MuslimHeritage.com

Highly Valued Virtues of Classical Ottoman Turkish Medical Ethics View (Continued)

Contentedness is an everlasting virtue to be practiced by man, not a historical issue. Hazards posed by the human appetite for dominating nature to realize economical progress can be traced specially in our quickly detoriating environment. Contemporary biomedical researches, medical technology and clinical practices are also fields that encourage eagerness for gain.

Medical service has the potentiality of profit and it does provide high profit. The unnecessary increase of therapeutic expenditure is fostered through monetary profit. Medical service and tools presented to people has the potentiality for manipulating the desire for it, too. A new medical product may be introduced as a great development. The desire for diagnosis and treatment of health problems creates and increases the request for medical service, even though it might be unnecessary or futile. Medical developments might be reflected in an exaggerated way so that more patients might be drawn. Utilizing media for advertisement, aiming profit might cause unjustifiable gain and personal interest. Medical practitioners are subject to the influence of the producers and dealers of firms who are eager to sell and gain more and more. Being eager to gain, a product not to be chosen at the first stage of treatment might be used, or a product might be used much more and longer then needed. Organized cooperation with the drug industry and prescription of drugs in accordance with promotion, monetary profit through medical research laboratories, unnecessary use of medical technology, directing patients to private health institutions, medical practice in more than one place, mediation of the organ trade, false prescriptions and reports, medical intervention in a health institution not equipped sufficiently, utilizing medical authority for gaining money, widening the accepted effective limits of technological products and drugs aiming profit unethically are various complaints reflected in the mass media, as well as in social researches [31].

Developing medical technology helps saving lives of many patients, but also disaffects the intimid patient-physician relationship. The health service is in danger of turning into routine trade relationship in a liberal bazaar economy. Traditional patient-physician relationships based on mutual respect, monetary profit being valued only secondarily, has changed highly. Sometimes we see a merciless competition in a medical bazaar community. The most modern diagnostic and therapeutic equipments and titles of rank and dignity may be used as a means of trade in medicine [32]. Medical practice should not be regarded as a trade. Treatment of a patient is not a means for gaining money. The interrelation of health and money contradicts the expectation of a justifiable distribution of health service to people.

Large image

Contemporary health service is in danger of being a means of trade and advanced technology being valued as a source of income, a great number of centers of imaging technology have started acceleratingly. Various ways are being tried for attracting more patients to these centers in order to win the cost of technological apparatus. Necessity for technology has the potentiality to transform a physician to an enterpriser, starting a market. Physicians are sometimes appointed to be sharers of diagnostic and therapeutic centers. A percentage of payment is sometimes paid to the physician for a patient sent to these centers. Such health practitioners are eager to send patients, medically indicated or not, to these centers in order to gain more money [33].

Products of high technology are really beneficial. However, in contrast to the beginners in the field, experienced physicians' high diagnostic capability without recourse to technological and laboratory investigations, is a paradoxical comparison we often encounter [34]. Do medical decisions sometimes come to be more difficult in the course of collecting results of complex diagnostic techniques and laboratory parameters, increasing in number continuously?

Without contentedness, the health service is regarded as a means for gaining money and the patient as a "client" (customer), health issues will be considered as merchandise. If the aim to earn money leads the way, distribution of the health service will be determined by productivity. The continuous problem of economical necessities and the need for a healthy life by people can be eased by contented health practitioners, who are not eager to be rich tradesmen.

The placebo effect of fidelity in the treatment of a patient is a subject for research. Feelings of alienation and disaffection are shared by many patients who attend hospitals in highly populated cities. Patients may be demoralized by the complex machinery of million dollars value, products of advanced technology and the distressing impression of highly busy hospitals. Worried patients might feel themselves inferior in health institutions' unusual circle. On the other hand, an indifferent health practitioner who has lost his/her sensitiveness of reaction to a patient, alienated to his job will increase patient perplexity. Being a member of a health team, sharing the patient responsibility also dangers a physician's feeling of fidelity and sensitivity to the patient. Consequently, the "my patient" and "my physician" attitudes are in danger of diminishing. However, the fact that the patient's life is entrusted to a physician is an unchangeable reality. The contemporary health practitioner is in danger of turning to be a technologist, thus loosing identity. Fidelity is the virtuous attitude that can help both physician and patient to be free of the feeling of alienation [35].

