in research and lead to discoveries. Today he or she is
either employed directly by commercial corporation or if not is
his research effort is heavily financed ( and therefore contro
lled) by commercial corporations (for profits) in the name of
'service to humanity’. The commercial priorities invariably
leed to secrecy, unethical conduct of research (witness the
contraceptive research) and 'doctored results' and when scien
tific expertise and commercial power combine (as it is today)
all this become ever so easy and free from challenge.
If there are strict laid down norms for drug research, why can
their not be similar rigidity of conditions in research for
developing technologies ? The guestion of consent in research
& in practice is a virtual farce.
Ethics of research and prac
tice is evident by its absence. Use of technologies to serve
defence medicine - whether right or otherwise - can be a matter
of debate in United States but in India (today) does it have any
place ?
Fears s
There can be no conclusions to a paper of this sort only
FEARS. When one overviews the situations one distinctly gets
the impression that the entire persuit is one of concentration
of power, centralization of power - Medical Power; Contraceptive
technology is shifting from end-user control to doctor-institution
control. High priced instruments are phasing investigation patho
logy from individual doctor to institution.
Function replacement
technology vulnerably chains the patient to medical establishment.
Artificial Life Support systems virtually confines the patient.to
institutions with ~very little else. Through selective foeticide
and sex-preselection technology, medical establishment aquires a
manipulative potential and this is further compounded with
emergence and proliferation of genetic engineering.
We have had
-- •
■’ • ’
r we have had religious
political leaders controlling
populations,
leaders controlling populations. Will
U^ll the
LI-- Medical man ; Commerce
man combine also jump into the arena ?
NOTE
2
We appeal to your generosity and pardon us for stretching
the point to ridiculous extent but believe us the intention is only to provoke discussion.
— oOo—
!
7
/
<
■
01.04.1999 (Thursday)
9.30 — 10.00 am
Session 6
Summary of previous day’s
proceedings___________________
Dr. V.L. Pattankar
Dr. T.K. Nagabhusfoanam
10 - 11.00 am
Session 7
Teaching/Leaming Ethics in Medical
Education: Problems; opportunities
Dr. C.M. Francis
11 — 11.15 am
Coffee
11.15-12.15 pm
Session 8
Ethics Teaching Programme in St.
John’s Medical College, Bangalore.
Dr. Prem Pais
Dr. G.D. Ravindran,
Dr. Sanjiv Lewin
Dr. Fr. Kalam.
12.15 —1.15 pm
Session 9
Group work on Evolving Action
Plan for implementing RGUHS
Syllabus on Ethics — Who, When,
Where, How?
1.15 — 2 pm
Lunch
2 — 3.15 pm
Session 10
3.15 — 3.30 pm
Tea
3.30 - 4.30 pm
Session 11
Plenary: Group Reports
Discussions
Chairperson: Dr. C.M. Francis
Evolving a consensus.
Recommendations; Wrap-up
Chairperson: Dr. (Mrs.) S.
Kantha.
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SECTION C : APPENDICES
Appendix — C-l
Raja Gandhi University of Health Sciences, Karnataka, Bangalore.
Workshop on Medical Ethics in Medical Education
PROGRAMME
31.03.1999 (Wednesday)
10.15 a.m.
11 — 11.15 am
11.15-12.30 pm
12.30-1.15 pm
Session 1
Dr. (Mrs. S. Kantha,
Vice Chancellor, RGUHS,
Bangalore.
Introductions
Workshop objectives
Dr. D.K. Srinivasa
Keynote inputs
a) Medical Ethics & Health Care
in India
Chairperson : Dr. G.V.Satyavati
(retired DG, ICMR)
Dr. Madhava Menon
Session 2b
b) Medical Ethics — An Indian
Perspective
Chairperson: Dr. S. V. Joga Rao,
NLSIU,
Dr. K.H. Krishnamurthy
Session 3
International Declarations; Codes
of conduct; Principles of Medical
Ethics.
Coffee
Session 2a
1.15-2.00 pm
Lunch
2 - 3.30 pm
Session 4
3.30 — 3.45 pm
Tea
3.45 — 4.45 pm
Session 5
4.45 - 5.30 pm
Inauguration
Session 5
Contd.
Dr. D.K. Srinivas
Ethical issues related to:
Patient care
Public Health & Rights to Health
Research
Dr. Om Prakash
Dr. Thelma Narayan
Dr. Vasantha Muthuswamy
Group Discussion on:
1. Alternative Systems of Medicine
2. Assisted Reproductive
Technologies
3. Genetics and medical ethics
4. Organ transplantation
5. Patients’ rights
Resource Persons
1. Dr. Jayaprakash — Group 1
2. Dr. Gomathi Narayan - Group 2
3. Dr. Sayee Rajangam-Group 3
4. Dr. H.S. Ballal — Group 4
5. Dr. C.M. Francis — Group 5
Plenary; Reports; Discussions
Chairperson
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gives the conclusive comments to end the hour of discussion. Thought-provoking
posters are displayed all over the campus before the meeting to arouse interest.
TABLE HI
TOPICS FOR THE CLINICAL ETHICS MEETING FOR
INTERNS
•
•
•
•
•
•
•
•
•
Ethical work up of a case
Truth and confidentiality
Ethics at the beginning of life
Ethics at the end of life
Resource allocation
Transplant ethics
Pharmaceutical ethics
Doctor-patient relationship
Doctor-doctor relationship
Debates
When contemporary issues arise, they are used to debate ethical issues. Topics used
for such debates between interns guided by faculty, included in the past: genetic
cloning, abortions, euthanasia, liver transplants and kidney sales.
How is this teaching evaluated?
At the end of the seventh term, an examination, which includes an essay and a
situation analysis, is held. The best essay is awarded a college prize in clinical ethics
on Graduation Day. The interns log book contains essential skills to be completed
through the course. Included in this log book is essential ethical skills and also the
need for 50% attendance at Interns ethical conferences before an internship
completion certificate is awarded.
Problem encountered
There is a lack of a systematic collection of Indian court rulings involving medical
issues. There is also little available on the application of Indian philosophical thought
to problems of medical ethics. There also exist problems of skewed role models and
the difficulty in sustaining an interest among staff and students in attending /
participating in medical ethics programs.
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Table II
CURRICULUM ON MEDICAL ETHICS FOR
UNDERGRADUATES
•
•
•
•
•
•
•
•
•
•
•
•
Introduction to medical ethics
Definition on medical ethics
Approaches to medical ethics
Perspectives to medical ethics
Ethics of the individual
The ethics of human life
The family and society in medical ethics
Death and dying
Professional ethics
Research ethics
Ethical work-up of cases
Special situations in Christian bioethics.
What methods of teaching are used in St. John’s?
Lectures
Group Discussions
Role plays
Video Cassettes
Case studies
Pre-clinical/Clinical phase
In addition.
Case presentations/Discussions
Debates
Internship
Role Plays
Role Plays:
Appropriate topics, for example, Resource Allocation, Ethics are discussed using
students playing roles of a hospital administrator, super-specialist, primary physician
and patient. Each player gives his/her reasons for decisions taken regarding resources
allocation. Students are then sensitized to ethical issues pertinent to the topic.
Intern Case Presentation
The weekly hospital clinical conferences are chosen for the internship clinical ethics
teaching program. Once in two months, an intern presents an actual hospital case
with an ethical conflict. He or she presents to the audience the ethical issues in
conflict, solves the dilemma or atleast raises issues. A faculty member makes a brief
presentation on one major ethical issue being discussed. The interns in the audience
are encouraged to actively participate in discussion and arguments for and against
various options to solve the conflict. A faculty member from the core group then
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conducted in the institute. Teaching of medical ethics is by members of the
Department of Clinical Ethics headed by the Professor of Medical Ethics, who is
trained in Psychology and religious studies. Other members include members of the
clergy and medical faculty members interested in teaching ethics. Together they form
the core teams.
In the pre-clinical years, value classes are conducted by student counsellors, pastoral
care members and medical faculty. During the clinical years, clinical ethics is taught
by the professor of Ethics and medical faculty of the core team. As interns, the
medical faculty of the core team involve other medical faculty, lawyers, social
activists and lay persons in conducting ethical case discussions. The approach is
multidisciplinary and reveals the relevance of clinical ethics in clinical medicine.
Table I
TOPICS FOR VALUE CLASSES IN THE PRECLINICAL YEARS
•
•
•
•
•
•
•
•
•
•
Adjustment
Knowing myself
My religious beliefs
My value system
Concern for the needy
The need for each other
Sharing
Meaning to life
Character and temperament
Love.
When does St. John’s teach Medical Ethics?
There is a conscious effort to inculcate ethical values throughout the undergraduate
training program. A dress code and strict attendance is adhered to throughout the
course. Internal examinations are strictly marked and internship includes a three
months residential rural posting. Sensitization to rural needs is stressed upon through
the two Rural Orientation programs held for all students, one during the first year and
the second, halfway through the course. During the initial preclinical years, value
classes are held. Formal clinical ethics classes are held during the third year (fifth
semester) and fourth year (seventh semester).
Formal undergraduate medical ethics teaching involves 40 hours of teaching. This
excludes the two Rural Orientation Programs and the bimonthly Hospital conferences
on Ethics during Internship.
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B5
THE
ST. JOHN'S MEDICAL COLLEGE
ETHICS COURSE*
TEACHING MEDICAL ETHICS**
Medical Ethics should be an important part of a under-graduate medical curriculum.
It should not be left to a “laissez-faire” process of osmosis from teacher to students.
St. John’s Medical College, Bangalore, was established in 1963. It is the only
catholic medical college in the country and has a 60 undergraduate student intake per
year.
Why does St. John’s teach Medical Ethics?
Since 1963, St. John’s has had a Department of Medical Ethics which has grown to
include a professor of Medical Ethics, Clergy and Medical faculty. Apart from
regular medical ethics teaching, St. John’s also has a value paper as a part of its All
India entrance examination. The reason for the value paper is an attempt to screen for
appropriate human values which would make a ‘good’ human doctor. In addition, a
further analysis of these values occurs during the vigorous four day interviews and
discussions before admittance to the undergraduate course. This entrance procedure
and medical ethics teaching is to fulfil two of the objectives set by St. John’s for their
undergraduate training program. The first objective is that graduates are trained and
oriented towards health care in a rural and underserved area. The second objective
requires the training to assist students acquire an exemplary steadfastness to principles
and moral values; to a life of honesty and integrity; and also to develop respect for
human life from time of inception to its end.
What does this teaching of medical ethics hope to achieve?
The team at St. John’s is clear that they can neither create a person of sound moral
character nor indoctrinate a person. The stress is on sensitizing the students to
examine and affirm personal values and recognize ethical aspects of the medical
profession. There is also an attempt to impart moral, social and legal knowledge, and,
teach skills of clinical analysis enabling the utilization of this in decision making.
This teaching is directed towards producing a young doctor with all human values of a
‘good’ doctor.
Who teaches ethics in St. John’s?
St. John’s has a Pastoral Care Department, a Hospital Ethics Committee, Research
Ethics Committee and a Department of Clinical Ethics.
The Pastoral Care
Department takes care of the spiritual needs of all staff and patients in the hospital.
The Hospital Ethics Committee comprises the Medical Superintendent,
HospitalAdministrator and three other faculty including members of the Medical
Ethics team. They decide on ethical issues referred to them by clinical teams. The
Research Ethics committee studies and gives ethical clearance to all research
*Dr. Prem Pais, Dr. Sanjiv Lewin, Dr. Fr. Kalam, Dr. G.D. Ravindran.
** This is a compilation of all the four short presentations by the St. John's Medical College
Ethics Course team - integrated into one article.
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In our country, the Indian Council for Medical Research gave in 1980, detailec
guidelines on research and experiments in human beings. It is being revised and a
modified code known as ICMR code would be issued soon.
As registered medical practitioners, we are also bound by Code of Medical Ethics of
the Indian Medical Council Act, 1956, and some of the general principles of ethics
apply as well.
Principles of Ethics
Medical Ethics is part of general ethics. Ethics is derived from ‘ethos’. It deals with
the right conduct. It is a level of thinking and reflection prior to action. It seeks to
answer two fundamental actions: (a) What I ought to do? And (b) How I ought to be?
It helps in distinction between what is considered as right or wrong at a given time in
a given place, with the moral consequences of the action.
Every profession has an ethical code. It assures members of profession and the public
a standard of professional relationships. The code defines norms and serves as a
guide. Professionals are expected to adhere. It is different from legislation.
A. Respect for Persons
•
•
•
Autonomy respecting, Choices & Wishes of competent individuals.
Protection of the Vulnerable.
Paternalism
B. Beneficence : Promoting welfare of others
C. Non maleficence. Avoiding needless risk, if inevitable minimise risk.
D. Justice. Giving what they are entitled to. Giving according to: need, contribution
and efforts.
E. Utility : Producing the greatest possible balance of value over disvalue.
F. Fidelity : Principle of Institutional arrangement. Principle of Compliance.
Eg.:
Keeping promise with funding agency - All procedures required are
complied with and all institutional arrangements required to be made are
duly made in a bonafide manner. Using funds as stipulated. Ensuring
research reports, materials and data connected with the research are duly
preserved and archived.
Rules of Biomedical ethics
A. Veracity
Telling truth and not deceiving others.
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B4 - ETHICAL CODES IN MEDICAL PRACTICE
AND BIO MEDICAL RESEARCH
Dr. D.K. Srinivas
Introduction
Biomedical Scientific Progress is based on research which ultimately must rest in part
on experimentation involving human subjects.
In the field of biomedical research a fundamental distinction must be made between
medical research in which the aim is essentially diagnostic or therapeutic for a patient
(clinical research) and medical research the essential object of which is purely
scientific (Non-clinical Biomedical Research) without direct diagnostic or therapeutic
value to person subject to the research.
Special caution must be exercised in the conduct of research which may affect the
environment and welfare of animals used for research must be respected.
This paper will mainly deal with ethical codes related to medical practice and
biomedical research in human subjects, and briefly on guidelines for care and use of
animals in scientific research.
Background
Research on human beings is regulated by international and national codes. After the
second World War (1939-45), there was concern about the use of human subjects for
medical research. Nazi Physicians were tried in Nuremberg for cruel experiments on
prisoners, mentally retarded persons and those held in concentration camps. The first
international declaration was the Nuremberg Code of 1947.
In 1964, the International Organisation of Medical Sciences (CIOMS) and the World
Medical association formulated the Declaration of Helsinki It has been reviewed
from time to time and modified by the World Medical Assembly in 1975, 1983 and
1989.
In 1966, the International Covenant on Civil and Political Rights specially stated,
among other things, “no one shall be subjected to without his consent to medical or
scientific treatment”.
In 1982, the World Health Organisation and CIOMS, proposed international
guidelines, and in 1993 the CIOMS issued International ethical guidelines for
biomedical Research involving Human subjects.
Over the years various countries have also drawn ‘national codes’ based on the
international codes and universal principles.
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7. Children
• Age to consent to treatment
• Parental/Child/Clinician conflict
8. Mental disorders and disabilities
• Detention and treatment without consent
• Conflicts of interests
- patient, family, community.
9. Life, death, dying and killing
• Life prolonging treatment
• Life shortening palliatives
• Transplantation
• Death certification
10. Duties of doctors
• Public expectation of medicine
• Teamwork
• GMC and professional regulation
• Clinical mistakes
\
11. Resource allocation
• “Rationing”
• Equitable health care
• Needs, utility, efficiency
12. Rights
• Rights and links with moral and professional duties
• Concepts of rights, including human rights.
Methods of teaching / learning
Charaka has stated that medical wisdom is acquired by three methods (upayani)'.
1. Study (adhyayand), earnest and continuous
2. Teaching (adhyapana) : imparting lessons concerning life in general medical
profession, medical ethics and science of medicine.
3. Academic discussions (tatvidya - sambhasd) with colleagues and fellow students.
X.
OVV.V.y
---- --------- J.)
—---- — — -- ----------- —----------------------------------------
Active learning is given great importance. Specific mention is made of medical ethics
among the broad divisions to be taught. What are the methods to be employed today?
•
•
•
•
•
•
•
Small group, problem-based learning
Class-room teaching, especially of the larger concepts
Seminars; debates on specific ethical issues
Bed side clinics. Role model
Case studies; written vignettes
Doctor’s stories; patient’s stories
Guest lectures
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Care of the terminally ill
Death and dying
Euthanasia; the living will
Suicide.
