MEDICAL ETHICS AND DEONTOLOGY. Bikbov M. M., Abdrakhmanova E. S. the World of ophthalmology №1 March-2013
MEDICAL ETHICS AND DEONTOLOGY
Bikbov M. M., Abdrakhmanova E. S.
GBU "Ufa research Institute of eye diseases of the Academy of Sciences of Belarus"
In 2013, the newspaper "World of ophthalmology" begins publishing a series of articles devoted to medical ethics, ethical relationship in conducting research works, publication ethics. March 21, 2013 in the framework of the conference "Modern technologies in vitreoretinal pathology treatment" editions of the newspaper "World of ophthalmology" and the magazine "New in ophthalmology" will be held "round table" on theme: "Ethical issues in scientific research".
"I swear to Apollo the doctor, Asclepius, Hygiea and Panacea and all the gods and goddesses, taking them as witnesses, to perform honestly, respectively, my powers and my understanding, the following oath and written commitment: to read taught me medical art equally with my parents, to share with him their wealth and, if necessary, to assist him in his needs;...instructions, oral lessons and everything else in the teachings to tell his sons, the sons of his teacher and students, bound by the obligation, but no one else. I direct a mode of patients to their benefit in accordance with my ability and understanding, refraining from harm and injustice. I won't let anyone ask me a lethal drug and does not show the way for such a purpose; similarly, I will not be awarded to any woman abortion pessary. Pure and undefiled I will conduct my life and my art... In every house I entered, I will enter there for the benefit of the patient, being far from all intentional, unjust and damaging. To the treatment, and without treatment, I neither saw or heard about human life that should not ever disclose, I keep silence about believing such things a secret. Me performing the unbreakable vow, Yes, this is happiness in life and in art andglory to all people in perpetuity; to transgress the same and giving a false oath Yes will reverse it."
For two and a half millennia this document remains the quintessential ethics of the doctor. His authority is based on the name of the Greek physician Hippocrates - the "father" of medicine and medical ethics. Hippocrates proclaimed the eternal principles of the medical art: the purpose of medicine - the treatment of the sick; healing can be learned only at the bedside; the experience is the true teacher of the doctor. He explained an individual approach to each patient. However, if he is Hippocrates in medicine was seen primarily art, then later, one of the followers of Hippocrates, and Roman physician Galen, came to medicine as a science and hard work. In the middle ages Avicenna gave a beautiful poetic personality characteristics of the doctor. He said that the doctor should have eyes of a Falcon, the hands of girls, to have the wisdom of the serpent and heart of a lion. But did Hippocrates to the medical oaths in any matter, is not known. In his era of medicine in Greece ceased to be a purely family affair, when the profession was passed from father to son. Physicians took pupils, and from the side. Doctors have formed a Corporation with the internal code. (Hence the prohibition to inform medical knowledge to unauthorized persons and the requirement to behave so as not to cast a shadow on colleagues.) In society it is widely believed that after graduating from College and bringing canonical Hippocratic Oath, young physicians are legally considered physicians. In fact, to swear by pagan gods was impossible in the middle Ages. The texts that were uttered by the graduates of medical faculties of that time were very different from the traditional Hippocratic Oath. In the nineteenth century, the era of scientific medicine, the text is replaced completely. However, the basic principles (doctor-patient confidentiality, "do no harm", respect for teachers) was saved.
The Hippocratic oath and similar to her oath and promises – a tribute to the traditions of a particular country or institution. Article 71 of the Federal law of the Russian Federation of 21.11.2011 № 323-FZ "About bases of health protection of citizens in the Russian Federation"fixed oath of the doctor in the following wording: "Receiving the high title of doctor and getting professional activity, I do solemnly swear: to faithfully discharge their medical debt, devote their knowledge and skills to the prevention and treatment of diseases, preservation and strengthening of human health; to be always ready to provide medical assistance, to maintain confidentiality, to be attentive and careful to the patient, to act exclusively in its interests regardless of gender, race, nationality, language, origin, property and official status, place of residence, attitude to religion, belief, belonging to public associations, and other circumstances; to exercise the highest respect for human life, never to resort to euthanasia; to store gratitude and respect to their teachers, to be demanding and fair towards their students and contribute to their professional growth; friendly attitude to colleagues, to turn to them for help and advice if required in the interest of the patient, and most never open to colleagues to help and advice; constantly improve their professional skills, to protect and develop the noble traditions of medicine".
