Virtues such as modesty, contentedness, fidelity and hopefulness expected from a physician must be perceived as general criteria of ethical standards, since principles are also the criteria for the preference of values, in a sense. Virtues are based on and directed by moral values, too. Ottoman medical ethics was based on the trust of people to physicians believed to be virtuous. Moral behaviour expected to be observed by physicians depended on virtues turned into regulations as guides for action. Several examples dealing with the subject are quoted from Ottoman medical manuscripts, and are discussed with respect to contemporary medical ethics in this article.
Nil Sari*
Table of contents
2. Virtues Ignored as a Result of Changing Values
a. Modesty
b. Contentedness
c. Fidelity
d. Hopefulness
3. Discussion on Contemporary Medical Ethics
a. Modesty
b. Contentedness
c. Fidelity
d. Hopefulness
5. Bibliography
a. Turkish Medical Manuscripts
b. Other Sources
***
Ottoman medical ethics was based on the trust of people to medical practitioner believed to be virtuous. Moral behavior expected to be observed by medical practitioner depended on virtues turned into rules as guides for action [1]. What kind of virtues might be highly effective for training one to be a virtuous physician? The four virtues, modesty, contendedness, hopefulness and fidelity were specifically noted by Ottoman physician writers as inevitable for being qualified as a virtuous physician. Several examples dealing with the subject are quoted from Ottoman medical manuscripts, and discussed with respect to contemporary medical ethics in this essay.
2. Virtues Ignored as a Result of Changing Values
Experience is as important as experimentation in gaining knowledge. Social sciences specially owe much to historical experience, both individual and social. Ignoring past experience means failure in utilizing valuable knowledge accumulated by man in history. Utilizing past experience is also important for studies on medical ethics. Patient-medical practitioner interrelation and its mutual moral elements in medical history have developed as a result of interaction in the course of time. Today great change has taken place in the field of medical ethics due to the fast development of medical knowledge and technology. Some values lost importance, while others came to be favored and new values have developed, which regressed some virtues, while fostered others [2].
Ottoman Turkish physician compilers described and suggested “what ought to be done or not”, that is, proper and improper behavior in medical practice. When ethical advices (vasiyyet) in Ottoman medical manuscripts are studied, one can find a principle included in these advises guiding health practitioners to virtuous behavior. Ottoman Turkish expectations for medical morality were concentrated on the virtuous behavior of a practitioner [3]. In this study, the virtues modesty, contentedness, fidelity and hopefulness, considered to be a necessity in Ottoman Turkish patient-practitioner relationship, are quoted as ignored today.
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Figure 1: An illustration of a medical practitioner and a patient. (Source: Millet Kutuphanesi, Ali Emiri, nr. 79.). |
During the last quarter of the 20th century great progress has been achieved in the field of medical ethics studies, and great effort has been paid in developing ethical principles and rules to lead decision making in the medical field. Contemporary medical ethics concentrated on solving moral dilemmas in accordance with ethical principles and rules [4]. Actions came to be prescribed for certain cases, described within the frame of specific groups of ethical conflicts. The practitioner having justified his/her action on the basis of principles and rules, a probable risk of omitting “virtuous behavior” needed for ethical patient-practitioner relationship, arose. Prefering principles and rules for guidance in developing ethical behavior for medical practitioner, the quality of practice that is “how to act” has come to be ignored. Yet, physician’s behavior is perceived as a physical and literal language of the practitioner by the patient, not as ethical principles suitable for the case. Ethical principles and rules isolated from virtuous behavior patterns will speed up the regress of the values that virtues are derived from. There are some declined moral values which led to virtuous behavior in the past that played highly important role in patient-practitioner relationship. However, they are no less important today, as it may harm the patient when they are ignored. Some of the ignored virtues fostered by some values are indispensable in acting within the frame of ethical principles properly.
a. Modesty
A Physician has always been authorized and effective, having means and tools which might be useful or harmful, such as drugs and surgical instruments. It is the belief in the role of Godly power on the acts of man, though, that drove Ottoman Turkish physicians away from considering himself esteemed. Modesty was a highly valued virtue, because the duty of physician was conceived as being a caliph of the Creator, whose will was believed to realize the treatment. The Ottoman Turkish physician was expected to perceive himself as a caliph of God in the act of healing and not conceive himself as the real healer. Although the cause of disease was considered to be the imbalance in humours and it was the nature/temperament of the patient regarded as important in treatment, the belief that both illness and healing are God’s will, sublimated the value of modesty. The belief that a physician was only a means and the real healer is God, the Creator, and without his generosity no cure could be achieved, fostered modesty as a valuable virtue. Many Ottoman Turkish medical writers adviced physicians not to be proud and not to over trust themselves. Physicians were perceived to be impotent like everybody, as physicians, whether able or unable, all passed away. While a physician was sublimated as a caliph of the Creator, being reminded that the real healer is Allah – God the Creator himself, pride was disapproved. Authorative behavior was not suitable for medical practitioners [5].
