Fundamental questions of biomedical ethics:

 

30. Fundamental questions of biomedical ethics: Medical anthropology, health and sickness. Models of doctor - patient relationship. Informed consent and communication of the truth. Principle of proportionality of medical treatment. Organ transplants: criterion of death, typologies, argumentation and moral evaluation, Sterilization.

Introduction: The fundamental questions of biomedical ethics are very important. Medical anthropology, health and sickness, criterion of death, typologies, sterilization, these are related with ethics.  The medical science and medical treatment have improved a lot. But if human body is distorted in the name of saving life or a human person is killed willingly to save another is disgracing God’s acts and Himself as well, and it is a grave sin. A human person does not have any right to kill another human person. Therefore, it is against God’s commandment. It is an immoral act and a deadly sin. For this reason we have to know about it very clearly.

Medical anthropology and health care:  Medical anthropology studies "human health and disease, health care systems, and bicultural adaptation". It views humans from multidimensional and ecological perspectives. It is one of the most highly developed areas of anthropology and applied anthropology, and is a subfield of social and cultural anthropology that examines the ways in which culture and society are organized around or influenced by issues of health, health care and related issues. The term "medical anthropology" has been used since 1963 as a label for empirical research and theoretical production by anthropologists into the social processes and cultural representations of health, illness and the nursing/care practices associated with these. Medical anthropology helped a lot in developing the medical science and health care in the societies and ethnic in the world.

Applied medical anthropology: Collaboration between anthropology and medicine was initially concerned with implementing community health programs among ethnic and cultural minorities and with the qualitative and ethnographic evaluation of health institutions (hospitals and mental hospitals) and primary care services. Regarding the community health programs, the intention was to resolve the problems of establishing these services for a complex mosaic of ethnic groups. The ethnographic evaluation involved analyzing the interclass conflicts within the institutions which had an undesirable effect on their administrative reorganization and their institutional objectives, particularly those conflicts among the doctors, nurses, auxiliary staff and administrative staff. The ethnographic reports show that interclass crises directly affected therapeutic criteria and care of the ill. They also contributed new methodological criteria for evaluating the new institutions resulting from the reforms as well as experimental care techniques such as therapeutic communities. The ethnographic evidence supported the criticisms of the institutional custodialism and contributed decisively to policies of deinstitutionalizing psychiatric and social care in general and led to in some countries such as Italy, a rethink of the guidelines on education and promoting health.

The empirical answers to these questions led to the anthropologists being involved in many areas. These include: developing international and community health programs in developing countries; evaluating the influence of social and cultural variables in the epidemiology of certain forms of psychiatric pathology (transcultural psychiatry); studying cultural resistance to innovation in therapeutic and care practices; analyzing healing practices toward immigrants; and studying traditional healers, folk healers and empirical midwives who may be reinvented as health workers. There are the problems associated with implementing community health mechanisms. These problems are perceived initially as tools for fighting against unequal access to health services. However, once a comprehensive service is available to the public, new problems emerge from ethnic, cultural or religious differences, or from differences between age groups, genders or social classes.

The agenda of medical anthropology: Currently, research in medical anthropology is one of the main growth areas in the field of anthropology as a whole and important processes of internal specialization are taking place. For this reason, any agenda is always debatable. In general, the following six basic fields may be considered:

o   the development of systems of medical knowledge and medical care

o   the patient-physician relationship

o   the integration of alternative medical systems in culturally diverse environments

o   the interaction of social, environmental and biological factors which influence health and illness both in the individual and the community as a whole

o   the critical analysis of interaction between psychiatric services and migrant populations

o   the impact of biomedicine and biomedical technologies in non-Western settings

Other subjects that have become central to the medical anthropology worldwide are violence and social suffering as well as other issues that involve physical and psychological harm and suffering that are not a result of illness. On the other hand, there are fields that intersect with medical anthropology in terms of research methodology and theoretical production, such as cultural psychiatry and transcultural psychiatry or ethno psychiatry.

Doctor-patient relationship: The doctor–patient relationship is central to the practice of healthcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor–patient relationship forms one of the foundations of contemporary medical ethics. Doctors should maintain a professional rapport with patients, uphold patients’ dignity, and respect their privacy, so that, patients may feel friendly with the doctors and tell their problems openly and clearly.

Aspects of relationship: The following aspects of the doctor–patient relationship are the subject of commentary and discussion.

·         Informed consent

·         Shared decision making

·         Physician superiority

·         Benefiting or pleasing

·         Formal or casual

·         Transitional care

·         Other people present

Importance of doctor-patient relationship

A patient must have confidence in the competence of their physician and must feel that they can confide in him or her. For most physicians, the establishment of good Rapport with a patient is important. Some medical specialties, such as Psychiatry and Family medicine, emphasize the physician–patient relationship more than others, such as Pathology or radiology. The quality of the patient–physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment, causing decreased Compliance (medicine) to actually follow the medical advice. In these circumstances and also in cases where there is genuine divergence of medical opinions, a Second opinion (medicine) from another physician may be sought or the patient may choose to go to another physician.

 In terms of efficacy (i.e. the outcome of treatment), the doctor–patient relationship seems to have a small, but statistically significant impact on healthcare outcomes. Patients receive the best care when they work in partnership with doctors.

The principle of proportionate and disproportionate means

Proportionate means: It is any treatment that, in the given circumstances, offers a reasonable hope of benefit and is not too burdensome for the patient or others. What is a reasonable hope of benefit to the patient should be judged within the context of the whole person (i.e., considered holistically, not just physiologically). Generally, a treatment or means is not too burdensome when it offers benefits that outweigh the burdens to the patient and others. These determinations should be patient specific and include considerations of the expected medical outcomes and the patient’s personal, financial, familial, and social circumstances.