At all times the doctors were treated with respect. After all, the people of this profession come to the rescue in the most critical moments of human life, starting from birth and to the dying hours. But not only the respect surrounds man in a white lab coat is misunderstanding, skepticism, ridicule, and even curse are escorted by doctors from antiquity to the present day. The cautious attitude of the doctors appeared from the first steps of medicine. In ancient times laughed at modest and even questionable by the possibilities of contemporary medicine on the background of the inordinate conceit of the doctors. In Srednie century there was a saying: "the doctor three faces - the face of a decent man in everyday life, the face of an angel at the bedside and the appearance of the devil, when he demands the fee". The source of most of the accusations sharply increased the expectations of people who are not able to justify the modern practice of medicine. Why this profession is so much passion, often the opposite? First, it is related to the person's life. And secondly, everydoctor - fair or not - has to deal with different patients, different characters. Some are grateful for any attention and help. Others, even the selfless actions of physicians perceive indifferent or hostile. But it is a good man who really eliminates suffering, not rarely and saves lives, it brings to patients sincere deep sense of gratitude. Doctors often have to make decisions related to the life, health, dignity and rights of people. So ethics - moral principles and rules of conduct in medicine is a special place.
Over the long history of medicine, many ethical principles took shape in clearly defined rules, norms of behaviour of the doctor. A set of rules called medical deontology. The term "deontology" (derives from the Greek word "Deon" - needs) was introduced in the eighteenth century English philosopher Jeremy Bentham. This term, he outlined the rules of professional conduct of the person. Medical deontology includes the teaching of medical ethics and aesthetics, medical debt and medical privacy, etc. It examines the principles of behavior of medical personnel, the system's relationship with patients, their families and themselves. In the circle of its tasks also included the elimination of "the harmful effects of defective medical work." For thousands of years of medical practice many of the rules of ethics became a kind of ritual, like the rules of etiquette, the deeper meaning which people do not always understand, but tries to abide by them. These rules constitute medical etiquette and code of "good manners", which almost without thinking, should every self-respecting doctor. Information about the disease and about the personal life of the patient, who became famous medical and non-medical secret, in any case can not be transferred to unauthorized persons without the consent of the patient. This rule is insisted on by Hippocrates, and in modern Russian legislation provides for criminal liability for the disclosure of medical confidentiality. The requirement of secrecy is not only ethical, but also practical. In accordance with article 13 of the Federal law of the Russian Federation of 21.11.2011 №323-F3 "About bases ofthe health of citizens in the Russian Federation" - information about the fact of a citizen for the provision of medical care, his condition and diagnosis, and other information obtained during his medical examination and treatment constitute a medical secret.
In addition, note that the doctor will not be able to effectively treat, if he does not have enough information about the symptoms of the disease, about the circumstances of the life of the patient. And the patient will be quite Frank with him without confidence that information will remain between them. However, there are situations where the secrecy can bring
harm to the patient or others. For example, normally should not be a mystery to parents information about the health of their child.
