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Basics of medical ethics (deontology) Medical ethics (Latin ethica, from Greek ethice – teaching of morals), or medical deontology (Greek deon – ‘duty’ or ‘obligation’; the term ‘deontology’ has been in wide use in the domestic medical literature over past years) is a set of ethical standards and principles of behaviour of medical workers while executing their professional duties. According to modern conceptions, medical ethics include the following aspects: Scientific - the section of medical science studying ethical and moral aspects of medical workers’ activity; Practical – the area of medical practice the tasks of which are the formation and application of ethical standards and rules of the professional medical activities. Historical background • ancient sources concerning medical ethics and deontology: “The Laws of Hammurabi” (laws of Ancient Babylon, 18th century B. C.), “About the physician”, "The Oath" and "The Law" by Hippocrates (5-4 centuries B. C.), Indian “The Book of Life” (“Ayurveda” – 5-4 centuries B. C.). The term "ethics", meaning “a concept of human morals” was introduced by Aristotle (384-322 B. C.). • Middle Ages: “The Canon of Medical Science” and “Ethics” by Ibn Sina (Avicenna, 10-11 centuries), the medical school of Salerno (1213). • Jeremy Bentham (English philosopher, lawyer, priest; 1748-1832) introduced the notion of deontology as meaning “… the teaching on the due behaviour of a person while achieving his end” (18 century). • Russian medicine: “The Word Concerning Piety and Moral Qualities of a Hippocratic Physician” and “The Word Concerning the Ways of Teaching and Learning the Practical Medicine” by Matvey Yakovlevich Mudrov (1776-1831), “Letters from Heidelberg” and “The Diary of an Old Doctor” by Nikolay Ivanovich Pirogov (1810-1881). • The Nuremberg process, 1947: the verdict to the Nazi physicians, “The Nuremberg Code”, postulates not legal, but also moral regulations of medical experiments. • 1947 - the World Medical Association was created. Its main action was the adoption of “The Geneva Declaration” – the oath of a physician – the doctor (1948), the International Code of Medical Ethics (1949), “The Helsinki Declaration of Human Rights” (1964), “The Helsinki-Tokyo Declaration” (1975), and “The International Declaration on Human Rights” (1983). The medical ethics studies and defines the solution of various problems of inter-personal mutual relations in three basic directions: • medical worker – patient, • medical worker – relatives of the patient, • medical worker – medical worker. Such qualities as compassion, kindness, keenness and responsiveness, care and attentive attitude to the patient should be inherent in any worker of medical sphere. It was Ibn Sina who had already demanded a special approach to the patient: “You should know that every separate person possesses the special nature inherent in him personally. It seldom happens, or it is absolutely impossible, that somebody would have the nature identical with his”. The great importance has also a word, which means not only a culture of speech, but also the tact, skill to cheer the patient up and not to harm him with a careless statement. A special importance in the medical profession have such universal human norms of intercourse as ability to respect and listen attentively to the interlocutor, to show interest in the contents of the conversation and opinion of the patient, as well as the correct and accessible construction of speech. No less importance has the tidy external look of the medical personnel: clean dressing gown and cap, accurate replaceable footwear, well-groomed hands with shortly cut nails, etc. In the ancient Indian medicine physician used to tell to his disciples: “You now leave your passions, anger, greed, madness, vanity, pride, envy, roughness, buffoonery, falsity, laziness and any vicious behaviour. From now on, you will have your hair and your nails shortly cut, wear red clothes, conduct a pure life”. It is necessary to remember always, that to the physician it is inadmissible to use perfumery and cosmetic means without any measure. Strong and pungent smells can cause undesirable reactions: from nervous irritation of the patient and various displays of allergy up to a sharp attack of bronchial asthma. PRIMUM NON NOCERE (Latin) - FIRST, DO NO HARM – this maxim is the main ethical principle in medicine. The moral responsibility of medical worker means his observance to all the principles of medical ethics. Wrong diagnostics, treatment, behaviour of doctor and representatives of middle-ranking and junior medical personnel may lead to physical and moral sufferings of patients. Such actions of medical worker, as disclosure of medical secret, refusal to give medical aid, infringement of personal life’s inviolability and so forth are inadmissible. The care of patients assumes, among other, the need to observe to certain rules of the intercourse with him. It is important to give the patient the maximum of attention, to calm him, to explain the necessity to observe the regimen and to take medicines regularly, as well as to convince him of a possibility of recovering or improvement of his condition. It is necessary to observe greater caution during conversations with patients, especially those suffering from oncological diseases, who should not be informed of the true diagnosis. These days, the statement of the great physician of the antiquity, the father of medicine Hippocrates, “Surround the sick man with love and reasonable