Disproportionate means: It is any treatment that, in the given circumstances, either offers no reasonable hope of benefit (taking into account the well-being of the whole person) or is too burdensome for the patient or others, i.e., the burdens or risks are disproportionate to or outweigh the expected benefits of the treatment. Again, these determinations should be patient specific and take into consideration the patient’s personal, financial, familial, and social circumstances.

If one uses the terms ordinary and extraordinary means (as opposed to proportionate and disproportionate), are must be taken not to confuse the terms “ordinary care” and “ordinary means.” While patients may forego treatments that are disproportionate or extraordinary means, there is always an obligation to provide ordinary are due to the sick person, that is, to provide non-medical nursing interventions. 

Organ transplant: Organ transplant may be autografts, heterografts or homografts. Autografts are transfers of tissue, e.g. skin or bone, from one part of the patient’s own body to another part. They are justified for any reason of health. Heterografts are transplantations of animal tissue to a human body. They are permissible as long as they do not effect changes of personality. Since the transfer of animal sex glands to a human recipient involves such serious changes, it must be rejected as immoral. Homografts consist in the transfer of tissue from one human being to another. The tissue may originate from the body of a deceased person or from a living donor. Some of the questions connected with homografts have to be discussed more in detail.

There is no moral objection to the making of grafts from cadavers (skin, cornea from the eye) and from legitimately usually not be permissible- apart from exceptional cases- without the consent of the family or the responsible relatives, or contrary to the explicit refusal of the deceased.

Heart can be taken from a deceased person. A person is clinically death is not considered as dead until he or she has a brain death and it is fully valid. This death would have to be sure by several doctors even though this checking must not be done for only purpose of heart transplantation.

Another discussion concerns the transplants of tissues or organs from one living person to another. In this case skin graft and blood transfusion are lawful because they can restore themselves. Another reason is they are not the organ as a whole that is transplanted, but only a small part of it. So a person is allowed to donate his or her neighbor a part of his body. In the case of kidney though there are two kidneys but their function is done together. So a man can donate his kidney if he keeps alright after having donated one. That would be considered as the gift of love towards his neighbor.

Nobody under age is allowed to give an organ to other person.

Finally also consent of the recipient must be sufficiently assured for any transplants which must be considered extraordinary treatments. If the patient is unconscious or under age, the consent of his representatives (husband, wife, parents) is required. Physicians may not treat or operate against the will of the recipient or his representatives, certainly not if extraordinary treatments are concerned.

The moral evaluation of organ transplant and sterilization

Organ transplantation is the moving of an organ from one body to another or from a donorsite to another location on the person's own body, to replace the recipient's damaged or absent organ. Organs or tissues that are transplanted within the same person's body are called autografts. Transplants that are performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source. And sterilisation is a term referring to any process that eliminates (removes) or kills (deactivates) all forms of life and other biological agents (such as viruses which some do not consider to be alive but are biological pathogens nonetheless), excluding prions which cannot be killed, including transmissible agents (such as fungi, bacteria, viruses, prions, spore forms, unicellular eukaryotic organisms such as Plasmodium, etc.) present in a specified region, such as a surface, a volume of fluid, medication, or in a compound such as biological culture media. Sterilization can be achieved with one or more of the following: heat, chemicals, irradiation, high pressure, and filtration. Sterilization is distinct from disinfection, sanitization, and pasteurization in that sterilization kills, deactivates, or eliminates all forms of life and other biological agents.

Sterilization: The term sterilization is often used in the wide sense of any mutilating procedure which deprives man or woman of the power of generation. Sterilization only comprises those medical interventions which merely suppress the generative functions by certain surgical operations (e.g. ligation or section of the tubes, vasectomy) or by medications, while leaving the reproductive glands intact.

There are two kinds of sterilization: Direct and indirect.

Direct Sterilization: Direct Sterilization in the case of female can be brought about by the removal of the uterus, the removal or ligation of the Fallopian tubes, or the removal or irradiation of the ovaries.

Indirect Sterilization: In indirect sterilization the first and only purpose of the physician is very definitely different. His first and only purpose is to correct a pathological condition presenting danger to his patient. The steps that must be taken to correct this condition will result in sterilization, but he intends this sterilization only indirectly, not directly.

The general principle is that any one of these procedures is licit if a pathological condition of the organ renders it necessary for the preservation of the patient’s life or health, but that it is illicit if the purpose of the operation or treatment is to prevent the inconveniences or dangers of childbearing.

Sterilization is permitted, according to traditional moral theology, when it is immediately directed to the cure, diminution or prevention of a serious pathological condition and a simpler treatment is not reasonable available. The sexual organs themselves ought to be sick, or they must be the physiological cause of a sickness in some other part of the body. Thus removal or irradiation of the ovaries is allowed in treat in carcinoma of the breast or ulcer resulting from them. But sterilization or castration would not be allowed in order to remedy psychological disturbances in a woman which result from fear of further pregnancies. In this case the procedures are immediately directed to the suppression of the procreative function and only mediately to the cure of a disease. This would be unlawful, direct sterilization.

Conclusion

God has created human being in such a way that the human body has its capacity to perform its own acts including generating life. The medical science and medical treatment have improved a lot. But if human body is distorted in the name of saving life or a human person is killed willingly to save another is disgracing God’s acts and Himself as well, and it is a grave sin. Autograft is considerable but other organ transplantations are to be totally prohibited because they cause damages human body as well as life. Sterilization kills human life. A human person does not have any right to kill another human person. Therefore, it is against God’s commandment. It is an immoral act and a deadly sin.