Ethics & Wisdom in Medicine

Conscious of the trust placed in us as physicians and defenders of life, of the progress in medical knowledge and technologies, and of the ever better understanding gained into the physical, psychological, educational, spiritual, religious and existential needs of our patients and our society,

• while aware of the dangers of ethical relativism and of moral permissiveness around us and in our midst;
• in view of ongoing debates over the permissibility of abortion, euthanasia, the use of human embryos for research and so-called therapeutic purposes, human cloning, the creation of human-animal hybrid embryos, contraceptive and sterilization procedures and artificial reproductive technologies;
• faced with the silent assumption that those carrying out the above procedures will be doctors;

authorized by the Christian traditions and ethos of European and world medicine, in dialogue with all doctors who believe in the dignity and freedom of the human being,

1. We affirm that ethical norms and principles precede enacted laws and should influence their contents in accordance with natural law and the teaching of the Church.
2. We affirm that in making decision on the medical treatment of the patients who place in us so great a trust, we should be guided above all by our conscience.  Moral evaluation of medical practice must not be based upon superficial opinions or passing trends but on the sensitivity of a conscience formed according to objective ethical norms common to all people and  consistently defended by the Church.
3. In order to guarantee the freedom of practice of the profession, we have to uphold the right to conscientious objection
4. We believe that one of the basic demands made of doctors should be ongoing personal development in both practical know-how and in moral stature.
5. The special vocation of the doctor to serve the life and health of others requires a clear formulation of  the principles of an objective and universal ethics.
6. We affirm that the source and basis for all ethical norms is the inalienable dignity of the human person throughout the course of his or her life – from conception to natural death.
7. Just as human dignity requires the protection of human life, it also demands special concern  for its initial phases and respect for human procreation and sexuality.
8. We promote activities which permits the protection of patients from procedures that violate their human dignity:

●  Decisively rejecting euthanasia, we support the development of palliative medicine;

●  Refusing to agree to abortion, we aim to ensure proper all-round care for the family and the sick child both before and after birth;

●  We choose the treatment of the underlying causes of infertility and not successive techniques of artificial reproduction;

●  We support the development of research into the use of stem cells taken from adults and umbilical cord blood, rejecting the use of human embryos for this purpose.

1. 9.     We affirm and emphasize that medical practice with respect to matters as genetic manipulation and the end of life has to be realized without intentional loss of human life.

10.We want to protect our children and young people from neglect, abuse and other threats to their health and dignity. We have to ensure proper education for all aspects of life.

11.Aware of the number of people in our midst who are subject to abject poverty or under threats caused by misfortune, we uphold the tradition of the freedom of physicians to offer humanitarian and charitable aid, especially in neglected areas of the world, on the basis of principles and criteria lying beyond economics.

12.Taking into account the responsibility doctors carry for the health and life of patients, we are convinced that medicine must be practiced in dignified conditions, which are due both to patients and to doctors,  and we consistently affirm that in our activities the good of patients should have priority over other obligations.

Signed by:

President of the XI Congress of the European Federation of Catholic Medical Associations, prof. Josef Marek (in substitution signed by dr Francois Blin);

President of the Catholic Association of Polish Doctors,

dr Anna Gręziak;

Secretary of the European Federation of Catholic Medical Associations,

dr Hans Stevens

The GMC have asked for submissions in connection with child protection and the role of doctors. Below is a summary of the MEA`s response.

There are a number of  ethical considerations concerning  child protection such as natural   justice, the common good,  and issues of good medical practice and confidentiality.

When putting in place procedures to safeguard children and vulnerable adults it is vital that the requirements of confidentiality do not take precedence over the need to protect their welfare.

Particular difficulties  may arise in the case of suspected fabricated or induced illness. Detailed investigations would be normative and the diagnosis may only emerge over time. An example of good practise would be for the doctor with ultimate responsibility to share the tentative diagnosis with consultant colleagues to see if there is agreement on the diagnosis. It would also be good practice to seek the advice of colleagues in a tertiary centre.

The confidentiality that is required by law in furnishing  reports for prosecutors and the giving of evidence in the civil courts is proscribed. Open evidence will be required in Crown Court and the doctor should not be afforded any anonymity and publicity cannot be avoided. If, however, the doctor has taken the steps outlined above this will afford some protection. Rarely  a doctor may choose to take independent legal steps to protect their interests.

Difficulties can arise when English is not understood or where because of a particular culture, the head of the family is the only person who will speak on behalf of parents and may fail to translate what is said by doctors. There can also be fears that translators may breach confidence in close knit ethnic groups. In Family Proceedings Courts and Criminal Courts accredited translators must be provided by law. In the clinical situation difficulties arise and an independent translator is advisable.

Regrettably many doctors are loath to become involved in child protection as a result of adverse publicity, threats of legal action or complaints to the GMC. Direct threats also occur and many doctors feel that they or their own families are endangered. Ultimately, if many doctors refuse to become involved in the legal process child protection will fail. Fortunately most doctors feel that they are obliged in conscience to do their utmost to protect children.