But, paradoxically, it is for strict medical ethics makes one exception to the rule "do not lie". This exception – "the Holy lie" or "lie". Doctors are required to tell the truth to colleagues, superiors, representatives of Supervisory and law enforcement bodies puff. At the same time, the tradition of medicine has long been prescribed to mislead the hopeless sick, to hide from them that the disease is incurable. Many hundreds of years this rule seemed eminently sensible and humane: it is impossible to deprive a person of hope, doomed to severe suffering, associated with the proximity of death. "Holy lie" was obliged to medic early Indian treatise III century BC, Ayurveda. The need to lie was justified: that is useful to the patient, and the truth, even if it's a lie. The real reason for such beliefs, of course. At the end of XX century the attitude to the "Holy lie" has changed. Doctors and society are entrenched in their opinion that the patient has the right to know the truth about the state of his health. A conversation with the seriously ill or dying from a doctor requires special tact and skill, true compassion, and great emotional warmth. Doctors specially trained on how and when to inform the patient about his situation. Some clinics have psychologists who help patients and their relatives to accept the inevitable, to find peace of mind. Can also help the priest or just a wise man,whom the patient trusts. There is even a special medical institution - hospice, whose purpose is not to cure but to ease the last days of hopeless patients. In Russian medicine rotation in relation to the "Holy lie" cannot be called complete. It requires changes in the perception of death, not only from doctors but also from the whole society. In the early XX century, the famous Russian lawyer A. F. Koni insisted that the doctor should inform the patient about impending death, so that he could perform legal and spiritual duties. Today this right is enshrined in law. In article 22 of the Federal law of the Russian Federation of 21.11.2011 № 323-FZ "About bases of health protection of citizens in the Russian Federation" States that: "everyone has the right to obtain in an intelligible form available in the medical organization information about their health status, including information on the results of the medical examination, the presence of the disease, about the diagnosis and prognosis, methods of delivering a half-breed care, associated risks, possible types of medical intervention, consequences and results of medical care. Information on health status is provided to the patient by the attending physician or other health care professionals involved in medical examination and treatment".
Surgery is an area of medicine where the importance of practical skills of medical personnel is extremely high. All the thoughts and attention of the surgeons, the operating and ward sisters to concentrate on operating, where the main job is surgery. If operating in the leading role is given to doctors, surgeons and anaesthetists in preoperative, and especially postoperative period much depends on the Careful and sensitive attitude to the patient nurses and Junior medical staff. Many surgeons rightly argue that the operation — the beginning of the surgical treatment, and the outcome of it defines good nursing, i.e. appropriate care in the postoperative period.
To psychological problems refers to the fear ofoperation. The patient may be afraid of the operation itself, the related suffering, the pain, the consequences of intervention, to doubt its efficiency and Fear etc. the patient often increases under the influence of "information" that you willingly provide to patients undergoing surgery and, as a rule, exaggerating everything that happened to them. It is advisable to hold a conversation with patients undergoing surgery, the adverse effects of their stories on newly admitted patients preparing for surgical treatment. In preparing for surgery it is very important to establish a good contact with the patient, in the course of the conversation to learn about the nature of his fears and concerns in connection with the upcoming operation, to calm, to try to change the attitude towards the upcoming stage of treatment.
The rules of ethics and deontology are:
- Work in the office or hospital must submit to strict discipline must be observed in subordination, that is the official subordination of Junior positions to senior.
- A medical worker in attitude must be correct, careful not to allow familiarity.
- The doctor should be a specialist of high qualification, comprehensively literate. Now patients read medical literature, especially in his illness. The doctor should professionally and tactfully communicate with patients.
- To deontology includes the relationship with colleagues. Not to criticize or evaluate the actions of colleagues in the presence of the patient. Remarks colleagues need to do if necessary with face to face, without undermining the authority of the doctor. You should never tell the patient that the consultant is wrong if he does not agree with your diagnosis. The doctor does not have the right to publicly question the professional qualifications of other doctor, or some other way to discredit him. Professional remarks about colleagues must be reasoned, non-offensive, made in the form, preferably in a personal conversation.
- In difficult clinical cases of experienced doctors should give advice and assistance to less experienced colleagues in the correct form. But the treatment process is the full responsibility carriesonly the attending physician, who may accept the recommendations of colleagues or to refuse them, guided by the interests of the patient.
- Relationships with middle and Junior medical staff should be democratic - they know and hear all you need to attract them to their side in terms of patient confidentiality - not to tell anything to the patient or relatives about the underlying disease or pathology, treatment methods used, etc. should Also be brought up a sense of duty, responsibility, kindness; the necessary knowledge and skills.