4. Special concerns
Human and animal research
Organ transplantation
HIV/AIDS; emerging / re-emerging diseases
Rational use of drugs; ethical promotion of drugs
Medical ethics and law
Alternative systems of medicine.
General Medical Council, U.K.
The General Medical Council, UK, which regulates medical education, has worked
out a core curriculum for medical ethics and law. This consists of
1. Informed consent and refusal of treatment
• Respect for autonomy
• Adequate information
• Treatment without consent
• Competence, battery, negligence
2. Truthfulness, trust and good communication
• Building trust
• Honesty; Values in clinical practice
• Communication skills.
3. Confidentiality
• Privacy
• Compulsory/discretionary disclosure
• Public vs. private interest
4. Medical research
• Regulation of medical research
- patients, volunteers, animals.
5. Human reproduction
• Embryo; foetus
• Assisted conception
• Abortion
• Prenatal screening
6. Genetics
• Treating the abnormal vs. treating the normal
• Genetic therapy and research
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4. Where to Teach?
Most of the teaching will be in class rooms and conference halls to begin
with but must gradually move to all outpatient teaching; inpatient bedside
teaching and community based teaching (during community / rural / urban,
postings.)
5. Evaluation
a.
All major subjects should have at least one short answer question on
Medical Ethics appropriate for the subject introduced in the University
question paper, and a few questions may be asked during the viva voce
examination eg., basic principle in informed consent, confidentiality,
etc.
b.
Some felt that Evaluation may be formative indicating behaviour
changes. This would include periodic assessments of knowledge and
skill (example communicating skills), prize examinations, and honours (university / college).
6. Recommendations to RGUHS
a. There is need to have learning resources such as reference books and case
studies, AV aids, journals and newsletters to support Medical Ethics
teaching in the colleges. RGUHS could do this through identification and
dissemination of such resources.
The University could also gradually facilitate the preparation of work books
or manuals or other teaching aids to facilitate the course.
b. There is need to support / facilitate sensitization workshops at regional /
college levels where resource persons identified by the University can
sensitize / orient / train teachers to support the training programmes.
c.
There is need to constantly monitor the evolving experimentation in Medical
Ethics teaching in different colleges and encourage greater interaction
between colleges to learn from each others experiences. Exchange of
resource persons could be facilitated.
d. Since this is a special and significant contribution to Medical Education in the
country, the RGUHS should document the evolving process to evolve a more
detailed curriculum outline and guidelines and work books that can be used not
only in the state but elsewhere as well.
e. The starting of a correspondence course may be explored to prepare large numbers
of teachers to develop an interest and skill in the teaching of ethics.
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During these phases the course content mentioned in 3.3 to 3.10 may be
taken up (See Appendix C-5).
Teaching methods may include lecture - discussions, case studies, role
plays, debates, seminars and quiz. In the last four terms clinical case
presentations can be included in which ethical issues in clinical decision
making and patient care could be discussed (See Appendix C-3)
Inter college competitions, essays and debates could be encouraged to
include current ethical dilemmas and issues.
Recommended distribution of Teaching hours in different phases
of MBBS Course
Total Teaching Hours : 40
Phase I : Preclinical Period - 6 hours
2 hours each by Anatomy, Physiology, Biochemistry during the I year.
Phase II : Paraclinical Period - 6 hours
2 hours each from Pharmacology, Pathology and Microbiology.
Phase III: Community Medicine - 4 hours
2 hours each from Ophthalmology and ENT = 4 hours.
2 hours each in two terms from Medicine, Surgery, and OBG=12 hours
8 hours from other clinical departments.
N.B.: The teaching of Medical Jurisprudence by the department of
Forensic Medicine will continue as before.
e) Internship
Ethical issues should be discussed during the grand rounds in each
department.
Special Ethical case conferences can be introduced at least once a month
during the internship
All interns must be encouraged to participate in at least one such special
case conference during the period of internship.
B. Long term plan
As more of the faculty become involved in 'Medical Ethics' teaching, the
issues of Medical Ethics should be discussed routinely as part of all bedside
teaching.
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e. Non core team medical teachers are to be included in teaching sessions from
time to time to enable exposure and the development of interest in teaching
Medical Ethics.
f.
The core team may need a few more 'sensitization' and 'methodology'
training before initiating the course. The team of St. John's Medical College
and other resource persons identified by the University should plan and offer
short courses to support this 'teacher training'. Alternatively some could join
the distance learning course offered by National Law School of India
University, Bangalore.
g. While the core team will share the main responsibility of teaching they
should from time to time invite guest speakers and other resource persons
from other faculties, Professions and disciplines and from 'Civic Society' to
make their courses more interesting and stimulating .
B. Long term plan
h. All teachers should accept the responsibility of teaching and practising
Medical Ethics in the collage and hospital. Medical Ethics should be
component of all teaching in the Medical College.
3. When and How to Teach?
A. Short term plan
a. The course will be throughout the whole MBBS Course - starting
from the pre-clinical phase till the end of internship.
b. For the present, 40 hours have been recommended during the 4 1/2
year period. All departments / disciplines will allot 2-4 hours each
for medical ethics teaching for this integrated course. The details in
the three phases follow.
c. Preclinical (1st & II term)
(6 - 10 hours)
Following aspects of course content may be taught:
During this phase the Introduction to Medical Ethics (3.1 of the
revised ordinance) and; Definition of Medical Ethics (3.2). Value
orientation classes as is done in St. John's Medical College may also
be included (See Appendix C-4).
Teaching methods may be lecture discussions and discussions with
case studies (See Appendix C-3)
d. Para clinical and Clinical
Phase H and HI
No. of teaching hours - Para Clinical (10)
Clinical (20)
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A4: RECOMMENDATIONS AND ACTION PLAN
The following ecommendations were made by the participants during the Workshop:
Medical Ethics in Medical Education organised by Rajiv Gandhi University of health
Sciences, Bangalore (30 March / 1st April, 1999)
[These workshop recommendations must be read in conjunction
with and complements those guidelines. The Ordinance of the Rajiv
Gandhi University of Health Sciences - 7997 which governs MBBS
degree programme includes Section V - on Teaching of Medical
Ethics in MBBS.]
The Action Plan prepared for implementation of the curriculum in the medical
colleges also formed part of the recommendations. The plan recommended short
term and long term actions.
1. The teaching of Ethics curriculum is the responsibility of all the faculty of the
Medical College and not just those of one department or the other. The
Ethics course will therefore be multi disciplinary, integrated and extend
throughout the MBBS course and including the period of internship.
2. Who is to teach Medical Ethics?
A. Short Term Plan
a. The Principals will meet all HOD's and faculty of their colleges and share the
key recommendations of the workshop.
b. They will select 4-5 members of the faculty who are motivated and interested
to teach Medical Ethics. Volunteers must be encouraged. This team will
form the core team for Medical Ethics. The team must include Clinicians.
One member must be designated as Coordinator. This could be a rotating
responsibility. The core team is responsible for initiating and organising
activities regarding Medical Ethics.
c.
The institution should have a structure which would consider and help in the
ethical issues involving medical education, patient care and research. One
suggestion is that the institution should also appoint a College Ethics
Committee (CEC) and a Hospital Ethics Committee (HEC) which could
include the above team members and others. These committees will be
responsible for 'ethical issues' in medical education, patient care and research
apart from supporting the planning and execution of the Medical Ethics
teaching programme. The core team will co-ordinate with the activities of the
Medical Education Cell and the Postgraduate training and research committee.
(See Appendix 8 & 9).
d. The core team will organise meetings and workshops to sensitise all the
teachers including HOD's to the needs and challenges of Medical Ethics in
undergraduate education.
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decisions in their day to day medical care and health care work. (See Section B-5
for details).
21. After the participants had an opportunity to get more details and clarifications
from the St. John’s team, they broke into groups for the final and most important
task for the workshop i.e., to evolve an Action plan for implementing RGUHS
curriculum on Ethics.
The groups were made in such a way as to allow for. regional level continued
interaction among them after the workshop:
Group I
Group II
Group ID
BLDEA Bijapur; Al Ameen, Bijapur; MRMC, Gulbarga;
VIMS, Bellary; JNMC, Belgaum.________________________
AIMS, Bellur; Government Medical College, Mysore; JSSMysore, St. John's Medical College, Bangalore._____________
BMC; KIMS, Bangalore; AMC, Bangalore, DUHC, Kolar;
Siddartha, Tumkur.
Each group was asked to respond to four questions as a task to arrive at an Action
Plan. These were i) Who is to do the teaching; ii) When and How and where to
teach;
iii) How to evaluate; iv) Any other issues in teaching of Medical
Ethics.
Each group had resource persons to help in the discussion. Members of the St.
John’s Medical College team were requested to be additional resource persons in
each of the three groups.
After an interactive, participatory and enthusiastic group discussion, three action
plans emerged which have been integrated in the next section. These were
presented at the final plenary session at which a small committee was formed to
integrate the suggestions and take this agenda forward.
22. The participants were given certificates of participation and the workshop
concluded having generated a lot of enthusiasm and commitment in the group, to
make the new experiment of RGUHS - of introducing Medical Ethics as a
curriculum subject in Medical Education in Karnataka, a success.
12
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Day 2
19. The key theme of the second day was Teaching/learning ethics and after a very
concise but comprehensive report of the first day by Dr. V.L. Pattankar and Dr.
T.K. Nagabhushan, the session started by a keynote address by Dr. C. M. Francis,
Consultant - CHC, Bangalore on Teaching/Learning Medical Ethics in
Medical Education (See Section B3)
His comprehensive overview included Medical Ethics and national goals; some
examples of Ethics courses form other parts of the world - both graduate and
postgraduate; objectives of teaching ethics; curricular design and content; methods
of teaching and learning ethics, resources and who will teach and some issues in
assessment as well as some obstacles to teaching ethics which should be
overcome.
20. Following the keynote address, the St. John’s Medical College Ethics training
team then made a comprehensive presentation of all facets of Ethics teaching at
St. John’s. The teaching of Ethics was started in 1965 and over the years the
contents and teaching style have been modified based on feed back and reflection.
Dr. Prem Pais started by answering six general questions that would be faced by
all medical college teachers who embark on an Ethics course in the curriculum.
These were i) Should and can Medical Ethics be taught?; ii) What are the
attainable objectives of Medical Ethics teaching?; iii) Who should teach Medical
Ethics?;
iv) When and to whom should Medical Ethics be taught?; v) How
should Medical Ethics be taught?; vi) Evaluation - can it be done for Medical
Ethics course? He then answered these in the context of the St. John’s experience
(See Section B5).
Dr. G.D. Ravindran then outlined the stresses and strains faced by a new medical
college entrant at the beginning of the course and how a few sessions on value
orientation would help them to understand ethical choices and dilemmas. He then
went on to explain the curriculum on Value Orientation which was introduced at
pre-clinical level at St. John’s Medical College (See Appendix C-4). He also
outlined the the curriculum for UGs and the methods used including the nature of
the assessment. He highlighted some of the constraints faced by the ethics’ course
teachers which included lack of relevant reading material and studies in relation to
the Indian context, and lack or skewed ‘role models’ in the institution.
Dr. Sanjiv Lewin enthusiastically presented the interns programme highlighting
the issues discussed and methods utilized. He stressed from the St. John’s
experience, the need to involve all the departments in the programme. With
numerous case studies he brought out the dilemmas in ethical teaching as well.
The main challenge was to make students sensitive and aware of the issues; think
for themselves; decide and 'refer to peer support and guidance when required.
(See Section B5 for further details).
Finally, Fr. Kalam, the Professor of Medical Ethics at St. John’s summarised the
need for making ethics central to medical care and the need to make the ‘ethics
curriculum’ produce doctors who were equipped to make their own ethical
11
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d) Justice and Equity
i) Loss of job opportunity due to genetic disposition; ii) Loss of health
insurance; iii) Allocation for services and access; iv) conflicts of interest.
(See Appendix C 7- for further details).
16. Following the three presentations, the participants deliberated in five small
theme specific groups. The group discussions were interactive and interesting
and all the participants actively participated. Each group was given a set of
questions to stimulate the group discussion ( See Appendix C-6) The main
purpose was to give the participants an experience of identifying the ethical
issues and dilemmas in different areas of current medical practice or health care,
(see Appendix C-7)
17. In the plenary session, Dr. Sambashiva Rao presented the group reflections on
Alternative Systems of Medicine, followed by some comments by Dr.
Jayaprakash, Member - Central Council of Indian Medicine who was the resource
person for the group.
Dr. Sanjiv Lewin reported the ethical dilemmas of Assisted Reproductive
Technology and Dr. Gomathi provided additional comments as the resource
person for the group.
Then, Dr. O.P. Bhargava presented a report on Genetics and Medical Ethics
followed by some comments and further clarifications by Dr. Sayee Rajangam Prof of Anatomy of St. John’s Medical College.
Dr. Chandrashekar presented a report on the ethical dilemmas in Organ
transplantation followed by comments and further clarifications by Dr. H.S. Ballal
who was resource person for that group. (See Appendix C-7)
Finally, Dr. Medha Rao highlighted the key issues and dilemmas on Patients
Rights. Dr. Francis added further comments. (See Appendix C-7)
18. The group reports were followed by intense, discussion in which participants
raised several important questions and resource persons including Dr. Kantha, Dr.
C.M. Francis, Dr. D.K. Srinivas and Dr. Ravi Narayan provided helpful
clarifications and observations.
While the keynote addresses and the input sessions had provided lot of stimulus
for the participants, the enthusiastic participation in the group discussions was
proof enough that the challenges of understanding the ethical issues and dilemmas
was beginning to receive the serious consideration it deserved. A key issue that
came up again and again during the plenary was the need for greater effort to
'ethicalise’ the teaching, patient care and community care and examination
environment in the medical colleges to support the teaching of ethics as a
curriculum subject. This was a significant concern.
10
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collaboration as well as donor driven research. (Please see ICMR - 1997-98
guidelines for further details).
12. Session five was designed as an interactive group discussion session. The
participants were divided into five groups and each group was guided by a
resource person. The topics were: a) Alternative Systems of Medicine; b)
Assisted Reproductive Technology; c) Genetics and Medical Ethics; d) Organ
transplantation and e) Patients Rights. Since, some of these were of great
significance in the context of recently emerging events and concerns, three
resource persons made short presentations to all the participants before they met in
small groups for discussion.
13. Dr. H.S. Ballal, Director, Manipal Institute of Nephrology and Urology, gave a
short overview of the ethical issues in organ transplantation by presenting 2 recent
case studies. He emphasised the ethical principles of transplantation including i)
no harm to donor; ii) informed consent; iii) significant benefit to recipient. He
outlined the unethical practices which included utilizing a) donor who is unfit;
impaired
decision
making
capacity;
b)
Coercion/blackmail;
c)
Commercialization/middlemen. He went on to highlight the issues in living
transplant. These included i) Altruistic stranger; ii) Grey basket (rewarded
gifting); iii) Rampant commercialization; iv) Criminal. He listed out four key
issues in cadaver transplant: i) brain death; ii) directed donation; iii) incentive for
donation; iv) who gets the organs? decision. Finally, he touched upon four other
issues in the context of transplant which included a) donations from
minors/mentally retarded; b) donations from prisoners; c) donations from
embryo/fetus; d) xenografts.
14. Dr. Gomathi Narayan, Professor of Obstetrics and Gynaecology, Kempegowda
Institute of Medical Sciences, Bangalore, then gave a short summary of a survey
she undertook of 50 internees about the knowledge and attitude to ART and the
questions that they raised which had important ethical dimensions, (see Appendix
C-7)
15. Dr. Sayee Rajangam, Professor of Anatomy, St. John’s Medical College, shared
16 ethical issues in genetic counselling outlined under the four major principles
of ethics. These were illustrated with examples.
a) Respect for autonomy:
i) Genetic testing with difficult follow up choices; ii) Testing of children;
iii) Pregnancy termination for mild conditions; iv) Sex selection; v) PND to
select for an affected individual.
b) Beneficence and non-maleficence;
Experimental therapy (Gene therapy); ii) PND and its appropriateness.
i)
c) Privacy and confidentiality
i) Paternity; ii) Duty versus confidentiality; iii) Wrongful life; iv) Wrongful
births.
9
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she highlighted that the RGUHS Ethics curriculum already included some of
these issues and needed to be discussed with medical students during the course.