Fidelity comprises the responsibility for transfering a patient to another physician when needed, as well as continuing treatment in case a patient turns back. Fearing a compensation for malpractice, there is the risk for physicians to avoid treatment of patients with probability of complication. Attitude of fidelity and the rules derived have the potentiality of preventing this, too.

Respect to patient autonomy should not be a reason for ignoring fidelity in treatment. Respecting a patient's decision "alone" may lead to the isolation of a patient, which is not the aim of increasing the patient autonomy. Autonomy, even when conceived as the primary principle of ethics, should not be interpreted as an excuse for abandoning the patient. Attitude of fidelity by a physician to a patient has the potentiality to protect the patient against being neglected. Assuming a patient's decision for withholding or withdrawing his/her treatment as an autonomous action, and consequently abandoning the patient may be harmful, and sometimes a risk of negligence. Fidelity as a virtuous attitude to a patient also comprises encouraging treatment, after balancing beneficence and risks and informing the patient of it. Presuming the probability of a diminished autonomy of a disappointed patient, because of suffering from disease and extended painful treatment, a physician should encourage a patient's will for probable treatment [36].

A patient may not have the chance to disclose critical information to a physician who impresses by language or manners that he/she is too busy, and does not have time enough to hear the patient. Telephone calls from around, books and writings piled up in front of physician, many other patients waiting on the line might be evaluated by patient as, "hurry up, so that another patient can come in." Because of being too busy, the "right not to be informed" or "right to refuse being treated" might be exploited by a physician in public service. Fidelity as a virtuous behaviour has the potentiality of preventing the busy physician's untimely decisions. For example, when a patient who benefits from treatment is exhausted and wants to end tiring treatment like physical therapy, it is not proper to approve the patient's decision without further effort for encouraging the patient.

A physician has to consider fidelity to the patient to prevent grief of incurable or terminally ill patients, too. Fidelity to seriously or terminally ill patients means that a physician's responsibility to a patient does not end when there's no hope of cure. Keeping in mind that a physician should not have the patient make unnecessary payment for treatment not expected to be beneficial, and being wary from forcing or misleading a patient, the physician's fidelity to the patient will not end in incurable cases. Fidelity to a patient and respect to the autonomy of a patient should be valued together. Fidelity also comprises respect to the patient.

Contemporary medicine, its technology and the much more dependable prognosis of illnesses by today's medical practitioner must not be compared with the medicine before the 19^th century. Ottoman Turkish physicians observing signs and symptoms had an idea about the prognosis of some illnesses, though not so certain as today. Death could only be noted by means of senses as the end of palpation, heart beats and breathing. It seems to be inevitable for a physician in history not to speak with certainty about prognosis, because decision could be arrived only through observation, physical examination, previous experiences and patient complaints. However, the fact that the patient is in need of being kept away from unnecessary anxiety and fear, has not changed [37].

Large image

Figure 6: Illustration in Şerefeddin Sabuncuoǧlu's treatise of an example of a physician using a forceps to remove a foreign body from the forehead. (Source). © 2004 American Association of Neurological Surgeons.

The importance paid to the autonomy of a patient today [38] led to the virtue of truthfulness to be most valued by contemporary health practitioners, while hopefulness came to be ignored in the course of time. Allocation of limited resources also lowers the chance for fostering hopefulness. Actually, telling the truth to a patient is the easiest behaviour. Seeking for and discussing how much, which and how information is to be disclosed to a patient is more painstaking than telling the patient the truth promptly, as it will take time, necessitating greater effort by a physician.

Each patient is impressed differently by a physician's attitude and behaviour. Verbal communication and manners of a physician may have a placebo or a harmful effect on a patient, depending on the situation [39]. Practitioners must keep in mind that loosing hope for treatment may stress the patient and cause anxiety or fear, too. It is a fact that sorrow and fear weakens eagerness for living and the function of man's natural tendency for healing. Physicians must never forget that "the natural instinct of healing is a most effective medicine" and must not be oppressed. Stress and worry discords the homeostasis of the body. We know that the stress of a patient weakens the immunity system through psycho-physiological/neurological relation. Depression and anxiety can alter the biochemical processes, such as the hormonal and immunity function, leading to deterioration of health [40]. In contrast, a patient's belief in and hope of being treated may have a biological/placebo effect promoting faster recovery from illness or injury. Neurotransmitters inform all organs and cells of our feelings and emotions. Physicians should not hinder, but help the natural healing power of patients. (The intrinsic healing power of human beings should be noted and observed) The process of treatment involves reducing stress by encouragement and hopefulness for treatment provided by the physician, as well as administration of drugs and medical intervention. Observing the effect of hopefulness of a patient being cured should be noted by a practitioner.