Several examples of the perspective, “physician assuming to have cured patient must not boast“, are found in Ottoman medical literature. Within the same perspective, Nidâî, a physician of the 16th century, advices his colleagues as described in the following couplet:
“Consider what awarded to you by God
Always keep (your) inefficiency in mind.”
Nidâî describes in verse the failure of the physician assuming to have cured a patient:
“Don’t say I have cured a patient
This assumption is a real lie
Both suffering and remedy is emerged by the Creator
He does whatever he wishes; it is his, the Creator’s will” [6].
According to Emir Çelebi, another physician of the 16th century, “Physician conceiving himself to be humble, should not relate the effects of treatment with his knowledge and skill. He should not conceive himself to be able; should not be proud of his art and practice; whatever may take place he must believe that God’s favor will always be helpful. He must not behave proudly at the side of patient; he must even try to please and console patient.” Emir Çelebi believes that a physician should also be dignified [7].
The meaning of modesty reflected other aspects of a physician’s behavior, as well. Modesty was noted useful with respect to the development of medicine, as an attitude of a physician questioning himself/herself, too. For example, Abbas Vesim, a physician of the 18th century, deals with modesty with respect to a physician’s consultation to his colleagues, valued as a favorable attitude in medical practice:
“Physician should travel from one country to another and should get in touch with those who were informed enough to discuss and present information about drugs and medical compositions; and should inquire and learn how drugs effect the body; should not pride with his ability; should not miss even a single word to be learned. For, facts and real knowledge are ideas and affirmations spoken by virtuous man” [8].
b. Contentedness
Justice and the right of equality in medical treatment was an important ethical norm and the value of justice fostered contentedness as a preeminent virtue expected from medical practitioners [9]. The assumption that “an ambitious physician eager to make money and own goods may drive him/her away from observing justice and truthfulness, consequently patients would not only be harmed, but trust in physician and medicine would be lost”, is recorded in Ottoman Turkish medical manuscripts [10].
The developing function of the virtue of compassion by observing the virtue of contentedness can be noted in medical manuscripts, too. Perceiving a physician as compassionate meant that people trusted him as well. Şerafeddin Sabuncuoǧlu, a surgeon of the 15th century, advices not to treat illnesses difficult to operate, in aiming to gain money:
“Do not try to operate a patient hopeless to be healed. While you are regarded as virtuous, beware being perceived as vulgar, being fond of gaining money. Act so that your mercifulness will overweigh your respectability and ambition” [11].
Nidaî describes his evaluation of the expectation from a physician to “contend with the reward paid to him” in verse:
“Don’t be fond of money, be satisfied with what you have a right to
Do not be fond of this temporary existence
Be careful to observe your destiny
Behave truthfully, so that you will not be distressed” [12].
Abbas Vesim relates that a physician must be contended with what he/she has a right to get, that is, the sum of what is spent in treatment, the drugs used and the fee mentioned. Abbas Vesim advices physicians to be “contented, not to be ambitious and zealous for making money.” The following words of Abbas Vesim describe clearly the real aim and function of medical practice [13].
“The meaning of physicians being unambitious means the ambition for obtaining estates and gaining money, not willingness to cure the patient and the poor. Because, ambition for property and money lowers respect for the physician and trust for his treatment” [14].
c. Fidelity
Fidelity also being a highly valued virtue, a physician who started treating a patient was expected to continue his treatment so long as he can. A physician was expected to continue his treatment in spite of patient’s improper behaviour disturbing him. It was an ethical rule for physician not to seize treatment, abandoning a patient untimely [15]. This rule was imposed as a responsibility to the physician. Abbas Vesim describes the rules of fidelity as:
“Physician must bare the misbehaviour of his patients. Physician should not retaliate his patient, even if patient behaved impolitely. Physician should ignore patient’s rude acts. Physician should not react to patient’s improper behaviour, on the contrary he should act within the framework of medicine and his skill, that is he should not incline to stop treatment, not feel offended, but try to continue treatment.