11. Dr. Vasantha Muthuswamy, Deputy Director General of Indian Council of
Medical Research, New Delhi gave a comprehensive overview of the Ethical
issues and challenges in medical research and the emerging guidelines for
research on animals, human subjects, and bio ethics. She traced the evolution of
ethics and ethical principles over the centuries and then highlighted all the codes
of ethics for research from Nuremberg Code (1948) till the evolving ICMR's
ethical guidelines on Biomedical research involving human subjects (1997). See
box
EVOLUTION OFMODERNBIO ETHICS (BIO MEDICAL ETHICS)
♦
♦
♦
♦
♦
♦
♦
♦
Nuremberg Code (1948)
UniversalDeclaration ofHuman Rights
Helsinki Declaration (1964)
National Commission for the Protection of Human subjects of Biomedical
and Behavioural Research, USA (1979)
Policy Statement on Ethical issues in Biomedical Research on Human
Subjects, ICMR, India 1980)
Proposed International Guidelines on Biomedical Research, WHO/CIOMS
(1982)
Ethicalguidelines for EpidemiologicalResearch - WHO (1991)
Ethical guidelines on Biomedical Research - Human Genetics (1990)
- Human Tissues (1993)
■ Xenotransplantation (1995)
Ethical guidelines on Biomedical Research involving Human Subjects, ICMR,
India (1997)
She outlined the general principles included by ICMR in its recently evolving
guidelines for biomedical Research on Human Subjects in India which included
(i) Essentiality
(ii) Voluntariness, informed consent, community agreement
(iii) non-exploitation
(iv) privacy and confidentiality (vi) professional
competence (vii) Accountability and transparency (viii) Public interest and
distributive justice (ix) Institutional arrangements (x) Public domain (xi)
Totality of responsibility (xii) Compliance. The ICMR evolving guidelines also
include specific principles and guidelines for a) Human Genetics b) Organ
transplantation including fetal tissue transplantation c) Clinical evaluation of
Drugs / Diagnostics / Vaccines / Herbal remedies d) Epidemiological Research
e) Assisted Reproductive Technologies.
She then outlined some of the issues in animal experimentation and research and
some of the problems of collaborative research especially international
8
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£
i0:
i
JI
I
i
i
)
ii. The Declaration of Geneva (1948)
iii. The Oath of Professional Fidelity (later amended in 1968 and 1983)
iv. The Duties of the Physician in general, to the sick; and to others (1949)
v. The code of Medical Ethics of the Indian Medical Council Act (1956).
He described the challenge of new bio technology and medical procedures and
therapeutics like Assisted Reproductive technologies; Organ transplantation; and
human genome analysis and gene therapy.
Finally, he described the widening vision and challenge of ethics beyond the
confines of the doctor-patient relationship including issues relating to health
policy; health economics; health as a human right; distributive justice in health
care and allocation of resources; the Health for All goal, and bioethical issues in
Population Health, Equity and Human Rights.(See Section B-4).
8.
In Session 4 ethical issues related to patient care, public health and medical
research were highlighted by resource persons. The session was chaired by Dr.
D.K. Srinivas.
9. Dr. Om Prakash, Head of Department of Medicine from St. Martha's Hospital,
Bangalore, spoke on Ethical issues related to Patient Care with suitable
examples from day to day clinical practice. His lucid presentation covered a large
number of issues related to ethical medical care especially the clinical approach;
the art of communication; the role of caring, comforting and education; the
diagnostic process and the degree of investigation; the cost factor; the role of
clinical acumen; judicious use of procedures; cost of care and need for care;
issues in hospitalisation and those involved in advising expensive therapies; life
support systems; admission decisions; dialogue with patients and relatives; moral
dilemmas and their magnitude; and newer problems due to evolving tests,
biotechnology and therapeutic modalities. He particularly stressed the urgent
need to help develop culture sensitive and effective communication skills in
medical students and interns to enhance the practice of ethical care for their
patents.
10. Dr. Thelma Narayan, Coordinator of the Community Health Cell, an
Epidemiologist and Public Health Policy Consultant then explored the key
Ethical issues related to Public Health. She highlighted the individual versus
community dilemma; the right to health; the challenge of distributive justice and
equity; the need for priority setting; the dilemma of'health for some' versus health
for all; the commercialisation of health care; the corruption and political
interference; the continuing discrimination based on gender, caste or communal
factors and the violence of the state.
She then highlighted some indicators of fairness in ethical health care such as
universal access; minimising non financial barriers; emphasis on primary care and
prevention; public accountability and democratic decentralisation. She identified
some disturbing trends in the country like commercialisation of medical
education; privatization and glorification of hi-tech diagnostics, doctor-drugproducer axis and others which were making health care more unethical. Finally
7
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Ethical issues in Medical Research
35. Can a study be done even though it has already been proved before? Can a
pharmaceutical company sponsor a study and decide whether to publish or not?
What is the duty of the doctor after completion of the study especially if the
results are not in favour of the company?
36. Can children be included in any study? From who shall consent be asked? Can a
person walk away from a study before its completion? Can you pay the study
subjects? Can you ask medical students in your institute to participate in a study?
37. Can a study be done in a third world country when it has been disallowed in the
west?
38. Can animals be used in studies? Can animals be not used in studies especially
with respect to drug trials? Which animals would you object to in a study - dogs,
cats, rabbits, ants, cockroaches? Why are there different responses depending
upon the type of animal?
39. Can prisoners be used for experiments?
40. Who should implement the MCI’s code of conduct?
57
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4
24. Do medical students have a right to examine and see patients in a medical college
hospital? In the general ward? In the private ward? If different, is this
discrimination?
25. Does a doctor have the right to screen a patient for HIV before treatment? Does
the patient have a right to know the doctor’s HIV status?
26. Can a homosexual family or a single parent have a right to ART?
27. Can a donor sperm, ovum or zygote be stored? Destroyed? Who owns them if
the donor dies?
28. Should the identity of the donor and recipient of a cadaveric donation be kept
secret? Should the donors family decide who gets the donation? Should a non
resident of a place be given the donation? Who owns a cadaver if unclaimed?
Can we afford the concept of brain death? Who will pay for the life support once
brain death is declared and before the actual transplant is carried out?
29. Is it necessary to have a chaperon during the examination of a lady patient? In
Ophthalmology?
30. An interesting patient is admitted to the ward which is a potential publication.
Can we take a photograph of the patient and the lesion and send it for publication?
Do I need permission? Can I publish the problem in a newspaper? Can I publish
about availability of my specialized services in the newspaper? Can I be
photographed and interviewed in a newspaper as a good doctor? Can I have my
name, address and telephone number in the newspaper? In the yellow pages?
31. Can a patient demand a second opinion and then return to the first doctor for
treatment? Can a patient go shopping for the best deal? Can a patient ask for a
particular surgeon to operate on him or her? Can the patient decide his or her own
treatment plan?
32. Can sex determination be done in a prenatal clinic? Can any other prenatal
screening be done with the possibility to terminate life? Can universal screening
be done without parental consent? Whose consent -father or mother or both?
33. Can genetic engineering be used to correct defects? Can it be used to correct
cosmetic anomalies? Can it be used to produce the perfect person? Who decides
what is right? What right has the person deciding have that the condition or
anomaly or feature is bad or good hence decide the termination of life? What
right has anyone to prevent a family from preventing the birth of a child who is
defective and who will suffer or die early in life? Can the doctor distance himself
from the decision making and leave it to the parents? Is it not the same as
describing all the methods to murder and leaving the decision and responsibility
to the person? Is it separating science from ethics?
34. Can abortions be carried out to obtain fetal tissue for transplants? Can animal
tissue be used for similar purposes?
56
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*
*
•i
1
COUNCIL LOR IN TERNATIONAL
ORGANIZATIONS
OF
MEDICAL
SCIENCES
CIOMS
ESTABLISHED UNDER THE AUSPICES OF THE WORLD
HEALTH
ORGANIZATION
AND
CONSEIL DES ORGANISATION.
INTERNATIONA LES
DES SCIENCES MEEjlCALES
FONDt SOUS LES AUSPICES DE L'ORGANISATION
MONDIALE DE LA SANTE ET DE L'UNESCO
UNESCO
MS
ETHICS AND HEALTH CARE REFORMS
A GLOBAL VIEW
Norman Daniels
k
Chapter in forthcoming CIOMS publication entitled
Ethics, Equity and Health for All (in press)
ETHICS AND HEALTH CARE REFORMS:
A GLOBAL VIEW
Norman Daniels*
My comments today fall into three parts, a brief sketch of my views about
justice and health care and their implications for the design and reform of
health care systems,
some remarks about the ethical implications of market
reforms in the United States and Europe, and some preliminary thoughts about
the bearing of all of this on the health for all strategy in developing
countries.
I emphasize the "preliminary" nature of these last remarks, since
I must learn from all of you enough about the problems in developing countries
to say anything truly useful about them.
I conclude with a suggestion that
a project be undertaken to adapt a method of assessing "benchmarks of fairness
for health care reform" that I developed (with Don Light and Ron Caplan1) for
use in evaluating reforms in countries at various stages of development.
I.
Justice and the Design and Reform of Health Care Systems
I began to think about what contemporary work on the
Nearly 20 years ago,
general theory of justice implied about the distribution of health care.
Could that work provide foundations for a right to health care and clarify
what it meant?
Using a narrower notion of health than the WHO definition,
namely,
species-typical normal functioning ("normal functioning" for short), I argued
that the central contribution of health care in any of its forms, whether
public health, preventive or acute or chronic care, physical or mental, was
to keep people functioning as close to normally as possible within reasonable
resource constraints.
Disease and disability,
viewed as departures from
normal functioning, restrict the range of opportunities open to individuals,
preventing them from participating as they otherwise might in the economic,
social and political life of their societies.
normal functioning,
thus makes an important,
assuring equality of
opportunity,
and
this
Health care,
if limited,
gives
by promoting
contribution to
an explanation of
special, though not unique, moral importance (see Daniels 19852, 19883).
Department of Philosophy, Tufts University, Medford, USA.
its
2
Although this focus on equality of opportunity might seem to emphasize
the importance of health care to the individual,
in contrast to European
appeals to the more communitarian concept of solidarity, there really is deep
Both ways of conceiving the problem agree that we must
point of convergence.
share the burdens of keeping people as close as we can to fully functioning
participants in the political, social, and economic life of society.
Herein
lies the sense in which health care is a social good, for promoting the health
of each contributes to the social well-being of all.
This equal
opportunity account of the justice and health care has
important implications for the design of health care systems, including
access, for types of services, and for financing.
foundations for universal coverage,
or
For example, it provides
since ability to pay should not be a
precondition for securing protection of equal opportunity.
It also provides
foundations for needs-based allocation of resources, since the relative impact
on opportunity becomes a way of assessing the relative importance of meeting
particular health care needs,
social
obligation,
the
Since protecting equality of opportunity is a
burdens
of
distributed according to ability to pay.
and
health
care
is
in
theory
that
providing
forms of
"tiering"
--
compatible
being more
should
be
The principled account of justice
with
private/public financing and delivery systems,
some
protection
both
public
and
mixed
It is also compatible with
concerned about
the
structure
of
inequality that emerges than the mere fact that some inequality is present,
Thus, a
; system that allowed a small best-off sector of society a more deluxe
healthi
care
adequately,
tier
at
the
top,
while
treating
the
majority
of
society
is open to fewer ethical objections than a system that allows
better off groups to leave the worst-off groups behind with just bare minimum.
The equal opportunity account can give much more specific guidance in
thinking about the fairness of health care reform.
Don Light, Ron Caplan, and
I, and drawing on work I had done with Dan Brock while we were on the Ethics
Working
Group
of
the
Clinton
Health
Care
Task
Force,
developed
the
implications of this account into a matrix of ten "benchmarks of fairness",
involving some 30 criteria, for assessing the fairness health reform in the
United States (see Daniels, Light, and Caplan 19961; see Appendix I below).
For example, Benchmark 1 evaluated financial barriers to access to service^ -- how much of the large insurance gap in the United States was reduced by the
3
reform -- and it also asked if the coverage was "portable" from job to job.
Benchmark 2 evaluated non-financial barriers to access.
the
comprehensive of benefits
allowed.
Other
benchmarks
and the kinds
of
of tiering that
considered
fairness
Benchmark 3 evaluated
equity
the
in
reform
financing
(community rating and the progressivity of financing), clinical efficacy (an
emphasis on primary care and on outcomes based medicine),
administrative
efficiency, public accountability, and the degree of choice available in the
system.
We used the matrix to make a comparative assessment of the fairness
of several major health care reform proposals before the 103rd Congress -none of which were adopted -- and to assess the market driven changes that
accelerated in the aftermath of the collapse of political reform.
I mention this effort not because the ten benchmarks and thirty criteria
provide the best framework as they stand for thinking about ongoing health
care reform around the world
problems of very poor,
they were not constructed with the special
developing societies
in mind
-- but because they
provide a model for how to make equity and fairness considerations play a role
in the evaluation of health care reforms.
I believe these benchmarks can be
modified, for example, by expanding those criteria that concern public health
and primary care, to reflect the crucial importance of these components in
developing countries and to emphasize their sensitivity to the introduction
of market reforms.
II.
Evaluating the Ethical Impact of Health Care Market Reforms
A.
Market reforms in the U.S.:
With the failure in 1994 of a political
effort at health care reform in the US, large employers have undertaken their
own measures to control rapidly rising health care costs.
purchasers,
they have
fuelled competition
--
As large scale
largely on price
-
among
competing health insurance plans, organized into quite varied forms of mana ged
care arrangements.
It is important to note that this competition involves not
only financing but production.
The precise effects of this market driven change (I hesitate to call it
"reform")
are not well documented,
but there
is good evidence
for
these
trends:
1)
The numbers of uninsured have increased even though health care
costs to employers --at least large employers -- have plateaued.
This
4
is
increase
despite
true
unemployment.
Fairness
universal coverage.
is
an
excellent
diminishing
as
economy
with
relatively
low
1,
for
measured by Benchmark
One modest counterforce is the new Federal legislation
that goes into effect in July and which limits the ways in which insurers
competing to secure healthier patient pools may exclude patients with prior
medical conditions.
These steps go only a fraction of the way toward the
protection that would have been provided by two of the comprehensive national
reform proposals
(Wellstone's,
modelled on the Canadian system,
and
the
The rate at which Americans have been pushed (or pulled)
into
Clinton plan).
2)
managed care arrangements has increased.
In the private insurance sector
majority of Americans are not covered by such plans.
a
In the public sector,
the majority of Medicaid patients now have such coverage, and an increasing
well.
proportion of Medicare patients do as well.
For many people this has meant
a disruption of long-standing relationships with particular physicians.
For
others, especially those with chronic health problems, there is reduced access
to specialty care and to choice among those providing such care.
Because of
Federal laws exempting "self insuring" corporations from state regulations
regarding insurance, there is also less accountability to the public for the
quality and scope of benefits enjoyed by an increasing proportion of workers,
The loss of choice and of accountability mean these trends increase unfairness
as measured by other benchmarks we use (Benchmarks 8 and 10) .
James Sabin and
I (Daniels and Sabin 19974) have been examining ways in which accountability
for decisions about coverage of new treatments might be
increased;
the
lessons generalize to include broader questions about limit-setting in private
organizations.
developing
A revision of
countries
should
the benchmarks
emphasize
the
to
cover privatization
importance
of
publicity
in
and
accountable in the procedures for limit-setting decisions.
3)
The dominant form of competition that has emerged has
(premiums) and not on quality,
been on price
Indeed, employers have found they have limited
technologies available for measuring the relative quality or efficiency of
competing health plans.
(e.g. HEDIS) ,
There has been a push to develop some such measures
but in their absence,
the piece of market theory that says
informed consumers (here employers) can use competition to improve quality and
not just price remains untested.
Instead, we have considerable anecdotal
evidence of patient dissatisfaction with quality, and what survey information
we have suggests the dissatisfaction increases the sicker the patients are.
5
This suggests we should worry about the degree to which these trends decrease
fairness on the criteria concerning the comprehensiveness and quality of
services covered (Benchmark 3).
Though costs to large employers have stopped rising rapidly, and in
4)
some cases may actually have decreased, there is also a growing concern about
cost-shifting.
In the US, services to uninsured patients were often cross
subsidized by increasing the premiums of insured payers.
form of cost-shifting is eliminated in the system,
As room for this
there is greater cost
shifting to public budgets that support unreimbursed hospital care in public
There is also considerable shifting of some costs to out-of-pocket
hospitals.
payments
by
including
patients,
private
contributions
coverage for dependents provided by many employers.
to
cover
reduced
Thus unfairness increa|ses
on some of the criteria governing fairness in the sharing of burdens
for
financing health care (see Benchmarks 4 and 5).