It has always to be remembered that, especially in cases of possible sexual abuse,  the medical evidence is often only a small part of the evidence upon which the court will rely. Paediatricians should not feel that their evidence is decisive, it is likely to be collaborative at best.

Those who are likely to be front line doctors with children. Paediatricians, accident and emergency doctors and general practitioners in particular need to be trained by their respective colleges using such documents as the RCPCH compendium “ Child Protection  Companion”, 2006 which should be used in the annual appraisal of paediatricians.

Clear guidance is required from the GMC which doctors would find helpful and supportive and in which they could be confident that their conscientious work and compliance would protect them from vexatious complaints.

• Palliative carers and geriatricians should try to improve care for the elderly.
• Community nurses and doctors must be trained to recognise dehydration and should rehydrate the patient as necessary.
• Anticipatory prescribing of drugs such as diamorphine, midazolam and haloperidol should not be permitted in care homes. If sedation is required a doctor should assess the patient and prescribe as necessary.

1. No Water- No Life: Hydration in the Dying. Craig GM (Ed) Fairway Folio (2005) ISBN 0 9545445 3 6. E mail: books341@ clara.co.uk. Also available to order from good bookshops in the UK.
2. Craig GM. Palliative Care in Overdrive: Patients in Danger. American Journal of Hospice & Palliative Medicine, Vol. 25 Number 2, April/May 2008 p155- 160. © Sage Publications 10.1177/1049909107312595

Doctors should do their best to preserve and protect the life of the patient
(Hippocratic tradition).
The Intention should be always pro-life and all actions should reflect that.
Efforts should be made to return the patient to good health.
In accordance with the above three principles, the best, most appropriate medical
treatment should be given to patients along with the best nursing care.
Food and fluid is a basic need for all people and is the right of every patient. It
is not allowed to withdraw food and fluid at any time except when they may not be
absorbed by the body as might occur in the final stages of the dying process. Food
and fluid is a basic need not medical treatment.
No doctor should play God. It is not for a doctor to make a decision about the value
of a person’s life based on his or her quality of life.
Safe, effective pain killers may be used to alleviate suffering.
Children and adults with disabilities have Equal rights to life and ethical medical
treatment, like any other patient.
It is forbidden to take any step to hasten the death of the patient (active/passive
euthanasia and assisted suicide are forbidden in Islam)
Doctors should respect every patient as a human being, as well as his/her religious
wishes.
During the dying process, it may by right to withhold medical treatment but
palliative care, i.e. keeping the patient comfortable and pain free, may always be
given.

Regarding patients

To look for the appropriate safe effective treatment, because we are taught that for
every disease there is a cure.
GOD Almighty is the real HEALER, doctors and medicine are the necessary means for
getting the healing!
The Moment of death has been fixed only by the Creator (natural death).
Medical treatment allowed in Islam should be (Halal/permissible), except in
emergency when there is no substitute or replacement.
Patience and Tolerance of one’s illness and suffering are great Islamic virtues and
are highly rewarded by GOD. (Angels are surrounding the patient).
It is forbidden to hasten your own death or to take any suicidal step or to ask the
doctor or any one to end your life.
Living wills (death wills) are forbidden in Islam. However it is a duty on every
Muslim to write early and in advance the Will with regards to inheritance.
Prayers and spiritual support are to be encouraged as we believe they are effective
in reducing suffering and curing the illness.
Visiting the sick patient is highly recommended and is highly rewarded by GOD
Care from the patient’s family, social support, and hospice care are to be
encouraged all the times

Dr A.Majid Katme (MBBCh, DPM)

Introduction

The Medical Ethics Alliance is a coalition of six World Faiths and Hippocratic medical and nursing bodies. It seeks to inform and initiate discussion within and without the  profession where ethical matters are involved. We have studied the draft which we find broadly helpful, but would wish to make a few general observations.

1        The medical profession is reflective of society as a whole and has many doctors of different religious and cultural backgrounds and doctors are in a close contact with vulnerable patients at important  times of their lives. In this we agree that they must fully respect the beliefs and values of all patients. We therefore  endorse the core guidance given in Good Medical Practice.

2        Many doctors draw inspiration from the from their own faith background and  values. These make them what they are and cannot be separated from their professional lives. In the multi national and multi faith profession that we enjoy today this represents a positive contribution to the welfare of patients. It is also likely to provide doctors with one of the motivations in their professional lives.

3        There is, furthermore, a strong residual Hippocratic tradition shared by doctors of all faiths and none, whether born here or coming into this country,  which we think the draft draws upon but does not directly acknowledge.  Nevertheless, that ethic has been weakened by legislation, most noticeably with regard to the status of unborn human life.

4        We have good reason to think that, not withstanding the conscience clause in the Abortion Act 1967,  those with a conscientious objection to abortion have difficulty in making a career in obstetrics and gyaenocology. This is particularly the case when seeking training posts. Difficulties are put in the way of applicants both by employing authorities and senior colleagues.