Patience of an efficient physician is a way of treatment
Patient’s function is always to cause pain” [16].
In return, the patient was expected to be responsible for experiencing the prescribed medicine and way of treatment. The patient was expected to act in accordance with the physician’s advices for treatment, both for the patient’s and physician’s beneficence. Disregarding the physician’s advices might be harmful both for physician and patient. This mutual responsibility is described by Siyahi, a physician of the 16th century:
“Some patients partly practice physician’s suggestions, consequently may not be cured, for which physician is blamed. Do not commit a sin by meddling with physician’s work” [17].
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Figure 2: An illustration of a medical practitioner during treatment of a patient. (Source: Millet Kutuphanesi, Ali Emiri, nr. 79.). |
Abbas Vesim advices physicians not to approach a patient disregarding a physician’s advices, as did Siyahi. In such a situation, observance of the fidelity rule by the physician can be disregarded. In case a patient neglects to observe the physician’s advices, the rule of fidelity can be ignored by the physician. Physician’s right to leave a patient who doesn’t observe his/her advices is defended and justified by Abbas Vesim, because, in such a case the patient may be harmed, consequently trust in the physician may be lost. If a patient hesitates to take the medicine adviced by the physician, or refuses to observe the physician’s advice or speaks with the physician so as to get physician misunderstand him, the physician must end his relation with the patient. For, this is sure to cause a mistake. This approach is commented by Abbas Vesim. He writes that, if a patient distorts the physician’s advice of treatment, being effected by advices of those inefficient in medicine and changes the treatment prescribed by his/her physician by the words of people who come and go; or not trusting the physician’s advices based on the rules of medicine and acting on his own will, this act being against the law of medicine, mistake is inevitable. This fault is sure to be imposed upon the physician who treated the patient. For this reason, avoiding the treatment of such a patient can be justified. Otherwise, a physician’s practice and advice will be comprehended/conceived as if he had not performed what he really did, and as if he had performed what he really didn’t; and what he says will be conceived in the same way. In short, the patient was expected to cooperate with his/her physician and in return physician was expected not to desert his/her patient. Fidelity to a patient is in a sense derived from the importance paid to the value of hopefulness in treating a patient [18].
d. Hopefulness
Physicians were expected to treat patients honestly, but not to express outrightly neither the patient’s cure certainly, nor the hopelessness of curing or of nearing death. Cases in the past were used as analogies. As it was impossible to know of the patient’s destiny certainly, the duty of the physician was to try to treat the patient until death. Ibn Shareef, a physician of the 15th century, utilizing his own experience, justifies the importance of being wary in disclosing the fatality of patient to relatives:
“If a physician is asked, ‘Is the patient going to die and when?’, the physician must not inform the patient’s relatives of his/her death; the physician must not say that the patient is going to die today or tomorrow. Not disclosing is beneficial, for we have come across many physicians who assumed that the patients treated and healed by us could not be cured and were going to die undoubtedly, they were not destined to die yet, so they recovered. We felt the pulses of many of them, it was a sign of death completely and prepared their shroud and dug their grave. However, they did not die, they recovered and got up. So, it is proper not to inform relatives and friends of a patient’s death, even if the physician preconceives it. God alone knows the truth. Whatever the illness may be, the patient must be nicely treated. Perform whatever they are willing, and try to protect patients against disappointment. Patients must be kept away from sadness and anxiety whatever your way of treatment may be. Please some by motivating and by means of hopefulness and others by awarding presents. Rejoice others by having their close friends and kind hearted people visit them, so, patients will feel happy and their morale will be improved” [19].
The physician was advised not to speak to the patient with certainty about the prognosis of his/her illness. Haci Paşa, a physician of the 15th century, puts forth the rule: “It is not proper to express outrightly that the patient is certainly going to die or be healed” [20].
Abbas Vesim puts forth similar rules: “A physician should not say that a patient is sure to go on living. Beware noting a certain period about the duration of patient’s illness” [21].