Despite
5)
the
slowing of the
growth of premium costs
to
large
employers, there is evidence that the proportion of health care costs going
to profits and administrative costs -- rather than health services
increasing,
sector.
is
especially with the rapid growth of a for-profit health care
These costs run well over 25% in some cases.
To show that these
costs are justifiable, one would have to show that the quality and scope of
coverage was not reduced,
and was even improved,
while permitting scarce
public and private health dollars to be diverted in these ways,
No one has
any evidence to show that (see Benchmarks 6 and 7).
B.
Market Reforms in Europe:
In the brief time I have today, I cannot review
in any detail the lessons from European "planned market" health reforms.
Fortunately, there are some excellent reviews of these reforms (Cassel 19955,
Saltman 19956) on which I draw here:
1)
With the exception of the Netherlands,
among the European QECD
countries, there has been little interest in introducing competition on the
finance
side.
The
Dutch
experience
suggests
considerable
threats
to
solidarity, and that is in a country with a strong legacy of concern at out
solidarity, but this is a lesson that could have been learned from the I .S.
context;
a technical obstacle that faced the Clinton reform was the lad of
a good technology for risk-adjustment that would remove the incentive of
competing insurers to segregate risk pools.
Using the benchmarks of fairdess
we used to evaluate the Clinton and other proposals, we would have to mark
6
of the Dutch experiment just as we did
for
the
Clinton
down the
score
proposal,
since there were technical obstacles to assuring fairness even
though there is awareness of the importance of avoiding risk exclusions (the
issues arise with reference to Benchmark 4).
2)
There is much more experience with planned market reforms that
involve allocative and production aspects of the health care system,
New
contract relationships may replace command-and-control public bureaucracies;
patient choice can be made to play a new role on the demand side that affects
budgetary decisions;
physician reimbursement schemes may be made to include
competitive elements through new capitation or other incentive mechanisms.
One lesson learned from some of these measures is that transaction costs can
be much higher than expected (cf. Benchmark 7).
always accompany mimicry of market methods.
Increased efficiency does not
A second lesson is that the goals
of some of these steps alter rather than really reduce the importance of the
role played by the state,
They call for increased state monitoring and
regulatory roles if there is to be any assurance that social goals in health
care are not being undermined.
A detailed analysis of these reforms, using
modified versions of our benchmarks for fairness, would highlight their impact
on equity issues.
I cannot undertake that analysis here, but a research
project to adapt the benchmarks for international use would have to examine
current experience carefully.
III.
Implications for Developing Countries
A.
Two
contradictions:
I
advance
these
comments
with
considerable
trepidation because of my limited knowledge of developing countries.
I trust
I will be corrected where I say foolish things and unhelpful things.
There seems to be two key motivations for emphasizing the importance of
a private sector and market mechanisms as a component of health care reform
in developing countries.
Each, I believe, leads us to a contradiction.
Let
me explain.
First, the grave scarcity of public material resources in many of the
poorer developing countries means that it is tempting, even necessary, to look
to encouraging development in the private sector.
By taking pressure off
public resources, it may be possible to target them better to meet the needs
of the poorest sectors.
The contradiction here -- revealed by the U.S. and
7
European experience --is that some forms of growth in the private sector will
undermine the public sector rather than strengthen its ability to meet the
For example,
needs of the poorest and most vulnerable groups.
low public
salaries paid to primary care personnel in the public sector, combined with
new opportunities to work part-time in the private sector, can lead to reduced
availability of public sector personnel and increased costs.
It is also
important to keep in mind the different problems for which market reforms are
introduced
in wealthy,
developed countries
and poorer,
developing ones.
Oversupply and overutilization of some resources in developed countries may
be corrected by some market mechanisms (if transaction costs do not prove
prohibitive), but that is a very different task from what is envisioned in
countries with scarcity of resources.
entrenched,
Second,
bloated bureaucracies,
ineffective
or
and weak
government structures, complicated in some cases by widespread corruption, act
as significant obstacles to achieving primary health care and other health-
for-all objectives.
The antidote that is promoted is the promise of much
greater efficiency and creative energy in private sector health markets,
The
contradiction here -- again illuminated by the European experience -- is that
planned market reforms do not reduce or eliminate the need for a strong stjate
in
role
planning,
monitoring,
and
regulation.
If
the
problem
is
an
ineffective and weak public sector, then encouraging private market growth may
make it difficult both in the short and long run to preserve fairness in the
health care system.
The point of highlighting these as contradictions is not to imply that
no
attempt
justified.
to
increase
private
sector
resources
or
market
We may well be driven to such steps out of necessity.
reforms
is
Rather, the
point is that we must examine the implications of all such proposals for their
impact on the fairness of the system as a whole, and we should do so in a way
that is not blinded by market ideology.
IV.
Extending the Benchmarks of Fairness
The CIOMS/WHO concern about equity in health care reform prompts me to propose
a research project aimed at modifying and extending the benchmarks of fairness
methodology for use in monitoring ongoing health care reforms around the
world.
Ideally, such a project would involve a close look at a range of
8
particular
countries
different
at
levels
of
development
that
have
been
undergoing diverse sorts of reform (e.g., Pakistan, Thailand, Finland,Ghana).
In that way, criteria can be fine-tuned to reflect crucial features in tljiat
broad range of contexts,
The benchmarks developed for evaluating U.S. reforms
are limited because the types of reforms there envisioned had little to do
with modification of public health, for example.
A brief glance at the case of Thailand (Sanguan Nitayarumphong and
Supasit Pannarunothai 19967) suggests that the benchmarks could be readily
modified to address
the concerns
that have arisen there about equitable
financing, universal coverage, equalization of benefits, equitable allocation,
geographical barriers, quality, clinical and financial efficiency.
these
are
criteria,
already
incorporated
including additions
to
in
the
them,
specific features of the Thai situation.
benchmarks,
but
revision
are needed to make
them
All of
of
the
capture
Once criteria were refined,
an
appropriate scale could be adopted, and some inter-country applications of the
matrix could be attempted.
The result might be a way to show that some types
of reforms undertaken in particular contexts tend to have a specific pattern
of effects -- across a wide array of countries and conditions -- on equity or
fairness.
We might then be
in a better position to make evidence-based
arguments about the fairness of certain reforms.
It might then become quite
clear how different market and public sector reforms contribute to a multi
dimensional analysis of equity or fairness considerations.
Using such a tool
may make it possible to avoid the simplistic "pro" or "con" debate that nas
surrounded at least the earlier stages of proposals regarding market-oriented
health care reform.
References
1. Daniels, N, Light, D, & Caplan, R.
Benchmarks of Fairness for Health Care
Reform, New York, Oxford University Press, 1996.
2. Daniels, N.
Just Health Care, New York, Cambridge University Press, 1985.
3. Daniels, N.
Am I My Parents' Keeper?
An Essay on Justice Between the
Young and the Old, New York, Oxford University Press, 1998.
4. Daniels, N, & Sabin J.
"Limits to Health Care: Fair Procedures, Democratic
Deliberation, and the Legitimacy Problem for Insurers", (unpublished ms
1997.
9
5. Cassels, A. "Health Sector Reform: Key Issues in Less Developed Countries",
Discussion Paper No. 1, Forum on Health Sector Reform, Secretariat:
National Health Systems and Policies Unit Division of Strengthening Health
Services, WHO, 1995.
6. Saltman, R. "Applying Planned Market Logic to Developing Countries' Health
Systems: An Initial Exploration", Discussion Paper No. 4, Forum on Health
Sector Reform, Secretariat: National Health Systems and Policies Unit of
Strengthening Health Services, WHO, 1995.
7. Sanguan, N, & Supasit, P.
"Thailand at the Crossroads: Challenges for
Health Care Reform", in Sanguan N, ed.,
Thailand at the Crossroads:
Challenges for Health Care Reform, Office of Health Care Reform, Ministry
of Public Health, Thailand, 1996.
10
Appendix 1
Table 3-2.
Benchmark 1:
Benchmarks of Fairness for National Health Care Reform
Universal access - Coverage and Participation
Mandatory coverage and participation
Prompt phase-in: Coverage/participation not held hostage to
cost control
Full portability and continuity of coverage
Benchmark 2:
Universal Access - Minimizing Nonfinancial Barriers
Minimizing maldistributions of personnel, equipment,
facilities
Reform of health professional education
Minimizing language, cultural, and class barriers
Minimizing education and informational barriers
Benchmark 3:
Comprehensive and Uniform Benefits
Comprehensiveness: All effective and needed services deemed
affordable, by all effective and needed providers.
No
categorical exclusion of services, like mental health or
long-term care
Reduced tiering and uniform quality
Benefits not dependent on savings
Benchmark 4:
Equitable Financing - Community-Rated Contributions
True community-rated premiums
Minimum discrimination via cash payments
Benchmark 5:
Equitable Financing - By Ability to Pay
All direct and indirect payments and out-of-pocket expenses
scaled to household budget and ability to pay
Benchmark 6:
Value for Money - Clinical Efficacy
Emphasis on primary care
Emphasis on public health and prevention
Systematic assessment of outcomes
Minimizing overutilization and underutilization
Benchmark 7:
Value for Money - Financial Efficiency
Minimizing administrative overhead
Tough contractual bargaining
Minimize cost shifting
Anti-fraud and abuse measures
I
<<
11
Benchmark 8:
Public Accountability
Explicit, public, and detailed procedures for evaluating
services, with full, public reports
Explicit democratic procedures for resource allocation
Fair grievances procedures
Adequate privacy protection
Benchmark 9:
Comparability
A health care budget, so it can be compared to other
programmes
Benchmark 10:
Degree of Consumer Choice
Choice of primary-care provider
Choice of specialists
Choice of other health care providers
Choice of procedure
From: Daniels, N, Light D, & Caplan, R.
Benchmarks of Fairness for Health
Care Reform, p. 68, New York, Oxford University Press, 1996.
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Pa
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f
t
ACASH secretary’s
dismissal stayed
By A Stall Reporter
BOMBAY. Nov 24
Secretary of the Association for
Consumer Action on Safety and
Health (ACASH) Dr Arun Bal,
whose services as honorary sur
geon at the Dhanvatri Hospital
and Medical Research Centre
were terminated without as
signing reasons, has ap
proached the labour court un
der theUnfair Labour Practices
Act.
Presidency officer of the 9th
labour court A£)Deshpande has
granted an ad-interim injunc
tion and ordered the secretary
of the Brahman Sahayak Sangh,
which runs the hospital at Shivaji Park, to temporarily with
draw the termination order, af
ter hearing the doctor’s
advocate. Chander Uday Singh.
Bal can thus look after his in
door and outdoor patients for
the scheduled time.
The case is expected to come
up for hearing again tomorrow.
In his complaint made in his
capacity as an employee, Bal
said he had been appointed as a
honourable surgeon in Septem
ber 1984 and had thus per
formed his duties continuously
in the 50-bedded hospital which
is run by a public charitable
trust. Apart from Bal, there are
45 other doctors and surgeons
employed as honorarians.
Bal has further stated that
throughout his career, first as a
lecturer in surgery at JJ Hospi
tal and as assistant professor in
surgery and later as a practic
ing surgeon, he has had an out
standing record. He also point
ed out that his relations with his
patients as well as his col
leagues were extremely genial.
Apart from his career, Bal has
enumerated his interests which
include social and public inter
est causes, particularly on be
half of consumers affected by
sub-standard drugs and medi
cal malpractices. As founder
secretary of ACASH, he had
been in the forefront of that or
ganisation’s activities like tak
ing up the ban on sale of harm
ful drugs and filing of petitions
in the Bombay High Court in this
regard. "However, the com
plainant’s aforesaid activities
has not made him very popular
with the establishment," the
complaint says.
On November 7. the secretary
of the trust came to his resi-
dence at 9.45 pm and handed
over the letter terminating his
services to his "utter shock and
surprise”, says the complaint. It
adds that the secretary refused
to state the reasons or comment
on the late hour of delivery.
Bal pointed out that as sur
geon he performed very critical
and delicate operations upon
his patients and a crucial aspect
was post operative care. Any
shortcoming would thus result
in disastrous and life-threaten
ing complications. Therefore,
any last moment change in the
doctor treating the patients can
have bad consequences.
The complaint says that the
termination was utterly mala
fide and smacked of victimisa
tion. His termination was in ut
ter disregard of natural justice
in as much as he was not given
the barest opportunity of a
hearing before the termination.
As his record had been out
standing and there could be no
valid reason for terminating his
services in the surreptitious and
hasty manner, which shows
that it was effected (or oblique
and collateral purposes and as a
measure of punishment for
some imagined grievances.
Tr
1
I
1
Doctor’s services
-W^ierminated
By A StaJT Reports?
BOMBAY, November 29: Dr Arun
I
a prominent campaigner against
| malpracuces in the drug industry and
^e medical profession, was terminated
ofhonouraDsureeon in j,
^rrh
HOSI>itaJ
*
SCuC“5^ntrc without any notice.
s
. J*0 1123
a complaint in the
pital at Shivaji Park for unfair labour
practice.
L
ka* be*33'forking in the
hospital for the last four yean reputediy pertormmg more operations than
most other surgeons.
He is an active member of the
consumer Guidance Society of India
and the Association for Consumer
A£?t?n0.n S?fety and Heajth (ACASH1
Dr Bal;said he was served a notice of
ternunauon of his service on Novem
ber ' night The termination, he says,
is mala fide and would seriously affect
totients who needed his care since he
alone knew of their problems.
1
1
jb(X)23
March 20,1997
DEAKTN UNIVERSITY ETHICS COMMITTEE
Application for Ethics Approval
GUIDELINES
1.
The University Ethics Committee
Deakin University has two institutional ethics committees; the Animal
Experimentation Ethics Committee which has its terms of reference composition
and procedures determined by The Prevention of Cruelty to Animals Act 1986, and
the Ethics Committee which operates according to guidelines established by the
National Health and Medical Research Council.
2.
Research Projects which Require Approval
A principle contained in the NHMRC Statement on Human Experimentation is that
all research involving human experimentation should be submitted for approval to
an institutional ethics committee (IEC). The NHMRC Statement is to be read in
conjunction with the Supplementary Notes. Supplementary Note I refines the
principle and requires those research projects involving human subjects and relating
to health to be approved by an appropriately constituted ethics committee.
There is a tendency to give health' a broad definition so that it encompasses all
research involving human participants. Therefore, projects which are not medical
and do not involve human experimentation will nonetheless need to be appraised
for their ethical acceptability if they involve human participants.
The need to conform to NHMRC principles is not restricted to research funded
under NHMRC grants as the University has entered into an agreement with the
NHMRC that all research within the University will be conducted in accordance
with these principles including research activities emanating from the teaching
program. However, the DUEC only conducts ethical reviews of research projects
undertaken by staff members and masters by research and doctoral students.
Application for ethical review of research projects/activities undertaken as part of
undergraduate, honours year, masters prelim., graduate diploma or masters by
coursework programs should be made to the relevant faculty ethics sub-committee.
3.
The Application Form
Applications for ethical approval for a research project must be made on the
DUEC Protocol form and be in type format. Handwritten applications will not
be accepted. The application form is available on disk or via email from the
Secretary, Academic Administration Support, AASD, Geelong. Ph: 273412, fax:
272789, email: keithwil
jb0023
2
March 20,1997
If a research grant application has been submitted to a funding body such as
ARC/NHMRC, a copy should be attached to the ethics application. The grant
application will be used to provide further information on the project if required,
but copies will not he circulated to the members of Ethics Committee and the
Ethics font: should be completed without reference to the grant application.
4.
Timing of application
The Deakin University Ethics Committee meets six times per year and applications
for approvals should be submitted to the Secretary by the relevant agenda deadline.
Information on meeting dates and agenda deadlines is published annually in
NETWORK and is also available from School administrative officers and the
Secretary of the DUEC.
Staff/higher degree students whose research requires ethical clearance from an
external IEC as well as the DUEC should apply to both committees
simultaneously.
Staff members applying for research grants from funding bodies such as the
ARC/NHMRC should make sure that their applications are submitted to the
DUEC in time to obtain clearance by the required date. NB: It is advisable to
apply in advance of the granting body's deadline to allow for any amendments
wjiich may be required by the DUEC.
Where ethical clearance is required for projects funded under the ARC Small
Grants Scheme, application should be made to the DUEC as soon as the grant is
announced as grant payments cannot commence until ethical clearance is obtained.
5.
Ethical Issues
All research or teaching activities involving human subjects must conform to
generally accepted moral and scientific principles and to the NHMRC Statement on
Human Experimentation attached to these guidelines.* Researchers should also
note the relevance of codes of ethical practice developed by their professional
bodies.