5        In your draft document at 21 this is dealt with but does not realistically address the position of junior doctors . In practise, we think many potentially good trainees are excluded. Given the wide nature of modern obstetrics and gynaecology, we think  there is scope for those with alternative interests such as oncology and urology who could make a considerable contribution and should not be involved in abortion. We would welcome a stronger statement from the GMC addressing this point.

6        Junior Doctors may find themselves unable to carry out certain treatment plans.This may arise in many different specialities from geriatrics to psychiatry. Furthermore, these dilemas may not be foreseeable when appointed. In these circumstances the only course of action open to the junior doctor is to inform the senior doctor managing the patient and withdraw from treatment. It then falls to the senior doctor to find another doctor. It would not be appropriate for the doctor who does not carry the ultimate responsibility for treatment to find another doctor. We are aware of difficulties created for anaesthetists, for example, who are asked to treat a woman undergoing an abortion in the middle of an otherwise routine list or where tube feeding is being withdrawn from a patient who is not dying.

7          Many patients approach their doctors with religious and cultural values that may not be familiar to many doctors. In this regard women doctors of similar cultural background may be sought by patients. This is a positive contribution to the welfare of patients, and whilst not wishing to segregate medical practice, a recognition of this in the draft would be helpful. For example women of Muslim background may wish to be treated by women gyaenocologists.

Conclusion

We  broadly welcome and support the core guidance. With regard to specific recommendations, we would like the GMC to address the problem of junior doctor training in obstetrics and gynaecology more realistically.

In general, we would welcome  more recognition that doctors from a variety of faith and cultural backgrounds may have a contribution to make to the care and comfort of patients in a multi cultural society.

Even though the GMC must make recommendations in the particular legal environment of our society, we would prefer to see some more explicit reference to the ethical code that has been traditionally characteristic of medicine and which is still strongly held by many members of the profession, whether born in this country or entering from abroad where such traditions are still strongly held.

Gdansk, 14 September 2008

Conscious of the trust placed in us as physicians and defenders of life, of the progress in medical knowledge and technologies, and of the ever better understanding gained into the physical, psychological, educational, spiritual, religious and existential needs of our patients and our society,

• while aware of the dangers of ethical relativism and of moral permissiveness around us and in our midst;
• in view of ongoing debates over the permissibility of abortion, euthanasia, the use of human embryos for research and so-called therapeutic purposes, human cloning, the creation of human-animal hybrid embryos, contraceptive and sterilization procedures and artificial reproductive technologies;
• faced with the silent assumption that those carrying out the above procedures will be doctors;

authorized by the Christian traditions and ethos of European and world medicine, in dialogue with all doctors who believe in the dignity and freedom of the human being,

1. We affirm that ethical norms and principles precede enacted laws and should influence their contents in accordance with natural law and the teaching of the Church.
2. We affirm that in making decision on the medical treatment of the patients who place in us so great a trust, we should be guided above all by our conscience.  Moral evaluation of medical practice must not be based upon superficial opinions or passing trends but on the sensitivity of a conscience formed according to objective ethical norms common to all people and  consistently defended by the Church.
3. In order to guarantee the freedom of practice of the profession, we have to uphold the right to conscientious objection
4. We believe that one of the basic demands made of doctors should be ongoing personal development in both practical know-how and in moral stature.
5. The special vocation of the doctor to serve the life and health of others requires a clear formulation of  the principles of an objective and universal ethics.
6. We affirm that the source and basis for all ethical norms is the inalienable dignity of the human person throughout the course of his or her life – from conception to natural death.
7. Just as human dignity requires the protection of human life, it also demands special concern  for its initial phases and respect for human procreation and sexuality.
8. We promote activities which permits the protection of patients from procedures that violate their human dignity:

●  Decisively rejecting euthanasia, we support the development of palliative medicine;

●  Refusing to agree to abortion, we aim to ensure proper all-round care for the family and the sick child both before and after birth;

●  We choose the treatment of the underlying causes of infertility and not successive techniques of artificial reproduction;

●  We support the development of research into the use of stem cells taken from adults and umbilical cord blood, rejecting the use of human embryos for this purpose.

1. 9.     We affirm and emphasize that medical practice with respect to matters as genetic manipulation and the end of life has to be realized without intentional loss of human life.

10.We want to protect our children and young people from neglect, abuse and other threats to their health and dignity. We have to ensure proper education for all aspects of life.

11.Aware of the number of people in our midst who are subject to abject poverty or under threats caused by misfortune, we uphold the tradition of the freedom of physicians to offer humanitarian and charitable aid, especially in neglected areas of the world, on the basis of principles and criteria lying beyond economics.

12.Taking into account the responsibility doctors carry for the health and life of patients, we are convinced that medicine must be practiced in dignified conditions, which are due both to patients and to doctors,  and we consistently affirm that in our activities the good of patients should have priority over other obligations.

Signed by:

President of the XI Congress of the European Federation of Catholic Medical Associations, prof. Josef Marek (in substitution signed by dr Francois Blin);

President of the Catholic Association of Polish Doctors,

dr Anna Gręziak;

Secretary of the European Federation of Catholic Medical Associations,

dr Hans Stevens