It was regarded an ethical rule for a physician to go on with treatment even with the hopeless patient, that is, never to give up treatment. Even if recorded in medical books that no medicine will cure an illness, it was believed that one should not seize hoping of God’s mercy. A patient or a wounded could be cured miraculously, though not expected. Patients should be informed and warned of the harmful consequences of ending treatment. Some physician writers pushed this attitude even further, defending the idea that a patient must not be informed of the disappointing prognosis, thus hopefulness for treatment and the will of patient for going on to live should not be ceased. Not to grow hopeless of being cured, going on to be hopeful of the Creator’s mercy and the body’s potentiality of getting healed itself was highly valued [22]. Ahmed b. Bali reflects this attitude by advising physicians to “encourage patient raising his/her morale by telling him that he/she is going to recover soon”; “Do away with patient’s troubles, supporting him/her willingly” [23].
The Ottoman Turkish physician practicing Hippocratic, Galenic and Islamic medicine regarded himself as an assistant of nature and its power to heal. This was the main approach to the different prognosis in observing patients treated in the same diagnosis and indication.
3. Discussion on Contemporary Medical Ethics
Contemporary medicine has developed fast along with the development in technology and physician utilizing technology shared its miraculous products. Today, the human body and its various functions are observed and noted by means of developed diagnostic methods, technological instruments and laboratory tests. As physicians got to know more and more about the secrets of human biology and depend highly on technology, he/she intervened increasingly to the human body.
Expectations from the scientific development of medicine influenced cultural and social views, too. Consequently, traditional ideas of health and life transformed, more or less, all over the world. However, as societies’ moral values differ from one another, proper argument of ethical issues in the developing medical field necessitates complementary knowledge, such as patients’ culture. Embodied in a particular society, each patient and family shapes and thus reflects the way he/she understands moral problems and what she/he takes to be feasible responses. Traditions and historical backgrounds of societies have to be valued to reach a better understanding of their contemporary morality.
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Figure 3: View from the exhibition in Edirne History of Medicine Museum. (Source). |
As quoted shortly above, Turkish medical ethics in history relied on a virtuous behaviour expected from a health practitioner. Health practitioners were required to have a virtuous character for employment in Ottoman hospitals [24]. This may be the reason why today “real informed consent from patient” is far from being practiced in Turkey, patients relying on a physician known to be virtuous and efficient. A virtuous physician is expected to protect the patient from being harmed from a medical intervention and act fairly [25]. However, paradoxically, written consent from patient before treatment has always been a requisite of law, both in Turkish history and today [26]. This subject is mainly a discussion of autonomy and paternalism.
In this article, however, I would like to discuss another point of view. Today we contemplate highly on the transformations in our moral views resulting from new medical technologies and methods of treatment and their consequences. However, we do not evaluate historical material by utilizing the hundreds of year’s experience of man as a field for learning. Study of ethics in the history of medicine has the potentiality of guiding us to moral attitudes and behaviours to be benefited from. I would like to start the discussion on the importance of past experiences, accumulated and developed through an evaluation of many case consequences over a long period of time.
Although the above mentioned Ottoman Turkish moral concepts and values are those of a period when scientific medicine was not developed and theology played a great part in the attitudes and behaviours of medical practitioners, they are reflections of ethical behaviour expected to be practiced in medicine, based on hundreds of years of experience. The above mentioned values, virtues and rules of ethics depend on empirical information on morality, collected in a long period of history, which includes valuable information and subjects to be contemplated and discussed.
a. Modesty
It is known from antique times to today that a physician has opportunity of being authoritative. In the Ottoman period, the belief that the Creator is the real healer prevented a physician’s authoritative attitude. Ottoman physicians, being astonished by the medical facts unveiling the amazing secrets of nature, were inclined to react modestly [27]. Modesty as a virtue had the potentiality of preventing an Ottoman health practitioner from acting authoritatively. (Not telling the truth about a patient’s nearing death was not regarded as an authoritative act, but a virtuous behaviour) [28].