The application should provide information on ethical issues including:
. the procedure for obtaining of informed consent of participants;
degree of protection of privacy for personal information;
source(s) of participants apd sampling procedures;
. details of any p^pposed payment to be made, or course credit to be
gran^d to participants. (Payment may be made for inconvenience or time
spent, but should not be so large as to be an inducement to participate);
. details of research'methods;
jb0023
3
use of invasive techniques or administration of drugs;
details of any proposed communication of findings to the
March 20,1997
participants;
. the benefits to be gained from the work as compared with any
discomfort
or risks involved (why this study is worth doing).
. safety of equipment and procedures;
. training of those conducting the research in handling contingencies.
6.
Classification of Project
All research projects involving participation of human subjects are classifiable
under one of the categories described in Question 3 on the Ethics Protocol form
unless the information to be acquired is a matter of public record. Applicants who
answer all parts of Q3 negatively should be sure that they have done so correctly.
7.
Procedures for Obtaining Informed Consent
a) The Plain Language Statement
Informed consent is based on the information provided in the plain language
statement. The statement should be addressed to the participants rather than the
DUEC and should be written in language which a layperson would understand. It
is permissible for the statement to take the form of a letter to the participant. What
is required is a short summary in simple language of the essential points which a
reasonable person would want to know before agreeing to participate. The
statement should include information on the following:
. aims of the project
. procedures involved
. time commitment expected of participants
. description of reasonably foreseeable risk or discomfort (if any)
. a statement describing the provisions to be made to preserve confidentiality of
records
. the researcher’s name and contact details.
For examples of satisfactory plain language statements see examples provided.
b) The Consent Form
Participants are normally required to give written consent before participating in a
research study and three sample consent forms are attached to the Ethics Protocol
form. The first is suitable for more invasive research or "human experimentation",
the second for research involving surveys or questionnaires, and the third for
consent on behalf of a minor. In some cases, consent will need to be witnessed eg.
where the subject is blind/intellectually disabled. A witness must be independent of
the project and may only sign a certification to the level of his/her involvement. A
suggested format for witness certification is included with the sample consent
jb0023
4
March 20, 1997
forms. The form should also record the witnesses' signature, printed name and
occupation.
The consent forms may be changed to suit the research study but the information
contained in the pro forma must be included. The name of the person(s)
undertaking the study and the purpose of the research should be added to the form.
The latter does not constitute a plain language statement.
A copy of the plain language statement and the consent form(s) should be attached
to the Ethics application The Plain Language Statement MUST include the
relevant contact names and numbers of the principal investigator. Where the
principal investigator is a student the Plain Language Statement MUST
ALSO include the contact name and number of the chief supervisor.
The plain language statement and consent form will normally be separate so that
the subject may keep the statement and return the signed consent to the researcher.
However, there will be occasions where it is appropriate to combine the two in the
one document eg. the consent form may be produced as a tear-off section.
The researcher is not required to obtain signed consents from the subjects before
applying for ethical clearance as the DUEC must consider the ethical implications
of the research before the subjects are asked to participate.
Where research involves video taping of classroom activities parental consent will
be required if the students could be identified from the video tape.
c) Informed Consent and Deceptive Research
There may be experimental procedures which would be defeated by the
participants knowing in advance what was happening. When assessing the
research protocol the DUEC will work to the following guidelines:
(i) the participants should not be subject in these situations to any procedure which
is reasonably likely to prove either physically harmful to them or of enduring
psychological harm (to be distinguished from mild alarm or temporary
embarrassment); and
(ii) they are to be fully informed at the close of the experiment as to its nature, the
disposition of results etc.
8.
Permission to undertake Research in Schools
Where research is to be undertaken in a primary or secondary school, written
pennission should be obtained from the School Principal, and if appropriate, from
the classroom teacher. Permission may be sought from the school before
application is made to the DUEC. However, permission from the principal does
not obviate the need to obtain parental consents where required by the DUEC.
(See Guidelines for approval for Research in (Ministry) Schools.)
jb()023
5
March 20,1997
9. Interview Questions
Where a questionnaire has been developed this should be attached to the
application for ethical clearance. Otherwise, the researcher should provide
information on the nature of the interview questions and the way in which they will
be asked in order for the DUEC to determine what ethical issues, if any, are raised
by the proposed research.
10.
Confidentiality
Precautions should be taken to protect the identity and privacy of subjects in a
research project and it is not sufficient for a researcher to simply state that subjects'
names will not be used when the data is written up. The DUEC needs to be
satisfied with the provision made to preserve confidentiality of records. For
example, where information is to be obtained through taped interviews,
confidentiality is more likely to be preserved if the researcher numbers each tape
and keeps a separate list of corresponding numbers and names; given names only
or aliases should be used during taped interviews.
11.
Storage of data
It should be noted the NHMRC procedures for the storage of data, make the
principal investigator of an approved project responsible for the storage and
retention of original data pertaining to the project for a
minimum of five years.
Individual researchers should be able to hold copies of the data for their own use.
However, original data should be retained in the School or research unit in which
they were generated wherever possible.
Approved:
Deakin University Ethics Committee
9.8.1993
DUECGUID ETH
* A copy may be obtained from the DUEC Secretary
Ext. 273412
Fax 272789
email keithwil
M Pad
MONASH UNIVERSITY
STANDING COMMITTEE ON ETHICS IN RESEARCH ON HUMANS (SCERH)
APPLICATION FOR ETHICAL APPROVAL OF A PROJECT USING HUMANS
COVER PAGE
(This page MUST be fully completed)
DO NOT alter the formatting or pagination of this application form
application number: ...........................
OFFICE USE ONLY
Project Title:
(limit to ten words)
Chief Investigator(s)/Supervisor:
(include title and department!location)
1.
2. ’
3.
Co-lnvestigator/Student Researcher:
4.
Contact Person:
(include department!full address! telephone number/fax number)
a) If applicable please give previous Monash University pro ject number:
b) Type of Research:
Staff Research
Class Project
Other:
Student Research - Name of degree:
Have you applied for external funding?
Yes
No
If YES, name granting body/bodies:
(Please attach the relevant pages from the grant application to this ethics application)
Has the funding been approved?
T
d) Has this project been submitted to any other Ethics Committees?
(see Question 4)?
Yes
No
Pending
Yes
No
Pending
Yes
No
Pending
Yes
No
If YES, name of Committee:
Has approval been granted?
(Attach copy of the approval if available)
e) Proposed Commencement Date for this Project:
Proposed Date of Completion for this Project:...
1) Does the Privacy Act apply to this Project? (refer Question 19)
g) Does this Project involve the CTN Scheme clinical trials?
Yes
No
If YES, please contact the Secretary to obtain the CTN application form and further details.
MONASH
UNIVERSITY
AUSTRALIA
STANDING COMMITTEE ON ETHICS IN RESEARCH ON
HUMANS (SCERH)
GUIDELINES AND APPLICATION FORM
FOR ETHICAL APPROVAL OF A RESEARCH PROJECT
USING HUMANS AS SUBJECTS
(Revised - January 1998)
Monash University has a central ethics committee - the Standing Committee on Ethics in Research on
Humans (SCERH). All research conducted by Monash University staff or students involving humans must
receive clearance from SCERH before commencing.
Historically the Monash SCERH is an NHMRC Committee. However, SCERH acknowledges that there are
other environments in which university research is conducted, and that research methodologies vary in
accordance with certain fields of study. The Committee has retained the NHMRC Principles in this
application form. They affirm fundamental rights for participants/subjects in research and provide guidance
in the conduct of research.
Although most research carried out by staff and students docs not entail serious risks there may be some
research projects where these may be present. The questions on this form are intended to assist SCERH to
minimise risk to everyone, including the researcher(s) and the subject(s)/participant(s).
You will be able to begin your research after receiving official notification of ethical clearance by
SCERH. Please note that SCERH does not grant retrospective approval of projects.
Instructions to applicants
• Please answer all the questions
• Do not alter the formatting or pagination of this application form. If you require further space
to answer any questions, please do so on p.13.
• Read the checklist (p.15) to ensure that all relevant documentation is attached to the application
• The application must be word processed or typewritten. You can obtain a copy of the file on disk
in Word for Windows by contacting the Secretary on 9905 2052. A copy of the form is also available
on the World Wide Web at the following address http://www.monash.edu.au/resgrant/
See page 15 for further information concerning deadlines and submission procedures.
1
STANDING COMMITTEE ON ETHICS IN RESEARCH ON
HUMANS
ADMINISTRATION
-------------------------------------------------------------------------------------------------------------------- ,—
Research must conform to generally accepted moral and scientific principles. To this end,
institutions in which human experimentation is undertaken should have a committee
concerned with ethical aspects and all projects involving human experimentation should be
submitted for approval by such a committee.
Protocols of proposed projects should contain a statement by the investigator of the ethical
considerations involved.
Research should be conducted only by suitably qualified persons with appropriate
competence, having facilities for the proper conduct of the work; clinical research requires
not only clinical competence but also facilities for dealing with any contingencies that may
arise.
Subject to maintenance of confidentiality in respect of individual patients, all members of
research groups should be fully informed about projects on which they are working.
Do not alter the formatting or pagination of this application form. If you require
further space to answer any questions, please do so on p.13.
1.
SHORT PROJECT TITLE
(10 words or less. This exact title must appear on your Consent Form and Explanatory Statement. Use
simple, non-technical words.)
APPLICANTS
Chief Investigator/Supervisor:
Co-Investigator/Student:
...................................................................................................................................... ].................
(Include your academic qualifications. SCERH assumes that the applicant
will be ultimately responsible for the ethical conduct of the research. In the
case of student research this responsibility is exercised by the supervisor.)
Contact Address:
Telephone numbers:
(Work) .............................
(The applicant should be readily available to answer queries)
Home campus:
2
. (Home)
3.
RESEARCH SOURCE
SlafT Research
□
Have you applied for external funding?
□ Yes
□ No
Has funding been granted?
□ Yes
□ No
□ Pending
Name of funding body: ......................
Student Research
□
Towards which degree:
Name and qualifications of supervisor: ......................
4.
RESEARCH REQUIRING ETHICAL CLEARANCE FROM OTHER INSTITUTIONS
(e.g. research on hospital patients or staff will require approval from that hospital's ethics committee)
Has this research project been submitted to any other ethics committees?
□ Yes
□ No
□ No
□ Pending
If NO, go to Q5.
If YES, please answer the following questions:
5.
a)
Name of committee:
b)
Has ethical approval been granted?
(If YES, please attach a copy of the letter of approval)
□ Yes
RESEARCH REQUIRING PERMISSION FROM OTHER ORGANISATIONS
If permission from an organisation is required, written advice must be submitted prior to commencement of
the project.
(e.g. the Ministry of Education where research in government schools is proposed, school principals, or
within commercial or government organisations)
Is permission required?
□ Yes
□ No
□ Yes
□ No
If NO, go to Question 6.
If YES, please answer the following questions:
a)
From whom should permission be sought?
b)
Has permission been granted?
□ Pending
(If YES, please attach a copy of the letter of permission)
(If PENDING, SCERII may grant provisional ethical clearance, whereby research procedures may
start as soon as permission documents have been officially received by SCERH)
6.
PROPOSED DATE OF COMMENCEMENT OF PROJECT
ANTICIPATED DATE OF COMPLETION
3
I
I
I
I
INTRODUCTION
BACKGROUND AND AIMS OF THE RESEARCH PROJECT
The research protocol should demonstrate knowledge of the relevant literature and wherever
possible be based on prior laboratory and animal experiments.
The investigator, after careful consideration and appropriate consultation, must be satisfied
that the possible advantage to be gained from the work justifies any discomfort or risks
involved.
7.
GIVE A SUCCINCT DESCRIPTION OF THE BACKGROUND AND POTENTIAL
SIGNIFICANCE OF THE RESEARCH PROJECT
(250 words or less. Attach a separate reference list if relevant.)
CLEARLY STATE THE AIMS AND/OR HYPOTHESES OF THE RESEARCH PROJECT
(250 words or less)
4
METHOD
SUBJECTS, MATERIALS AND PROCEDURES
FOR THE RESEARCH PROJECT
9.
DETAILS ABOUT THE SUBJECTS/PARTICIPANTS OF THE PROPOSED RESEARCH
In the conduct of research, the investigator must at all times respect the personality, rights,
wishes, beliefs, consent and freedom of the individual subject.
Volunteers may be paid for inconvenience and time spent, but such payment should not be
so large as to be an inducement to participate.
a)
How many people will be involved as subjects/participants?
(NB: give upper and lower limits of sample size.)
b)
What categories of people?
(e.g. teachers, undergraduate students, school children, epileptics, hospital patients, pensioners, etc)
c)
Age range:
d)
Criteria for exclusion:
(e.g. under 18-year-olds, pregnant women, people who have already experienced an experimental
condition, etc., may he unsuitable participants in your research project)
c)
How much time are you asking of each subject/participant and when will the time be required?
( e.g. during school hours)
0
Are you o He ring any payment?
□ Yes
If YES, give details:
5
□ No
10.
RECRUITMENT
a)
Who will be doing the recruitment of volunteers into the study?
b)
Is there an external agent/extemal body/third person doing the recruitment for the researcher?
(e.g. professional associate, leisure group, church organisation)
□ Yes
□ No
c)
What is the relationship between the recruiter and the subjects/participants?
d)
Will any special relationship exist between the recruiter and the participants?
(A special relationship may exist if the person recruiting the participants holds some power over the
participants in the research, e.g. counsellor/client, teacher/student, warder/prisoner, parent/child,
customer/supplier, doctor/patient.)
□ Yes
□ No
if YES, describe the nature of the relationship, and explain what special precautions will
preserve the rights of such people to decline to participate, or to withdraw from participation
once the research has begun:
e)
How and where will the recruitment process occur?
6
11.
EXPLANATION PROCEDURES
Ethical practice requires the researcher to inform potential participants of all features of the
research that might reasonably be expected to influence their willingness to participate in the
project and to explain any other aspects of the project about which the potential participant
asks.
Researchers should refer to the document "Writing an Explanatory Statement’, which includes a checklist
and an example explanatory statement. This document can be downloaded separately from the web.
Additional examples of statements as a reference are available by contacting the Secretary.
a)
Who will be explaining the project to potential subjects/parlicipants?
b)
How and where will the explanation take place?
(The safety of all parties needs to he assured. SCERIl also needs to he assured that the participants
are not placed in a potentially coercive situation.)
c)
Will subjects be fully informed about the true nature of the research?
(The researchers may not tell the participants the exact aim of the research. Certain types of
research would be impossible ifparticipants knew in advance what was happening.)
Yes
If NO, describe the procedure and explain why the real purpose needs to be concealed:
7
No
12.
INFORMED CONSENT PROCEDURES
_________________________________________________________________ L_
Before research is undertaken, (he free consent of (he subjects should be obtained. To this
end the investigator is responsible for providing the subject with sufficient information about
the purpose, methods, demands, risks, inconveniences and discomforts of the study at his or
her level of comprehension.
Consent should be obtained in writing unless there are good reasons to (he contrary, and
these reasons must be clearly stated below. If consent is not obtained in writing, the
circumstances under which it is obtained should be recorded.
It must be made clear that the subject is free to withdraw consent to further participation at
any time.
Special care must be taken in relation to consent, and to safeguarding individual rights and
welfare where the research involves children, the mentally ill and those in dependant
relationships or comparable situations.
a)
Attach the Consent Form(s) as an attachment to this submission, or explain why one is
unnecessary, or inappropriate.
Researchers should refer to the document 'Writing a Consent Form ’ for an outline of situations in
which consent forms are not required, and for guidance on writing the forms themselves. This
document can be downloaded separately from the web.
□ Yes
Consent Form attached?
□ No
U NO, the reason is:
b)
If the participants in your study will be unable to complete a Consent Form, explain how you
intend to obtain the informed consent.
(For young children or incapacitated participants, explain who will give consent on their behalf.)
c)
Who will be available to act as an independent witness to subject's/participant’s consent? If
you feel that a witness is unnecessary, please explain why.
(Independent means someone not associated with the research project. A witness to the subject's
signature is advisable where subjects will be exposed to any level of risk beyond that normally
encountered in everyday life.)
8
13.
USE OF EXISTING RECORDS WHICH ARE NOT IN THE PUBLIC DOMAIN
Are you intending to use existing records, which identify individuals, but which are not in the public
domain?
(e.g. medical records, personal diaries, computer data, or any other information not available in a public
library)
Yes
No
If NO, go to Question 14.