- Deontology refers to the preservation of medical confidentiality. In some cases it is necessary to conceal from the patient his real condition. The preservation of medical confidentiality applies not only to doctors, but also nurses, students, i.e. all those who are in contact with patients. Patient confidentiality does not extend to relatives of the patient. The doctor should inform the relatives of the true diagnosis, the patient's condition and prognosis.
- The patient has the right to be fully informed about the state of his health, but he may refuse it or to indicate the person who should report on the state of his health. Information can be hidden from the patient in those cases, if there are reasonable grounds to believe that it could inflict serious harm. However, according to clearly expressed demand of the patient the doctor is obliged to provide full information. In the case of unfavourable prognosis for the patient must inform him very delicately and carefully, leaving hope for renewal of life, the possible favorable outcome.
- At the request of the patient, the physician should not interfere with the enjoyment of his right to consult another doctor.
Tactics of the doctor, his behavior should always be built depending on the nature of the patient, level of culture, severity of disease, the nature of the psyche. With hypochondriac patients must have patience; all patients need comfort, but at the same time, in the firm belief of the doctor in the possibility of cure.
Feature of deontological tactics in ophthalmology is a frequent messagethe patient diagnosis in the event of adverse weather glaucoma, retinal detachment, optic nerve atrophy and other diseases. Especially hearty and delicate should be the attitude to patients with dramatically low vision and blind. Some patients coming on reception to the ophthalmologist, there are various fears (phobias). It should be remembered that often unfounded complaints of vision placing the mentally ill. In cases where operative treatment should be possible soon to establish the diagnosis and to convince the patient of the advisability of surgical treatment.
However, as an integral part of medicine is the person, making decisions, the risk of human error in this area was and remains almost unchanged (scheme 1).
Physicians in the paternalistic model of relations for a long time, the former almost completely protected from prosecution, now be under increasing pressure from the society through the judicial system. Mainly in the courts the number of patients who have been admitted mistakes in the diagnosis or treatment of glaucoma, and patients with complications after cataract surgery and refractive surgery. Noted that a common reason for patients ' dissatisfaction are deficiencies in the organization of communication between them and health workers.
The focus of the media to cases of medical malpractice, negligence and neglect, coupled with often unrealistic expectations of patients and the wrong evaluation of the risk of certain medical procedures, create the psychological prerequisites for increasing the frequency of appeals to courts with claims against employees of the health system.
The topic of medical malpracticein the exercise of their professional activities is becoming increasingly important, a growing number of complaints to the medical institutions and medical workers, increasing the number of criminal cases in connection with the failure, improper provision of medical care.
When the inadequate provision of medical care may have grounds for legal liability not only of the medical institution (in the framework of civil legal relations), but also the medical worker. As citizens (individuals) they are already subject to criminal responsibility - the most severe type of liability in such a situation, as it entails severe legal and ethical consequences of a tortfeasor.
The criminal code provides for various punishments for the same offense: deprivation of liberty, deprivation of the right to occupy certain positions or engage in medical activities, a fine, correctional labor. However, sentencing the man in a white coat, even softer, than imprisonment, is always of great public interest.
It must be remembered that the doctor, whose rights, incidentally, are disadvantaged to a much greater extent than the rights of the patient, often working in risky and even extreme conditions, can not objectively predict the occurrence of negative consequences for the patient.
All health care workers associated with the adverse effects, the majority of forensic medical experts and lawyers are divided into three groups: medical errors, accidents and punishable omissions or professional crimes.
Professional errors are at the doctor, as representative of any other profession, however, medical mistakes can acquire great public importance. The doctor has a moral responsibility to his patient and society (the doctors ' strike is prohibited by law in all countries).
style="text-align: justify;">the Causes of medical errors are subjective and objective (scheme 2).
In conclusion, it was noted that there are diseases, medical errors have been and will be. They are inevitable. It is important to understand their essence, that tragedies are not repeated.