Innovations by intellectuals provided higher ability for the contemporary physician. This increase of ability provided opportunity for some physicians to conceive themselves as an authority on patients. Consequences of medical technology created an amazing feeling of achievement and this caused a potentiality of overflowing self-confidence in several medical practitioners. Medical technology provides great ability, but without it a contemporary physician could have been no more successful then the physician in history. Modern physician’s efficiency would decline greatly without contemporary technology and pharmaceutical products. Without the tools contemporary physicians are bound to be in a worse position than the physician practicing medicine before the era of modern technology. This is reflected today in the reactions of newly graduated Turkish physicians appointed for compulsory service, who claim that they could not practice in rural districts with insufficient technological equipment. Modern physicians are not trained enough to utilize their five senses in physical examination for diagnosis as physicians in history; and they are not good observers as those physicians of the pre-technology period. Contemporary physicians are not willing enough to observe and examine patients, being dependent on the facts reached through laboratory findings and visual techniques [29]. Modern medical professionals are also not trained to compose/prepare drugs themselves as in history, and moreover are dependent on drug firms that sometimes provide various rewards to them. All of these reasons, I think, are enough to have the contemporary medical practitioner be modest. Is the modern practitioner aware of this?
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Figure 4: Süleymaniye Medical Madrasa in Istanbul. See Salim Ayduz, Suleymaniye Medical Madrasa. |
I would like to discuss modesty with respect to patient autonomy. The basic aim of the virtuous Ottoman Turkish physician ought to have been a patient’s beneficence. However, a physician’s “modest” behaviour has the potentiality of providing opportunity for a patient’s autonomous decision making, too. In order to be able to get an autonomous decision from a patient, a physician ought to provide an opportunity, behaving modest, so as not to disappoint patient. A real patient consent is a consent that would not be regretted, with a high probability, in the future. How can a patient trust a physician who does not listen to him/her carefully? I would like to relate a case I observed recently. I took an 85 years old male patient to an ophthalmologist for laser treatment. The patient told the physician that his primary physician had noted that “laser should be applied only to his right eye and the left eye should not be treated”. The ophthalmologist retorted nervously, “I am not a technician, and I am not in need of suggestion and I won’t practice it because of anybody’s suggestion.” I suggested to him, “Hear your patients speak and inform you of their trouble and let them ask the questions they want.” In fact I intended to tell him to be modest and let his patients speak. Confidence in the efficiency of a physician may not suffice for a patient to inform a physician satisfactorily, or ask questions to be informed by physician sufficiently. Another example of my observation is of a female patient transferred from a hospital of social insurance to the ophthalmology clinic of a university hospital. She was a patient from the rural area and had to be operated urgently. A young female doctor turned furiously to the nurse thereby and asked why she had been transferred there and what she wanted. The patient herself standing by the physician tried to express her problem; but the physician ordered her to stop talking, saying, “Nobody asked you to speak”.
I have observed that authoritative behaviour is risky in preventing a patient from informing his/her physician adequately. An authoritative physician may create oppression by the way he/she speaks and behaves. Oppressed patients will have or feel they have little control over their behaviour. A patient’s attitude will be determined by the physician’s behaviour –modest or arrogant, tolerant or intolerant. Patient tends to behave considering the consequences of his/her performance, that is, whether the physician would approve it or not. Patient’s interpretation about what a physician thinks of a certain attitude is influenced by the physician’s behaviour perceived by the patient. Presupposing what the physician expects, a patient will consider the implications of his/her attitude, before deciding to act. In interrelation with an authorative physician, a patient may be confronted with psychological inhibition and hence may conceal personal problems, as well as failing to ask questions, fearing from getting a physician angry, or being conceived by a physician as ignorant or stupid. The physician imposing that he/she is the one who knows and the patient is ignorant, so the patient will not understand the information provided by him/her may impede the behaviour of patient [30]. On the contrary, if the patient feels that the outcome of his/her behaviour, such as asking questions is to be approved, the patient will develop an attitude in order to realize it, and the way to the needed mutual cooperation, as well as the realization of patient autonomy in medical decision making will be freed. A patient who can speak and act freely will provide the physician with valuable information important for diagnosis and treatment. A physician observing patient autonomy can be perceived by the patient only from a physician’s behaviours, encouraging the patient to behave autonomously. The modest practitioner behaving sincerely can motivate a patient to be willing to give information about his/her health problems, without hesitation. Behaving authoratively is an unhealthy behaviour for a physician. The physician needs not to fear loosing respectability from a patient. So long as the physician respects the patient, his own respectability will rise.
Persuasion of a patient for autonomous behaviour, such as obtaining consent for treatment, can be provided by the behaviour of the physician. Consider a too busy physician in a hurry for a patient’s consent. Neither ethical rule nor regulation can secure a real informed consent, for it is dependent on the patient-physician relationship formed by the virtuous behaviour of the physician, modest and reliable as well. In order to be able to reach autonomous decisions, the patient could be able to argue related issues with his/her physician. Modesty may facilitate the physician to perceive the patient’s moral values, too. A physician’s modest behaviour may also help solving ethical conflicts in medical practice.
b. Contentedness
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.