If hopefulness has the potentiality to motivate a patient's instincts and stimulate immunity against illness, how should a physician behave so as not to disappoint a patient? Can we assume that, if stimulating hope is not misused by health practitioner, should it not be observed by a physician as a beneficial attitude (for beneficient consequences) when needed? The expectation by a patient of his/her health's improvement may be an innate treatment. When we contemplate on the placebo effect of hopefulness and the harmful effects of stress and grief on the immunity system, telling the truth might be medically harmful in some cases, so unethical. If the effect of placebo is being motivated by means of suggesting treatment and if hope is valuable for human health and if grief in fearing a bad prognosis or death might lower the patient's immunity system and harm the patient's health, we should reconsider fostering hope in an ethical manner in clinical circles [41].

Today, hope is estimated in accordance with statistical data. Loss of hope, like hopefulness in treatment, suggests an intellectual judgement concerning probabilities. The physician is the one who has to evaluate medical knowledge, but can this evaluation be always confirmed and free from probability? Probability estimation depends on the collection of facts and experiences. Evaluation of the probability of being cured and balancing beneficence, risks and other burdens of treatment, necessitates the use of statistical data. The expected prognosis of a disease or injury and the expected results of a treatment depend on the collection of data derived from many cases in a period and the medical practices of many physicians. However, various examples of the standard deviation should always be kept in mind. Statistical data may be misleading both from a physician's and patient's point of view, because each case is unique. Medical indications and complications should be valued carefully in every case, each being unique. Disposition of a patient, as well as environmental effects are influential on the prognosis of disease which should be observed by a practitioner. Cases noted statistically to be almost hopeless can be cured sometimes. It is not always possible to predict the prognosis of a case. Does undervaluing little hope of beneficence of treatment sometimes lead to withholding or withdrawing treatment untimely? The importance of informing the patient of the lowest probability of being healed, in order to enable him to decide whether or not to struggle for his own destiny, should be valued.

Treatment alternatives and outcomes are the most important aspects of informed consent practices. Alternative treatments' outcomes are derived from former experiences and depend on statistical data from different parts of the world obtained from many practitioners- some highly successful, others inefficient. For example, when I took my father to an urologist for the operation of his prostate, the physician suggested operating within scopy, and when my father said, "I have reached literature about the risks of such an operation", the physician answered, "these statistical data covers the figures from urologists all over the world. In my operations not a single complication has occurred." He was sincere and he was not to be paid for the operation. Each physician's degree of success is different and each patient's disposition to illness and treatment is different; and each patient-physician relationship is a special case of its own and should be evaluated separately.

Informing a patient of the outcome of treatment and the probable risks of being treated or not will stimulate a patient's emotions. Information of disappointing prognosis may draw some patients to hopelessness. Loosing confidence in treatment means giving up struggling, ready to except consequences. The reaction of a patient will depend greatly on "how" physician reflects the factual information, as well as the facts themselves. Informing a patient of risks and complications should not result in causing anxiety and fear. Alarmist statements creating fear or horror must be avoided. Facts can be told in an appropriate manner. The way in which a patient is informed of the risk or an outcome is morally significant as disclosing the risk. Physicians should help patients evaluate risks and complications of treatment, approaching compassionately in order to diminish anxiety of patients in pain. Physicians should help patients in coping with disease and adjusting its outcome. This does not mean lying or deceiving, consequently misleading patients.

Large image

How are we to know who is willing to learn the truth or who doesn't, and who is going to be harmed by the truth? This can be evaluated by a physician who acts as a modest and compassionate partner, trained in ethical behaviour. If needed, an attendant physician must consult a psychiatrist. Refusing to treat a patient difficult to cure and telling the patient that he/she can not be cured may be truth telling, though it may also be highly demoralising and consequently harmful. While the treatment of a hopeless case may be valued as a futility by a physician, it may mean despair and grief for a patient. Decision by a physician about the futility of treatment may lead to the abandonment of a patient, as well.