consolation, but, the main thing, leave him in ignorance of what threatens him”, still has not lost its importance. Yet, in some countries they do inform patients of the seriousness of their including of a probable lethal outcome (Latin letalis - lethal), in this proceeding from social and economic reasons. Thus, in the USA the patient even has the right to bring a suit against the doctor who had hidden from him the diagnosis of a cancer tumour. Iatrogenic diseases Infringement of deontological principles of the intercourse with patients may lead to the development in them of the so-called iatrogenic diseases (Greek iatros – ‘physician’, gепеs – ‘generated’, ‘arising’). An iatrogenic disease (iatrogeny) is the pathological state of patient caused by careless statements or acts of physician or another medical worker which create in patient the idea that some disease is present in his organism or of its special graveness. Inadequate, hurting verbal contacts, harmful for patient, may lead to various psychogenic iatrogenies. Yet, as early as 300 years ago, “the English Hippocrates” Thomas Sydenham (1624-1689) emphasized the danger to the patient of not only the actions of medical worker that injure his mentality, but also other probable factors, including undesirable consequences of medical manipulations. Therefore, at present iatrogenic diseases are called those diseases the development of which is connected with those or other actions of medical workers. So, along with the above-described psychogenic iatrogeny (iatropsychogeny), we may name: • iatropharmacogeny: consequence of medicaments’ influence on patient - for example, collateral actions of preparations; • manipulation-caused iatrogenies: adverse influence on patient during his examination - for example, complications at carrying out of coronaroangiography; • combined iatrogenies: consequence of the influence of several factors; • so-called mute iatrogenies – consequence of medical worker’s negligence. Medical secret Among deontological questions related to the care of patients it is possible to name the necessity to preserve medical secret. Medical workers have no right to disclose any data concerning patient that have deeply personal character. However, this requirement does not concern to the situations representing danger to other people: venereal and infectious diseases, infecting with human immunodeficiency virus (HIV), poisonings, etc. In these cases medical workers are obliged to inform the respective organizations about the received data immediately. With the purpose of carrying out sanitary-and-epidemiologic actions in the centre of infectious diseases’ occurrence, food poisoning or pediculosis, nurse is obliged to inform, within 12 hours from the moment of determining the diagnosis, the respective sanitary-and-epidemiologic station by phone and simultaneously to direct there the filled form of the emergency notification (the form No. 058/y). Mistakes and medical offences Observance by medical worker of morally-ethical standards means not only the execution of his duties, but also the responsibility for the evasion from, or nonprofessional execution of his duties. In medical worker’s activity both mistakes and medical offences may occur. Mistakes in medical practice may be caused by delusions. Medical offences are caused by undue approach towards professional duties. One such offence is, for example, wrong introduction of medical preparations, especially strong ones, which may lead to tragic consequences. Medical workers bear administrative responsibility for the infringement of rules of storage and account of poisonous, strong and narcotics means (Article 6.8 of the Russian Federation’s Code on administratively punished offences). Among medical offences may be also mentioned not rendering help to patient without valid excuse (Article 124 of the Russian Federation’s Criminal Code). “The Basic Principles of the Russian Federation’s Legislation on the health protection of citizens” (1993) regulate the legal responsibility of medical worker in case of causing harm to the health of citizens. • Article 66 – “Grounds for compensating the harm caused to the health of citizens”. • Article 67 – “Compensation of expenses for rendering medical aid to the citizens affected by illegal actions”. • Article 68 – “Responsibility of medical and pharmaceutical workers for the infringement of citizens’ rights of citizens in the field of health protection”. • Article 69 – “Right of citizens to appeal the actions of state bodies and officials infringing the rights and freedom of citizens in the field of health protection”. Depending on a degree of weight of offences committed, medical worker is exposed to official penalties (reprimand, strict reprimand, transfer to less paid work, etc.) or is made answerable according to the existing legislation. Thus, the care of patients assumes the legal responsibility of medical workers, along with strict execution of the professional duties by them and observance of principles of medical deontology. Physician’s encyclopedia Iatrogenic diseases (Greek iatros – ‘physician’ + gennaō – ‘ to create, make’; a synonym - iatrogeny) – psychogenic frustrations arising as a result of medical workers’ deontological mistakes, i. e. wrong and careless statements or actions. Frustrations of health resulting from the influence on patient of words and actions of physician were already known to ancient physicians. However, the term “iatrogeny” has come into wide circulation only after publication, in 1925, of the study by German