If YES, answer the following questions:
a)
Describe the type of records to be used.
(e.g. medical records, personal diaries, computer data, etc.)
b)
Which individuals or organisations control access to the information?
c)
Is any organisation listed in (b) above a ‘Commonwealth Agency’?
(i.e. any Commonwealth government department, any statutory agency created by Commonwealth
legislation, any federal union or employer organisation, any non-statutory body set up by the
Commonwealth, federal and ACT courts, and the Australian Federal Police)
Yes
No
d)
Has the organisation agreed to provide the information?
Yes
Ij YES, attach a copy of the letter.
No
Pending
c)
State any conditions imposed by the organisation on the release of information:
0
Will you have access to identifying information about any individual?
(i.e. Will you be able, either directly or indirectly, to match names to the information or opinions
contained in the records?)
Yes
No
If YES, will that individual's consent be sought by the researcher?
Yes
No
If NO, please give reasons, and show how such participants will be protected from having
identifying information made public.
NB: If you have answered YES to both 13(c) and 13(f), the Privacy Act WILL apply, so please answer
YES to Question 19.
9
14.
COLLECTION OF DATA - MATERIALS AND PROCEDURES
a)
Is there any special relationship between the person administering the test or procedure and the
participant?
Yes
No
If YES, describe the nature of the relationship:
b)
What techniques or methods of data collection and other measurement will be used?
Researchers should briefly outline all research/control procedures to be used with each category
of subjects/participants?
(e.g. questionnaires, interviews, video and taped interviews, observation, involvement in a clinical
drug trial as a subject or control)
c)
Where will these procedures take place?
d)
Does the research involve the administration of any tests or other procedures that can only be
used by people with particular qualifications?
(e.g. certain psychological tests, medical tests)
Yes
No
If YES, give details of the test or procedure, qualifications required, proposed administrator
and qualifications:
e)
Will radioactive substances, recombinant DNA techniques, toxins, mutagens, teratogens or
carcinogens be used?
Yes
No
If YES, specify which:
(If YES, submit evidence of clearance by University Radiation Protection Officer, and/or the Biosafety
Committee)
Evidence submitted with application?
Yes
10
No
Pending
15. COLLECTION OF DATA - RISKS AND PROCEDURES
New therapeutic or experimental procedures which are at the stage of early evaluation and
which may have long-term effects should not be undertaken unless appropriate provision
has been made for long-term care, observation and maintenance of records.
The investigator must stop or modify the research program or experiment if it becomes
apparent during the course of it that continuation may be harmful.
a)
Deline the risk of physical/psychological stress, inconvenience or discomfort beyond the normal
experience of everyday life, in either the short or long term, from participation in the project.
i
b)
Are all of these risks outlined on the consent form? If not, why not?
c)
Outline the arrangements planned to minimise the risks involved in these procedures.
d)
Should serious events or emergencies occur during the conduct of the research what will you
do? What facilities are available to deal with such incidents?
(e.g. an adverse drug reaction, subject/participant becomes distressed during questioning)
e)
What will the researcher do if, in the course of the research, highly sensitive information, or
information about the subject’s well-being is disclosed?
(eg. subject suggests: domestic abuse, potential suicide, substance abuse, HIV +, involved in crime)
0
Is the project to be conducted by researchers who are mandated by law to report certain
findings? (e.g. certain infections, child abuse, domestic violence)
Yes
No
If YES, this information must be included in the Explanatory Statement.
11
16.
DEBRIEFING PROCEDURES
□ Yes
Is a debriefing appropriate or necessary for the subjects/participants?
□ No
If NO, go to question 17.
If YES, answer the following questions:
a)
How will information about results of any tests be communicated to subjects/participants?
b)
What arrangements will be in place to deal with subjects’/participants’ distress in the case of
adverse test results?
17. CONFIDENTIALITY AND SECURITY PROCEDURES
(Researchers should avoid causing their subjects distress or harm from breaches of confidentiality.)
The Monash University Code of Conduct for the Responsible Practice of Research places obligations upon
researchers ( refer Part 3, Research Policy Monash University Education and Research Policy).
a)
University regulations require the following procedures concerning storage of data:
>)
Only the researchers will have access to the original data
ii)
iii)
Data will be retained in the Department for five years
□
□
Original data or electronically stored copies of the original
data, may be destroyed after five years
□
b)
If the above regulations are not being adhered to, how will information be handled to safeguard
confidentiality?
c)
Describe the procedures you will use to protect participants from any distress, embarrassment
or other harm that might be caused when the data is reported.
12
18.
ARE THERE ANY OTHER ETHICAL ISSUES RAISED BY THE PROPOSED PROJECT?
WHAT IS YOUR RESPONSE TO THEM?
In many research projects involving humans there is a trade-off to be made between the cost of the
interventions to those participating in them (e.g. in terms of discomfort, health risk, loss of privacy, etc) and
the value to be achieved by carrying out the research. The Committee must be in a position to evaluate
clearly that trade-off.
This space is to be used should you need to add further detail to any response made earlier on this
application form:
13
SIGNATURES
19.
STATUTORY PRIVACY PROTECTION
If the data used are held or to be collected by a Commonwealth Agency (see Question 13(c)) AND collection
will or might enable identification of any individual (see Question 13(f)), then the Privacy Act (1988)
applies.
Docs the Privacy Act apply to the proposed data collection?
Signature of Chief Investigator/Supervisor
20.
□ Yes
□ No
Date
DECLARATION
I/We, the undersigned, accept responsibility for the conduct of the research detailed above, the principles
outlined above and any other condition noted by the SCERH. If any changes to the protocol are proposed
after the approval of the Committee has been obtained then SCERH will be informed immediately. The
Associate Investigator will assume responsibility for the project in the absence of the Chief Investigator.
Signature of Chief Investigator/or Supervisor
Name:
(please print)
Signature:
Date:
Signature/s of Co-Investigator(s)/Student Researcher
Name:
(please print)
Signature:
2.
Date:
Name:
(please print)
Signature:
Date:
Signature of Head of Department
I certify that I am prepared to have this project undertaken within my Department.
Name:
(please print)
Signature:
Date:
Section:
14
21. CHECKLIST
Please ensure that those items listed below which are relevant to your application are attached to the application.
Failure to do so will hinder the approval procedure. This sheet must be submitted with the application.
Please type “N/A” if not applicable. Every box should be either checked or marked N/A.
□
□
□
□
□
□
□
□
□
□
Original plus three copies provided to the Secretary, SCERH (address below)
All details on SCERH Cover Sheet completed
If external funding is being provided, relevant pages from the grant application must be submitted
Q.5 - Copy of written advice from other organisations from whom approval must be sought
Q.7 & Q.8 - Reference materials
Q.10 - Copy of posters/announcements to be used to recruit participants into the study
Q.ll - Explanatory Statement(s)
Q.12 - Consent Form(s)
Q.13 - Copy of written permission to use information in records which are not in the public domain
. . Q.14 - Copy of data collection materials (questionnaires, interview schedules or specifications of
instruments) should be attached
□
Q.14 - If radioactive substances, recombinant DNA techniques, toxins, mutagens, teratogens or
carcinogens are to be used, researchers should submit evidence of clearance by a University
Radiation Protection Officer, and/or the Biosafety Committee
□
Q.15 - Copy of written advice from other groups who have agreed to follow-up should any participant
require assistance due to taking part in the research.
□
□
□
□
Q.16 - Where post-research de-briefing is offered, a copy of this information should be provided.
Q.19 - If the Privacy Act applies (refer Q.13c & Q.131), then the Privacy Declaration should be signed.
Q.20 - Have the researchers signed the Declaration concerning responsibility for the research projedt?
Q.20 - Has the Head of Department/Faculty also signed this Declaration?
Mail or deliver the ORIGINAL PLUS THREE hard copies of your application to:
Secretary
Standing Committee on Ethics in Research on Humans (SCERH)
Research Grants and Ethics Branch
Monash University
Wellington Road
CLAYTON VIC 3168
Deadlines
SCERH will meet every three weeks from February to December in 1998 - 16 meetings arc scheduled. To be
considered at a particular meeting, applications should be received by the Secretary three weeks before that
meeting. However, applications may be forwarded at any time as deadlines are of little concern given the
frequency of meetings. Please contact the Secretary for meeting dates (Ph: 9905 2052).
15
Writing a Consent Form
Subjects/participants under 18 years of age should be asked to give written consent to involvement
in the project if they are of an age and/or intellectual ability where they can understand the
proposed procedures.
Where projects involve any level of risk to participants beyond that encountered in everyday life,
an independent witness should also be present to sign the consent form.
If any potential subjects are under 18 years of age or are people over 18 who are unable to reacp an
informed decision about participation, additional, separate consent forms are needed for
parents/guardians.
(ie/ For research on children, the mentally ill, those in dependent relationships or comparable
situations, including unconscious patients).
Consent forms are only unnecessary where consent is implied (eg: anonymous return of
questionnaires by mail).
How to write your Consent Form(s) for your research project
Consent Forms may be produced on plain paper rather than letterhead, as they are collected and
retained by the researchers. Explanatory Statements, on the other hand, are kept by the subject, so
they need to be on Monash letterhead which provides corporate identity and address details.
Attached is a suggested format for consent forms. This is only intended as a guide, and variations
on this format are acceptable.
REVISED 5/11/97
Iiiformed Consent Form
Project Title: (Exactly as it appears on your SCERH Application Form)
I agree to take part in the above Monash University research project. I have had the project explained to me, and I
have read and understood the Explanatory Statement, which I retain for my records.
I understand that any information I provide is confidential, and that no information that could lead to the
identification of any individual will be disclosed in any reports on the project, or to any other party.
I also understand that my participation is voluntary, that I can choose not to participate, and that I can withdraw
my participation at any stage of the project.
Name:
(please print)
Signature:
Date:
Independent witness to participant’s voluntary and informed consent:
(please print)
Name:
Signature:
Date:
Address:
Informed Consent Form for Parents/Guardians of Project Participants
I agree that
(full name of participant) may take part in the above Monash
University research project. The project has been explained to
and to me, and I have read and
understood the Explanatory Statement, which I retain for my records.
understand that any information provided by
is confidential, and that no information
that could lead to the identification of any individual will be disclosed in any reports on the project, or to any other
party.
I also understand that
’s participation in the project is voluntary, that s/he can refuse to
participate, and that s/he can withdraw her/his participation at any stage.
Participant’s Name:
Parent’s/Guardian’s Name:
Your relationship to participant:
If appropriate, reason(s) why s/he cannot give written consent:
(please print) Participant’s Age:
Writing an Explanatory Statement
The explanatory statement should be designed so that potential participants of your research project can give
informed consent to participate in the project.
The items listed below should be used as a guide as to what information is required in the statement. This
list is for your own reference. Do not submit this with the application form. See the following page for an
example of how to design an explanatory statement.
0 Does you explanatory statement meet the following criteria:
□ Clear identification of the University as the responsible institution ( normally use letterhead)
□ The short title of the project exactly as it appears on your SCERH application form, name of chief
investigator(s) and any other person who will have direct involvement with research subjects
□ A statement of the purpose of the study, the inclusion and exclusion criteria and alternative treatments
available (where appropriate)
□ A description of the possible benefits for participants and/or society in general
□ An outline of all methods or procedures involving the potential participant
□ An indication of the expectations of the potential participant: time involved, level of inconvenience
and/or discomfort and any payment offered
□ A list of all possible or reasonably foreseeable risks of harm or possible side effects to the potential
participant (outlining likely incidence and severity) and contact details of someone who will answer any
inquiries about the research.
□ A statement about how you will discharge your responsibility to protect the subjects’ rights to privacy.
□ A statement of where the records will be stored and details of access and discard.
□ A clear statement that participation is voluntary, that subjects may withdraw at any stage, or avoid
answering questions which are felt too personal or intrusive, and an assurance that this will not affect
future treatment
□ An indication of whether participants will be informed of overall results, or any which might affect them
personally, and what debriefing procedures are available for those who withdraw (where appropriate)
□ The name and phone number of someone who can be contacted in an emergency or if the participant has
any concerns (this should not normally be a home phone number)
□ The University complaints clause:
Should you have any complaint concerning the manner in which this research is conducted, please do not
hesitate to contact The Standing Committee on Ethics in Research on Humans at the following
address:
The Secretary
The Standing Committee on Ethics in Research on Humans
Monash University
Wellington Road
Clayton Victoria 3168
Telephone (03) 9905 2052 Fax (03) 9905 1420
0 Is it written in language that potential participants could reasonably be expected to understand?
0 Is it free from coercive language or promises that cannot be kept?
REVISED 5/11/97
M
N
O
A
S
H
U
N
I
V
E
s
R
I
T
AUSTRALIA
Date
Project Title: (Exactly as it appears on your SCERH Application Form)
My name is
and I am studying for my
(eg GradDip, BSc
(Honours), MA etc) at Monash University. A research project is an important component of the course and I am
undertaking mine under the supervision of(eg Dr
) a
(eg lecturer/senior lecturer/professor etc) in the Department of.
The aim of this project is to
(eg explore the relationship between
a Quality Culture and job satisfaction. Quality Culture, sometimes referred to as TQM or TQC is becoming a
major part of business practice and it is important to be able to measure it and research its effectiveness. Employee
satisfaction is also critical to business performance). I believe that the findings of this research project will be
useful(eg in contributing to knowledge in these areas).
(eg adults in full employment) who are prepared to
(eg fill out the attached questionnaire on their organisation’s practices and theif own job
(Consequently, if you are
(eg under 18 years of age) or
satisfaction).
(eg unemployed), you are unable to participate in this research project.) The procedure would
take approximately
(eg thirty minutes) of your time, and would be undertaken at
(eg home, at your convenience).
I am seeking
No findings will be published which could identify any individual participant. Anonymity is assured by our
procedure, in which
(eg you are not asked to provide either your name or the name of
your organisation on your questionnaire response sheet.) Access t< data is restricted to my supervisor and to me.
Coded data are stored for five years, as prescribed by University regulations.
Participation in this research is entirely voluntary, and if you agree to participate, you may withdraw your consent
4 any time by(eg not returning the questionnaire) or decline to participate in any section
of the procedure, by(eg simply not marking a response).
If you have any queries or would like to be informed of the aggregate research finding, please contact telephone
fax (This must be a university address/telephone/fax not a personal contact number)
Thank you.
Should you have any complaint concerning the manner in which this research is conducted, please dlo not
hesitate to contact The Standing Committee on Ethics in Research on Humans at the following address:
The Secretary
The Standing Committee on Ethics in Research on Humans
Monash University
Wellington Road
Clayton Victoria 3168
Telephone (03) 9905 2052 Fax (03) 9905 1420
(Distribute photocopies
to potential participants;
(your signature)
use of original letterhead is unnecessary)
(your typed name)
(your phone number)
REVISED 6.3.98
( <4- A/
S) A
25
^7’
'del
C
D-jyjy
APPENDIX 2
NHMRC STATEMENT ON HUMAN EXPERIMENTATION
Aware of the Declaration of Helsinki, adopted by the 18th World Medical Assembly,
Helsinki, Finland, 1964, revised by the 29th World Medical Assembly, Tokyo, Japan, 1975,
and the 35th World Medical Assembly, Venice, Italy, 1993 and of the Proposed
International Guidelines for Biomedical Research Involving Human Subjects published by
the World Health Organisation and the Council for International Organisations of Medical
Sciences in 1982, the National Health and Medical Research Council issues the following
Statement on Human Experimentation. ‘These are intended as a guide on ethical matters
bearing on human experimentation, for research workers and administrators of institutions
in which research on humans is undertaken in Australia.
* The Statement is associated with the following Supplementary Notes in a document
which is available from Administrative Officers in research institutions or from the NHMRC
Secretariat or Publications:
Supplementary Note 1-
Institutional Ethics Committees
Research on Children, the Mentally ill, Those in Dependent or
Supplementary Note 2 Comparable Situations (Including Unconscious Patients)
Supplementary Note 3 -
Clinical Trials
Supplementary Note 4 -
In vitro Fertilisation and Embryo Transfer
Research involving the Human Fetus and the Use of Human
Supplementary Note 5 Fetal
Tissue
Supplementary Note 6 - Epidemiological Research
Supplementary Note 7.- Somatic Cell Gene Therapy
NHMRC STATEMENT ON HUMAN EXPERIMENTATION
i
(To be read in conjunction with the Supplementary Notes)
The collection of data from planned experimentation on human beings is necessary for the
improvement of human health. Experiments range from those undertaken as a part of
patient care to those undertaken either on patients or on healthy subjects for the purpose of
contributing to knowledge and include investigations on human behaviour. Investigators
have ethical and legal responsibilities toward their subjects and should therefore observe
the following principles:
(1)The research must conform to generally accepted moral and scientific principles. To this
end institutions in which human experimentation is undertaken should have a committee
concerned with ethical aspects and all projects involving human experimentation should be
submitted for approval by such a committee. (See Supplementary Note 1: Institutional
Ethics Committees).