A patient's life may not be prolonged by promoting hope and relieving distress, but it can provide ease. Hopefulness can be an important feeling even for the terminally ill patients. Especially when a physician informs patient about the critical decision of the futility of treatment, the patient will encounter the reality. Fatality probabilities must not be exposed to a patient in a way so as to create tension and to worry the patient. A physician evading responsibility for seeking further treatment of hopeless cases is a probability. Incurable diseases should not be considered to be the only reason for withholding or withdrawing treatment. Medical reasons for withholding or withdrawing treatment are discussed in detail by health practitioners, but the basic values starting and directing such decisions are sometimes ignored, and the importance paid to life and death by patients is not considered enough. It is also important for the terminally ill patient to be prepared for the end of life peacefully.

Hope is a golden key introduced to patients by alternative therapists, a virtue lacking in contemporary scientific medicine, I believe. There is a delicate line between encouraging hope virtually and behaving as an exploiter of hope. Exploitation of an incurable patient is an unethical behaviour, harmful both physically and financially. Unnecessary expenditure for futile treatment is unethical). It may open the way to quackery, undermining the essential trust between physician and patient. However, like norms described for truth telling, norms aiming when and how hopefulness ought to be motivated or not can be described. Hopefulness should be practiced without misleading the patient. A health practitioner must keep in mind that, in a sense, "hope" is similar to mutual "trust", once lost it is hard to re-establish [42].

Moral behaviour should be evaluated from the point of view of "virtuous behaviour", while being guided by moral principles and rules. Discussion and definition of ethical medical practice should always conceive both of these aspects of morality. Virtuous behaviour cannot be turned into principles all together, but it can be developed and conserved as attitude and behaviour through training.

Though contemporary virtue ethics gives importance to virtues such as mercifulness and compassion, virtues of modesty, contentedness, hopefulness and fidelity are disregarded, though inevitable virtues expected from health practitioners. A competent and virtuous physician is one who makes use of technological tools skilfully, but also modest, contended, loyal and hopeful. We must find ways to foster and sublimate the nowadays undervalued virtues modesty, contentedness, fidelity and hopefulness, important determinants for ethical physician-patient relationship. Trust in health practitioners and medicine itself can not be established if these virtues are not developed. A patient-physician relationship is a kind of agreement, which should provide the patient with courage, to give confidential and private information about himself/herself and put questions to physician. Physicians must establish emphatic relations with patients, so that patients will be able to approach him/her easily, without underrating professional respectability.

Ethical principles, rules, and regulations for patient rights are not sufficient for coping with the materialization and instrumentilization of medicine. Physician-patient relation dependent only on ethical principles may be misused for the justification of actions and may lead to ignoring virtuous behaviour. I have observed people justify their immoral behaviour by claiming to have practiced ethical principles.

A Behavioral Theory of Ethics must and can be developed. Ethical action guides making use of principles and rules for decision making are not sufficient. Ethical principles are somewhat isolated from patients' moral values. A patient does not perceive the ethical principles underlying actions of the health practitioner, but is impressed by his/her behaviours. A patient interprets mimics, gestures and literary style of physician. Isolating acts from behaviour facilitates theoretical definitions, though not realistic in practice.

Health practitioners must be trained for attaining ethical behaviour. Just like changing our life style, we can be trained to improve and develop our ethical attitude and behaviour. What is needed is to educate health practitioners to believe in ethical behaviour and be ready and determined for behavioral training. Models of virtuous behaviour to be practiced in the medical circle can be developed. Health practitioners may identify themselves with certain models of virtuous behaviour, developing a good professional moral identity.

Large image

Virtues such as modesty, contentedness, fidelity and hopefulness expected from the health practitioner must be perceived as universal criteria as the ethical principles, since principles are also the criteria for the preference of values, in a sense. Virtues are based on and directed by moral values, too. We can start educating ethical behaviour including virtuous behaviour patterns in our guidelines. For example, just as balancing the beneficence of treatment with its risk, cost etc. in ethical dilemma, a health practitioner must also be trained to balance several virtues and rights with one another: truth-telling/hopefulness; modesty/professional respectability; contentedness/right for being paid; fidelity/autonomy, etc.