psychiatrist Bumke “Physician as the cause of mental disorders”. Since then, the concept of iatrogeny has been actively studied by experts of different clinical fields. A stable tendency of broad interpretation of iatrogenic diseases is being observed. Many experts, especially abroad, cite among them the pathology resulting not only from deontological mistakes, but also from any actions of physician (from the complications of incorrectly executed manipulation or procedure to the occurrence of so-called medicinal illness), i.e. any negative consequences of medical intervention. Some researchers designate such states as iatropathies or somatic iatrogenies. For the development of iatrogenic diseases (in the traditional interpretation) both behaviour of physician and patient’s personal features (degree of emotionality, suspiciousness, etc.) are important. Many of sick people suffer not only from illness, but also from alarm and fears generated by it. This explains the especial attention paid by patient to words of physician, his behaviour and intonations, and even the expression of his face. Thus, depending on type of nervous activity, person’s disposition and peculiarities of mentality, different patients differently, sometimes in an opposite way, response to certain words and behaviour of medical worker. Of pathogenic importance can be not only unreasoned retorts (“Your heart attack is a first signal”; “...the main cardiac vessel lets only 30 percent of blood flow”, etc.) or vague meaning of some words and expressions (“hook-form stomach”, “the dystrophy of myocardium”, etc.), but sometimes even interjections or protracted silence of physician, which may be interpreted by patient as signs of special difficulty of diagnostics or treatment of his disease, its especial weight or hopelessness of the forecast. Risk of the occurrence of iatrogenic diseases, considering other equal conditions, varies depending on age, gender and educational level of patients. On the average, women have higher probability of iatrogeny than men. High risk age groups include people of so-called transitive age - teenagers and persons in the period of climax (especially women with pathological climax), as well as persons of advanced age, of whom many are over-concentrated on the idea that they have inevitable involutive changes and high probability of a lethal outcome of the arising illness. Among the factors conductive to the occurrence of iatrogenic diseases one should also mention the not always justified expansion of the volume of the medical information distributed among people (popular lectures, telecasts and broadcasts), when symptoms of this or that dangerous illness are stated and attention is fixed on its early displays. Iatrogenic diseases become apparent mainly through neurotic reactions in the form of phobias (cancerophobia, cardiophobia) and various kinds of vegetative dysfunction. Their development is furthered by increased emotionality and suggestibility. Depending on the character of psychic trauma and pre-morbid features of the person, the vegetative frustrations may have generalized character or are expressed by primary dysfunction of cardiovascular (cardiac arrhythmia, changes of AP, etc.), digestive (heartburn, vomiting, disorder of stool) or other systems, in a combination with senestopathies and negative effective background. The treatment of iatrogenic diseases runs along with the treatment of neuroses. The basic method is psychotherapy, supplemented, if necessary, by symptomatic treatment, depending on the character of displays of vegetative dysfunction. It is preferable that the treatment be conducted by psychotherapist or psychiatrist. It is inadmissible to let the patient know that he has no disease and therefore there is no need to cure him. Physicians should bear in mind that it is a question of a disease demanding careful studying of patient’s personal features and examination his social ambience. Psychotherapy demands that the features of a concrete iatrogenic disease, as well as the factors conductive to its occurrence be determined. A significant psychotherapeutic effect may be reached through notifying the patient of the convincing conclusion of an authoritative consultation or highly skilled expert. The prognosis of iatrogenic diseases is most cases favorable, and on the condition of duly and correct therapy the recover comes in some weeks or months. Late discerning of iatrogenic disease leads to its lengthy passing and worsens the prognosis. The existing preconditions of raise in the frequency of neuroses, as well as progressing increase in number of senior age groups people raises the risk of occurrence of iatrogenies. Against this background, the responsibility of physicians for their “verbal aseptics” and the necessity of constant control of their behaviour (intonations, sights, gestures) which can be incorrectly interpreted by the patient increase. In present conditions, when with patients are communicated, as a rule, not by one, but a few physicians, as well as by middle-rank and junior medical workers, the probability of the occurrence of iatrogenic diseases increases. Therefore, to prevent iatrogenic diseases, it is necessary to conduct regular work with all the personnel communicating with patients. The contents of the medical documentation given out to patients should be carefully thought-out. Extra care should be taken regarding those medical workers who have a relatively high rate of iatrogenic diseases occurrence.
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