(a) An application to the NHMRC for a research grant involving human experimentation is
required to be certified by the ethics committee of the applicant’s institution as complying
with the NHMRC Statement on Human Experimentation and the Supplementary Notes
before the application will be considered for funding.
a-<
26
(b) Persons undertaking human experimentation who are not associated with an institution
should ensure that comments on their protocols are sought from an established ethics
committee eg. in a university or hospital.
(2) Protocols of proposed projects should contain a statement by the investigator of the ethical
considerations involved.
(3)The investigator, after careful consideration and appropriate consultation, must be satisfied
that the possible advantage to be gained from the work justifies any discomfort or risks
involved.
(4)The research protocol should demonstrate knowledge of the relevant literature and,
wherever possible, be based on prior laboratory and animal experiments.
(5) In the conduct of research, the investigator must at all times respect the personality, rights,
wishes, belief, consent and freedom of the individual subject.
(6) Research should be conducted only by suitably qualified persons with appropriate
competence having facilities for the proper conduct of the work; clinical research requires
not only clinical competence but also facilities for dealing with any contingencies that may
arise.
(7) New therapeutic or experimental procedures which are at the stage of early evaluation and
which may have long-term effects should not be undertaken unless appropriate provision
has been made for long-term care, observation and maintenance of records.
(8) Before research is undertaken the free consent of the subject should be obtained. To this
end the investigator is responsible for providing the subject at his or her level or
comprehension with sufficient information about the purpose, methods, demands, risks
inconveniences and discomforts of the study. Consent should be obtained in writing unless
there are good reasons to the contrary. If consent is not obtained in writing the
circumstances under which it is obtained should be recorded
(9)The subject must be free at any time to withdraw consent to further participation.
(10) Special care must be taken in relation to consent and to safeguarding individual rights
and welfare where the research involves children, the mentally ill and those in dependant
relationships or comparable situations. [See Supplementary Note 2: Research on Children,
the Mentally ill and Those in Dependant Relationships or Comparable Situations (Including
Unconscious patients)].
(11) The investigator must stop or modify the research program or experiment if it becomes
apparent during the course of it that continuation may be harmful.
(12) Subject to maintenance of confidentiality in respect of individual patients, all members of
research groups should be fully informed about projects on which they are working.
(13)Volunteers may be paid for inconvenience and time spent, but such payment should not
be so large as to be an inducement to participate.
27
APPENDIX 3
STATEMENT ON ANIMAL EXPERIMENTATION
The policy of the National Health and Medical Research Council regarding animal
experimentation and the production, provision and care of experimental animals is set out in
detail in the publication Australian Code of Practice For The Care and Use of Animals For
Scientific Purposes which is sponsored jointly by the NHMRC, the CSIRO and the
Agricultural Council of Australia and New Zealand.
Applicants for NHMRC grants must accept the following guidelines and are referred to the
above publication for further details. These guidelines are based on the principle that
animals are to be treated with respect and care, and that consideration of their welfare ip an
essential factor in determining their use in experiments. Accordingly, animal
experimentation should be performed only to obtain and establish significant scientific
information relevant to the understanding of humans and animals, to animal production, to
the continued maintenance and improvement of the health and well-being of humans and
animals, or to achieve educational objectives where the use of animals is unavoidable.
GENERAL PRINCIPLES FOR THE CARE AND USE OF ANIMALS FOR SCIENTIFIC
PURPOSES
For the guidance of Investigators, Institutions and Animal Experimentation Ethics
Committees and all involved in the care use of animals for scientific purposes.
(1) Experiments on animals may be performed only when they are essential to obtain and
establish significant information relevant to the understanding of humans or animals, to the
maintenance and improvement of human or animal health and welfare, to the improvement
of animal management or production, or to the achievement of educational objectives.
(2) People who use animals for scientific purposes have an obligation to treat the animals with
respect and to consider their welfare as an essential factor when planning and conducting
experiments.
(3) Investigators have direct and ultimate responsibility for all matters relating to the welfare of
the animals they use in experiments.
(4) Techniques which replace or complement animal experiments must be used wherever
possible.
(5) Experiments using animals may be performed only after a decision has been made that
they are justified, weighing the scientific or educational value of the experiments against the
potential effects on the welfare of the animals.
(6) Animals chosen must be of an appropriate species with suitable biological characteristics
including behavioural characteristics, genetic constitution and nutritional, microbiological
and general health status.
(7) Animals must not be taken from their natural habitats if animals bred in captivity are
available and suitable.
(8) Experiments must be scientifically valid, and must use no more than the minimum number
of animals needed.
(9) Experiments must use the best available scientific techniques and must be carried out only
by persons competent in the procedures they perform.
(10) Experiments must not be repeated unnecessarily.
(11) Experiments must be as brief as possible.
(12) Experiments must be designed to avoid pain or distress to animals. If this is not possible,
A
7
28
(13) Pain and distress cannot be evaluated easily in animals and therefore investigators must
assume that animals experience pain in a manner similar to humans. Decisions regarding
the animals welfare must be based on this assumption unless there is evidence to the
contrary.
(14) Experiments which may cause pain or distress of a kind and degree for which anaesthesia
would normally be used in medical or veterinary practice must be carried out using
anaesthesia appropriate to the species and the procedure. When It Is not possible to use
anaesthesia, such as in certain toxicological or animal production experiments or in animal
models of disease, the end-point of the experiments must be as early as possible to avoid
or minimise pain or distress to the animals.
(15) Investigators must avoid using death as an experimental end-point whenever possible
4
(16) Analgesic and tranquilliser usage must be appropriate for the species and should at least
parallel usage in medical or veterinary practice.
(17) An animal which develops signs of pain or distress of a kind and degree not predicted in the
proposal must have the pain or distress alleviated promptly. If severe pain cannot be
alleviated without delay, the animal must be killed humanely forthwith. Alleviation of such
pain or distress must take precedence over finishing an experiment.
(18) Neuromuscular blocking agents must not be used without appropriate general anaesthesia,
except in animals where sensory awareness has been eliminated. If such agents are used,
continuous or frequent intermittent monitoring of paralysed animals is essential to ensure
that the depth of anaesthesia is adequate to prevent pain or distress.
(19) Animals must be transported, housed, fed, watered, handled and used under conditions
which are appropriate to the species and which ensure a high standard of care.
(20) Institutions using animals for scientific purposes must establish Animal Experimentation
Ethics Committees (AEECs) to ensure that all animal use conforms with the standards of
this Code.
(21) Investigators must submit written proposals for all animal experimentation to an AEEC
which must take into account the expected value of the knowledge to be gained, the validity
of the experiments and all ethical and animal welfare aspects.
(22)Experiments must not commence until written approval has been obtained from the AEEC.
(23) The care and use of animals for all scientific purposes in Australia must be in accord with
this Code of Practice and with Commonwealth, State and Territory legislation.
i >
The
g elmont
Report
rUU
Ethical Principles
and Guidelines for
the Protection of
i
Human Subjects
of Research
<n
i
Q-
X
The National
Commission
for the
Protection of
Human
Subjects of
Biomedical
and
Behavioral
Research
April 18, 1979
i
THE BELMONT REPORT
' Pfrge 2
________
-
Members of the Commission
The Belmont Report attempts to
4 DEPARTMENT OF HEALTH,
summarize the basic ethical princi
Kenneth John Ryan, M.D., Chair
education, and welfare
ples identified by the Commission in
man, Chief of Staff, Boston Hos
the course of its deliberations. It is
pital for Women.
Office of the Secretary
the outgrowth of an intensive fourJoseph V. Brady, Ph.D., Professor of
day period of discussions that were
Behavioral Biology. Johns Hop
Protection of Human Subjects
held in February 1976 at the Smith
kins University.
sonian Institution’s Belmont Confer
Robert
E. Cooke, M.D., President,
Belmont Report: Ethical Principles
ence Center supplemented by the
Medical
College of Pennsylvania.
and Guidelines for the Protection of
monthly deliberations of the Com
Dorothy I. Height, President,
Human Subjects of Research, Report
mission that were held over a period
National Council of Negro
’
of the National Commission for the
of nearly four years. It is a statement
Women, Inc.
Protection of Human Subjects of
of basic ethical principles and guide
Albert R. Jonsen, Ph.D., Asspciate
Biomedical and Behavioral Research
lines that should assist in resolving
Professor of Bioethics, University of
the ethical problems that surround
California at San Franciscd.
AGENCY: Department of Health,
the conduct of research with human
Patricia King, J.D., Associate Pro
Education, and Welfare.
subjects. By publishing the Report in
Uni-
fessor of Law, Georgetown Uni
the Federal Register, and providing
versity Law Center.
ACTION: Notice of Report for
reprints upon request, the Secretary
Karen Lebacqz, Ph.D., Associate
Public Comment.
intends that it may be made readily
Professor of Christian Ethics, Pacific
available to scientists, members of
School of Religion.
_MMARY:0n July 12, 1974, the
Institutional Review Boards, and
•David
W. Louisell.J.D., Professor of
i National Research Act (Pub. L. 93Federal employees. The two-volume
Law,
University of California at
348) was signed into law, there-by
Appendix, containing the lengthy
Berkeley.
"'creating the National Commission
reports of experts and specialists who
Donald W. Seldin, M.D., Professor
‘"for the Protection of Human Sub
assisted the Commission in fulfilling
and Chairman, Department of Injects of Biomedical and Behavioral
this part of its charge, is available as
ternal Medicine, University of Texas
‘ Research. One of the charges to the
DHEW Publication No. (OS) 78at Dallas.
Commission was to identify the basic
0013 and No. (05) 78-0014, for sale
Eliot Stellar, Ph.D., Provost of the
' ethical principles that should underlie
by the Superintendent of Documents,
University and Professor of Physiothe conduct of biomedical and behavU.S. Government Printing Office,
logical Psychology, University of
1 ioral research involving human sub
Washington, D.C. 20402.
Pennsylvania.
jects and to develop guidelines which
Unlike most other reports of the
♦Robert
H. Turtle, LL.B., Attorney,
1 should be followed to assure that
Commission, the Belmont Report
VomBaur, Coburn, Simmons &
'' such research is conducted in
does not make specific recommenda
Turtle, Washington, D.C.
accordance with those principles. In
tions for administrative action by the
‘ carrying out the above, the Commis
Secretary of Health, Education, and
•Deceased.
sion was directed to consider: (i) the
Welfare. Rather, the Commission
boundaries between biomedical and
recommended that the Belmont
’ 'havioral research and the accepted
Report be adopted in its entirety, as
Table of Contents
...id routine practice of medicine, (ii)
a statement of the Department’s pol
the role of assessment of risk-benefit
A. Boundaries Between Practice and
icy. The Department requests public
criteria in the determination of the
comment on this recommendation.
Research
appropriateness of research involving
B. Basic Ethical Principles
human subjects, (iii) appropriate
1. Respect for Persons
National Commission for the Protec
* 'guidelines for the selection of human
tion of Human Subjects of Biomedi
2. Beneficence
: subjects for participation in such
3. Justice
cal and Behavioral Research
t • research and (iv) the nature and
C. Applications
definition of informed consent in
1 Informed Consent
2. Assessment of Risk and Benefits
various research settings.
3. Selection of Subjects
j
*
Belmont Report
Ethical Principles and Guidelines for
Research Involving Human Subjects
Scientific research has produced sub
stantial social benefits. It has also
posed some troubling ethical questions.
Public attention was drawn to these
questions by reported abuses of human
subjects in biomedical experiments,
especially during the Second World
War. During the Nuremberg War
Crime Trials, the Nuremberg code
was drafted as a set of standards for
judging physicians and scientists who
had conducted biomedical experiments
on concentration camp prisoners.
This code became the prototype of
many later codes1 intended to assure
that research involving human subjects
would be carried out in an ethical
manner.
The codes consist of rules, some
general, others specific, that guide
the investigators or the reviewers of
research in their work. Such rules
often are inadequate to cover com
plex situations; at times they come
into conflict, and they are frequently
difficult to interpret or apply.
Broader ethical principles will pro
vide a basis on which specific rules
may be formulated, criticized and
interpreted.
Three principles, or general pres
criptive judgments, that are relevant
to research involving human subjects
are identified in this statement. Other
principles may also be relevant.
These three are comprehensive, how
ever, and are stated at a level of gen
eralization that should assist scient
ists, subjects, reviewers and interested
citizens to understand the ethical
issues inherent in research involving
human subjects. These principles
I
I
I
(
•Since 1945, various codes for the proper
and responsible conduct of human experimen
tation in medical research have been adopted
I
I
iz
I
Page 3
THE BELMONT REPORT
by different organizations. The best known of
these codes are the Nuremberg Code of 1947,
the Helsinki Declaration of 1964 (revised in
1975), and the 1971 Guidelines (codified into
Federal Regulations in 1974) issued by the
U.S. Department of Health, Education, and
Welfare Codes for the conduct of social and
behavioral research have also been adopted,
the best known being that of the American
Psychological Association, published in 1973.
cannot always be applied so as to
resolve beyond dispute particular eth
ical problems. The objective is to
provide an analytical framework that
will guide the resolution of ethical
problems arising from research
involving human subjects.
This statement consists of a distinc
tion between research and practice, a
discussion of the three basic ethical
principles, and remarks about the
application of these principles.
A. Boundaries Between Practice and
Research
It is important to distinguish
between biomedical and behavioral
research, on the one hand, and the
practice of accepted therapy on the
other, in order to know what activi
ties ought to undergo review for the
protection of human subjects of
research. The distinction between
research and practice is blurred partly
because both often occur together (as
in research designed to evaluate a
therapy) and partly because notable
departures from standard practice
are often called “experimental” when
the terms “experimental” and
“research” are not carefully defined.
For the most part, the term “prac
tice” refers to interventions that are
designed solely to enhance the well
being of an individual patient or
client and that have a reasonable
expectation of success. The purpose
of medical or behavioral practice is
JAllhough practice usually involves inter
ventions designed solely to enhance the well
being of a particular individual, interventions
are lometimes applied to one individual for
the enhancement of the well-being of another
(e.g., blood donation, skin grafts, organ trans
plants) or an intervention may have the dual
purpose of enhancing the well-being of a par
ticular individual, and, al the same time, pro
viding some benefit to others (e.g., vaccina
tion, which protects both the person who is
vaccinated and society generally). The fact that
some forms of pralice have elements other
than immediate benefit to the individual
receiving an intervention, however, should not
confuse the general distinction between
research and practice. Even when a procedure
applied in practice may benefit some other
person, it remains an intervention designed to
enhance the well-being of a particular individ
ual or groups of individuals; thus, it is practice
and need not be reviewed as research.
to provide diagnosis, preiventive
treatment or therapy to particular
individuals.2 By contrast, the term
“research” designates an activity
designed to test an hypothesis, permit
conclusions to be drawn, and thereby
to develop or contribute to generaliz
able knowledge (expressed, for
example, in theories, principles, and
statements of relationships).
Research is usually described in a
formal protocol that sets forth an
objective and a set of procedures
designed to reach that objective.
When a clinician departs in a sig
nificant way from standard or
accepted practice, the innovation
does not, in and of itself, constitute
research. The fact that a procedure is
“experimental,” in the sense of new,
untested or different, does not auto
matically place it in thd category of
research. Radically new procedures
of this description should, however,
be made the object of formal
research at an early stage in order to
determine whether they are safe and
effective. Thus, it is the responsibility
of medical practice committees, for
example, to insist that a major inno
vation be incorporated into a formal
research project.3
Research and practice may be car
ried on together when research is
designed to evaluate the safety and
efficacy of a therapy. This need not
cause any confusion regarding
whether or not the activity requires
review; the general rule is that if
there is any element of research in an
activity, that activity should undergo
review for the protection of human
subjects.
B. Basic Ethical Principles
The expression “basic ethical prin
ciples” refers to those general judg
ments that serve as a basic justifica
tion for the many particular ethical
prescriptions and evaluations of
’Because the problems related lo social
experimentation may differ substantially from
those of biomedical and behavioral research,
the Commission specifically declines to make
any policy determination regarding such
research at this time. Rathir, the Commission
believes that the problem ought to be
addressed by one of its successor bodies.