Virtuous behaviour models can help greatly in determining priorities when an ethical dilemma occurs, as in situations where ethical principles conflict. The question of which consequences of a choice or an action would promote the best possible outcome will be influenced by the behaviour of the physician, helping the patient in decision making. When we consider the high difficulty of universalizing ethical principles and rules, a virtuous behaviour approach to medical ethics can be a way of amending the deficiencies of acting on principles and rules.

[31] Gülhan, Y.: Hekimlik Uygulamalarinda Yüksek Teknoloji Kullanimi ve Etik Sorunlar (Usage of High Technology in the Medical Practice and Ethical Problems). Yüksek Teknoloji Tibbi ve Hekim-Hasta İlişkisi (High Tech Medicine and The Physician-Patient Relationship. (Edit. Ö. Öncel, A. Namal, A. D. Erdemir, H. Ertin, E. Atici), İstanbul, 2006.

[32] Gülhan, Y.: Hekimlik Uygulamalarinda Yüksek Teknoloji Kullanimi ve Etik Sorunlar (Usage of High Technology in the Medical Practice and Ethical Problems). Yüksek Teknoloji Tibbi ve Hekim-Hasta İlişkisi (High Tech Medicine and The Physician-Patient Relationship. (Edit. Ö. Öncel, A. Namal, A. D. Erdemir, H. Ertin, E. Atici), İstanbul, 2006.

[33] Sari H., Özaydin Z.: İleri Görüntüleme Yöntemlerinin Gelişimi ve Tipta Kötü Kullanimi. (The Develolopment of Imaging Techniques and Their Misuse in Medicine). Yüksek Teknoloji Tibbi ve Hekim-Hasta İlişkisi (High Tech Medicine and The Physician-Patient Relationship. (Edit. Ö. Öncel, A. Namal, A. D. Erdemir, H. Ertin, E. Atici), İstanbul, 2006.

[34] Sari H., Özaydin Z.: İleri Görüntüleme Yöntemlerinin Gelişimi ve Tipta Kötü Kullanimi. (The Develolopment of Imaging Techniques and Their Misuse in Medicine). Yüksek Teknoloji Tibbi ve Hekim-Hasta İlişkisi (High Tech Medicine and The Physician-Patient Relationship. (Edit. Ö. Öncel, A. Namal, A. D. Erdemir, H. Ertin, E. Atici), İstanbul, 2006.

[35] Sari N.: "Hekim-Hasta İlişkilerinde Güven Bunalimi ve İhmal Edilen Erdemler Ahlakinin / Etiǧinin Önemi (Trust Problem in Doctor-Patient Relation and the Importance of the Disregarded Virtue Ethics)." Uluslararasi Katilimli 3. Ulusal Tip Etiǧi Kongresi Kitabi. 3^rd National Congress of Medical Etihcs With International Participation, Congress Proceedings Book (vol. 1), Bursa 2003, pp. 1-13.

[38] Beauchamp LT, Childress FJ: Principles of Biomedical Ethics. Oxford University Press, New York, 1994.

[39] Godlee Fiona: "Reclaiming the Placebo Effect", BMJ 2008; 336 (3 May) [doi: 10.1136/bmj. 39567.551181.47]; Placebo Effect (in The Skeptic's Dictionary), 1994-2004 by Robert T. Carroll; Shapiro Arthur K. and Elaine: The Powerful Placebo. From Ancient Priest to Modern Physician. John Hopkins University Press, 1997.

[41] Dinççaǧ A.: Can Suyu. İstanbul 2006; and Careers in Health Psychology, op. cit.; E Ernst and A Herxheimer, "The power of Placebo", BMJ, Dec 1996; 313: 1569 - 1570.(see BMJ : British Medical Journal); Placebo Effect, op. cit..; Shapiro Arthur K. and Elaine: The Powerful Placebo. From Ancient Priest to Modern Physician. John Hopkins University Press, 1997.

[42] Sari N.: "Hekim-Hasta İlişkilerinde Güven Bunalimi ve İhmal Edilen Erdemler Ahlakinin / Etiǧinin Önemi (Trust Problem in Doctor-Patient Relation and the Importance of the Disregarded Virtue Ethics)." Uluslararasi Katilimli 3. Ulusal Tip Etiǧi Kongresi Kitabi. 3^rd National Congress of Medical Etihcs With International Participation, Congress Proceedings Book (vol. 1), Bursa 2003, pp. 1-13.

Michael Kors Outlet

Burberry Outlet