THE BELMONT REPORT
injure one person regardless of the
. Page 4_____________ __________ ______ The extent of protection afforded
benefits that might come to others.
' 'human actions. Three basic princishould depend upon the risk of har
However, even avoiding harm
' pies, among those generally accepted
and the likelihood of benefit The
requires learning what is harmful;
[n our cultural tradition, are particu
judgment that any individual lacks
and, in the process of obtaining this
larly relevant to the ethics of research
autonomy should be periodically ree
information, persons may be exposed
involving human subjects: the princi
valuated and will vary in different
to risk of harm. Further, the Hippoples of respect for persons, benefi
situations.
cratic Oath requires physicians to
In most cases of research involving
cence and justice,
benefit their patients “according to
1. Respect for Persons.—Respect
human subjects, respect for persons
their best judgment.” Learning what
for persons incorporates at least two
demands that subjects enter into the
will in fact benefit may require
ethical convictions: first, that in iresearch voluntarily and with ade
exposing persons to risk. The pro viduals should be treated as auto
quate information. In some situa
lem posed by these imperatives is to
nomous agents, and second, that per
tions, however, application of the
decide when it is justifiable to seek
sons with diminished autonomy are
principle is not obvious. The invol
certain benefits despite the risks
entitled to protection. The principle
vement of prisoners as subjects
involved, and when the benefits
of respect for persons thus divides
research provides an instructive
should be foregone because of the
into two separate moral requireexample. On the one hand, it won
risks.
ments: the requirement to acknowl
seem that the principle of respect fo^
The obligations of beneficence
edge autonomy and the requirement
requires that prisoners not he
investigators
I
S^^h-ppo/tunity to volun
to protect those with diminished
and society at large, because they
teer for research. On the other hand,
itonomy.
.
.
extend both to particular research
An autonomous person is an indiunder prison conditions they may be
projects and to the entire enterprise
vidual capable of deliberation about
subtly coerced or unduly influenced
of research. In the case of particular
personal goals and of acting ”nder
to engage in research activities for
projects, investigators and members
the direction of such deliberation. To
which they would not otherwise
of their institutions are obliged to
respect autonomy is to give we.ght to
volunteer. Respect for persons would
give forethought
forethought to the maximization
give
1 autonomous persons’ considered
then dictate that prisoners be pro
Of benefits and the reductio^of nsk
' ' opinions and choices while reframing
tected. Whether to allow prisoners to
that might occur from
f--- the research
from obstructing their act.ons unless
■‘volunteer’’ or to “protect’’ them
iC case
investigation. In the
case of
o scientific
presents a dilemma. Respecting pei
,
members
of the
they are clearly
c.—- , detrimental to others.
research in general,
■ To show lack of respect for an auto
sons, in most hard cases, is often a
larger society are obliged to recognomous agent is to repudiate that
matter of balancing competing claims
nize the longer term-benefits and
’person’s considered judgments, to
urged by the principle of respect
risks that may result from the
’ deny an individual the freedom to act
improvement of knowledge and from,
itself.
‘ on those considered judgments, or to
,Ke.._,Persons
....-------the development of novel medica ,
are
2. Beneficence.—
" withhold information necessary to
ethical manner not only
psychotherapeutic, and social
make a considered judgment, when
treated in an i-by respecting their decisions and pro
PrThed principle of beneficence often
11 there are no compelling reasons
tecting them from barm, but also by
occupies a well-defined justifying role
making efforts to secure their well'°However, not every human being
in many areas of research involving _
b-ing. Such treatment falls under t e
is capable of self-determination. The
human subjects. An exarttpde
1- is found
principle of beneficence. The term
m. Effecin
research
involving
chi|drei
“beneficence” is often understood to
of
treating
childhood
cover acts of kindness or charity
chanty that
five wavs g*----.disand some individuals lose this capaceases
and
fostering
healthy
develop...........
..
.
‘
?
go beyond strict obligation. In this
. Uy wholly or in part because of
benefits
that
serve
to
justify
document, beneficence is understood
meat are I---,
■ •• J i—even
' illness, mental disability, or circum
research involving childrenin
a
stronger
sense,
as
an
obligation.
i stances that severely restrict liber y.
when individual restcardh
—-.- subjects are
Two general rules have been formu
1 1 Respect for the immature and the
not direct beneficiaries. R^earch
lated as complementary expressions
. : incapacitated may require protecting
also makes is possible do avoid thof
beneficent
actions
m
this
sense.
(
)
. ' them as they mature or while they
harm that may result ftom the app
do not harm and (2) maximize possi
•fare incapacitated.
cation of previously accepted romine
ble benefits and minimize possible
• Some persons are in need of
practices that on closer investigation
extensive protection, even to the
harms.
turn out to be dangerous. But the
role of the principle of beneficenc s
’ point of excluding them from acti
The Hippocratic maxim do no
' ties which may harm them; other
harm" has long been a fundamental
not always so unambiguous. A diffi
principle ofmedicaletlucs. Claud
;• persons require little protection
cult ethical problem remains, for
'J beyond making sure they undertake
Bernard extended it to the realm of
example, about research that presnot
, "" activities freely and with awareness
research, saying that one should
s..•'
.
'of possible adverse consequences.
:!•
• »
______________ 5
THE BELMONT REPORT________
ents more than minimal risk without
immediate prospect of direct benefit
to the children involved. Some have
argued that such research is inad
missible, while others have pointed
out that this limit would rule out
much research promising great
benefit to children in the future. Here
again, as with all hard cases, the dif
ferent claims covered by the principle
of beneficence may come into con
flict and force difficult choices.
3. Justice.—Who ought to receive
the benefits of research and bear its
burdens? This is a question of justice,
in the sense of “fairness in distribu
tion” or “what is desen'ed.” An injus
tice occurs when some benefit to
which a person is entitled is denied
without good reason or when some
burden is imposed unduly. Another
way of conceiving the principle of
justice is that equals ought to be
treated equally. However, this state
ment requires explication. Who is
equal and who is unequal? What
considerations justify departure from
equal distribution? Almost all com
mentators allow that distinctions
based on experience, age, depriva
tion, competence, merit and position
do sometimes constitute criteria justi
fying differential treatment for cer
tain purposes. Il is necessary, then, to
explain in what respects people
should be treated equally. There are
several widely accepted formulations
of just ways to distribute burdens
and benefits. Each formulation men
tions some relevant property on the
basis of which burdens and benefits
should be distributed. These formula
tions are (1) to each person an equal
share, (2) to each person according to
individual need, (3) to each person
according to individual effort, (4) to
each person according to societal
contribution, and (5) to each person
according to merit.
!
Questions of justice have long been
associated with social practices such
as punishment, taxation and political
representation. Until recently these
questions have not generally been
associated with scientific research.
However, they are foreshadowed
even in the earliest reflections on the
ethics of research involving human
subjects. For example, during the
19th and early 20th centuries the
burdens of serving as research sub
jects fell largely upon poor ward
patients, while the benefits of
improved medical care flowed prim
arily to private patients. Subse
quently, the exploitation of unwilling
prisoners as research subjects in Nazi
concentration camps was condemned
as a particularly flagrant injustice. In
this country, in the 1940’s, the 1 uskegee syphilis study used disadvan
taged, rural black men to study the
untreated course of a disease that is
by no means confined to that popula
tion. These subjects were deprived of
demonstrably effective treatment in
order not to interrupt the project,
long after such treatment became
generally available.
Against this historical background,
it can be seen how conceptions of
justice arc relevant to research
involving human subjects. For
example, the selection of research
subjects needs to be scrutinized in
order to determine whether some
classes (e.g., welfare patients, particu
lar racial and ethnic minorities, or
persons confined to institutions) are
being systematically selected simply
because of their easy availability,
their compromised position, or their
manipulability, rather than for rea
sons directly related to the problem
being studied. Finally, whenever
research supported by public funds
leads to the development of thera
peutic devices and procedures, justice
demands both that these not provide
advantages only to those who can
afford them and that such research
should not unduly involve persons
from groups unlikely to be among
the beneficiaries of subsequent appli
cations of the research.
C. Applications
Applications of the general princi
ples to the conduct of research leads
to consideration of the following
requirements: informed consent,
risk/benefit assessment, and the
selection of subjects of research.
1. Informed Consent.—Respect for
persons requires that subjects, to the
degree that they are capable, be given
the opportunity to choose what shall
or shall not happen to them. This'
opportunity is prpvided when ade
quate standards for informed consent
are satisfied.
While the importance of informed
consent is unquestioned, controversy
prevails over the nature and possibil
ity of an informed consc it. Noncthcless, there is widespread Agreement
that the consent process can be ana
lyzed as containing three elements:
information, comprehension and
voluntariness.
Information. Most codes of
research establish specific items for
disclosure intended to assure that
subjects are given sufficient informa
tion. These items generally include:
the research procedure, their pur
poses, risks and anticipated benefits,
alternative procedures ( where ther
apy is involved), and a statement
offering the subject the opportunity
to ask questions and to withdraw at
any time from the research. Addi
tional items have been proposed,
including how subjects }irc selected,
the person responsible for the
research, etc.
However, a simple listing of items r
does not answer the question of what
the standard should be forjudging
how much and what soft of informa
tion should be provided. One stand
ard frequently invoked in medical
practice, namely the information
commonly provided by practitioners
in the field or in tne locale, is inade
quate since research takes place pre
cisely when a common understanding
does not exist. Another standard,
currently popular in malpractice law,
requires the practitioner to reveal the
information that reasonable persons
would wish to know in order to make
a decision regarding their care. This,
too, seems insufficient since the
research subject, being in essence a
volunteer, may wish to know consid
erably more about risks gratuitously
undertaken than do patients who
deliver themselves into the hand of a
clinician for needed care. It may be
that a standard of “the reasonable
volunteer” should be proposed: the
THE BELMONT REPORT
* Page 6
*____________________
of harm is intentionally presented by
extent and nature of information
]presentation of the information to
one person to another in order to
the subject’s capacities. Investigators
obtain compliance. Undue influence,
should be such that persons, knowing
are responsible for ascertaining that
by contrast, occurs through an offer
that the procedure is neither
the subject has comprehended the
of an excessive, unwarranted,
necessary for their care nor perhaps
information. While there is always an
inappropriate or improper reward or
fully understood, can decide whether
obligation to ascertain that the
other overture in order to obtain
they wish to participate in the
information about risk to subjects is
compliance. Also, inducements that
furthering of knowledge. Even when
complete and adequately compre
would ordinarily be acceptable may
some direct benefit to them is
hended, when the risks are more
anticipated, the subjects should
become undue influences if the
serious, that obligation increases. On
subject is especially vulnerable.
:
understand clearly the range of risk
occasion, it may be suitable to give
Unjustifiable pressures usually
and the voluntary nature of
some oral or written tests of
occur
when persons in positions of
participation.
comprehension.
authority
or commanding influence—
A special problem of consent arises
Special provision may need to be
especially where possible sanctions
where informing subjects of some
made when comprehension is
are involved—urge a course of action
pertinent aspect of the research is
severely limited—for example, by
for a subject. A continuum of such
likely to impair the validity of the
conditions of immaturity or mental
influencing factors exists, however,
research. In many cases, it is
disability. Each class of subjects that
and it is impossible to state precisely
sufficient to indicate to subjects that
one might consider as incompetent
where justifiable persuasion ends and
they are being invited to participate
(e.g., infants and young children,
undue influence begins. But undue
tn research of which some features
mentally disabled patients, the
influence would include actions such
will not be revealed until the research
terminally ill and the comatose)
as manipulating a person’s choice
' is concluded. In all cases of research
should be considered on its own
through the controlling influence of a
involving incomplete disclosure, sue
terms.
Even
for
these
persons,
close relative and threatening to
; research is justified only if it is clear
however, respect requires giving them
withdraw health services to which an
, that (1) incomplete disclosure is tru y
the opportunity to choose to the
individual would otherwise be
,t necessary to accomplish the goals of
extent they are able, whether or not
entitled.
I ,the research, (2) there are no
to participate in research. The
2. Assessment of Risks and
, undisclosed risks to subjects that are
objections of these subjects to
Benefits.
—'The assessment of risks
; 'more than minimal, and (3) there is
involvement should be honored,
and
benefits
requires a careful
. an adequate plan for debriefing
unless the research entails providing
arrayal of relevant data, including, in
subjects, when appropriate, and for
them a therapy unavailable
some cases, alternative ways of
'dissemination of research results to
elsewhere. Respect for persons also
obtaining the benefits sought in the
,‘them. Information about risks should
requires seeking the permission of
research. Thus, the assessment
/never be withheld for the purpose of
other parties in order to protect the
presents both an opportunity and a
‘ eliciting the cooperation of subjects,
subjects from harm. Such persons are
responsibility to gather systematic
and truthful answers should always
thus respected both by acknowledg
and comprehensive information
' be given to direct questions about the
ing their own wishes and by the use
about proposed research. For the
/research. Care should be taken to
of third parties to protect them from
investigator, it is a means to examine
'distinguish cases in which disclosure
harm.
whether the proposed research is
.'would destroy or invalidate the
The third parties chosen should be
properly designed. For a review
■ ■ ’ research from cases in which
those who are most likely to under
committee, it is a method for
' disclosure would simply inconven
stand the incompetent subject’s
determining whether the risks that
ience the investigator.
situation and to act in that person’s
will be presented to subjects are
Comprehension. The manner and
best interest. The person authorized
justified. For prospective subjects,
- ' context in which information is
to act on behalf of the subject should
the assessment will assist the
■; " conveyed is as important as the
be given an opportunity to observe
determination whether or not to
’ '■information itself. For example,
the research as it proceeds in order to
participate.
' presenting information in a
be able to withdraw the subject from
The Nature and Scope of Risks
' /disorganized and rapid fashion,
in
- the research, if such action appears i:.
and Benefits. The requirement that
1 ! allowing too little time for
the subject’s best interest.
research be justified on the basis of a
' 'f' consideration or curtailing
Voluntariness. An agreement to
favorable risk/ benefit assessment
! ^"opportunities for questioning, all
participate in research constitutes a
bears a close relation to the principle
'■ ■ may adversely affect a subject's'valid consent only if voluntarily
of beneficence, just as the moral
‘ ’/'ability to make an informed choice.
given. This element of informed
requirement that informed consent
' 11
Because the subject’s ability to
consent requires conditions free of
be obtained is derived primarily from
'I' understand is a function of
coercion and undue influence.
the principle of respect for persons.
‘ •l .intelligence, rationality, maturity and
Coercion occurs when an overt threat
' ' language, it is necessary to adapt the
/
v '
z•
THE BELMONT REPORT
Page 8
_____________ __
Injustice may appear in the
selection of subjects, even if
• individual subjects are selected fairly
by investigators and treated fairly in
the course of research. Thus injustice
arises from social, racial, sexual and
cultural biases institutionalized in
society. Thus, even if individual
researchers are treating their research
subjects fairly, and even if IRBs are
taking care to assure that subjects are
selected fairly within a particular
institution, unjust social patterns
may nevertheless appear in the
overall distribution of the burdens
and benefits of research. Although
individual institutions or investi
gators may not be able to resolve a
problem that is pervasive in their
social setting, they can consider
;tributive justice in selecting
F • «.
research subjects.
Some populations, especially
institutionalized ones, are already
burdened in many ways by their
infirmities and environments. When
research is proposed that involves
risks and does not include a
therapeutic component, other less
burdened classes of persons should
be called upon first to accept these
risks of research, except where the
research is directly related to the
specific conditions of the class
involved. Also, even though public
funds for research may often flow in
the same directions as public funds
for health care, it seems unfair that
populations dependent on public
health care constitute a pool of
preferred research subjects if more
advantaged populations are likely to
be the recipients of the benefits.
One special instance of injustice
results from the involvement of
vulnerable subjects. Certain groups,
such as racial minorities, the
economically disadvantaged , the very
sick, and the institutionalized may
continually be sought as res :arch
subjects, owing to their ready
availability in settings where research
is conducted. Given their dependent
status and their frequently
compromised capacity for free
consent, they should be protected
against the danger of being involved
in research solely for administrative
convenience, or because they are easy
to manipulate as a result of] their
illness or socioeconomic condition.
[FR Doc. 79-12065 Filed 4-17-79; 8:45 im]
.1!
11
GPO 887*809
•j U.S. GOVEPJ'MENT PRINTING OFFICE:
1983-38 1-132:3205
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