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Figure 5: Early anatomical scene from the treatise of surgery by Şerefeddin Sabuncuoǧlu. (Source). © 2004 American Association of Neurological Surgeons. |
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.
c. Fidelity
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.
d. Hopefulness
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 19th 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].
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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.
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Figure 7: Example of the application of the cautery for the treatment of wounds and bleeding in Şerefeddin Sabuncuoǧlu’s book. (Source). © 2004 American Association of Neurological Surgeons. |
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.
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Figure 8: Illustration showing the use of a rack to straighten the spine in the manuscript of Şerefeddin Sabuncuoǧlu. (Source). © 2004 American Association of Neurological Surgeons. |
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.
a. Turkish Medical Manuscripts
b. Other Sources
End Notes
[1] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[2] Sari N.: “Tip Deontolojisi”. Dünya’da ve Türkiye’de 1850 Yilindan Sonra Tip Dallarindaki İlerlemelerin Tarihi (Ed. E. K. Unat). Cerrahpaşa Tip Fak. Vakfi Yay.: 4, İst. 1988, pp. 403-423.
[3] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[4] Beauchamp LT, Childress FJ: Principles of Biomedical Ethics. Oxford University Press, New York, 1994.
[5] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[6] Nidaî: Menâfiü’n Nâs. Cerrahpaşa Medical School Medical History Museum, no. 84, 112, 318.
[7] Emir Çelebi: Enmûzec-i Tib. Süleymaniye Library, Fatih section, no. 3530.
[8] Abbas Vesim: Düstûrü’l Vesim. Ragip Paşa Library, no. 947.
[9] Sari, N.: “Osmanli Darüşşifalarina Tayin Edilecek Görevlilerde Aranan Nitelikler. (Qualifications and Morality Requisite for the Personnel to be employed in the Ottoman Hospitals)” Yeni Tip Tarihi Araştirmalari 1 (Editör Nil Sari), İstanbul, 1995, pp. 11-54; Sari, N.: “Osmanli Hekimliǧi ve Tip Bilimi.” Yeni Tip Tarihi Araştirmalari-The New History of Medicine Studies 5, (Editör Nil Sari), İstanbul 1999, pp. 11-68.
[10] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[11] Şerefeddin Sabuncuoǧlu: Cerrahiyetü’l Hâniye. Millet Library, no. 79.
[12] Nidaî: Menâfiü’n Nâs. Cerrahpaşa Medical School Medical History Museum, no. 84, 112, 318.
[13] Abbas Vesim: Düstûrü’l Vesim. Ragip Paşa Library, no. 947.
[14] Abbas Vesim: Düstûrü’l Vesim. Ragip Paşa Library, no. 947.
[15] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[16] Abbas Vesim: Düstûrü’l Vesim. Ragip Paşa Library, no. 947.
[17] Siyâhî Lârendevî: Mecma’-i Tibb-i Siyâhî. Cerrahpaşa Medical School Medical History Museum, no. 478.
[18] Abbas Vesim: Düstûrü’l Vesim. Ragip Paşa Library, no. 947.
[19] İbn-i Şerif: Yâdigâr. İstanbul University Library, no. 7067.
[20] Haci Paşa: Kitabü’l Teshîl fi’t Tib. Süleymaniye Library, Fatih Section, no. 3544.
[21] Abbas Vesim: Düstûrü’l Vesim. Ragip Paşa Library, no. 947.
[22] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[23] Ahmed bin Balî Fakih: Tercüme-i Hâvi fi ilmü’t tib. Üniversite Library, no. 190.
[24] Sari, N.: “Osmanli Darüşşifalarina Tayin Edilecek Görevlilerde Aranan Nitelikler. (Qualifications and Morality Requisite for the Personnel to be Employed in the Ottoman Hospitals)” Yeni Tip Tarihi Araştirmalari 1 (Editör Nil Sari), İstanbul, 1995, pp. 11-54.
[25] Sari, N.: “Osmanli Hekimliǧi ve Tip Bilimi.” Yeni Tip Tarihi Araştirmalari-The New History of Medicine Studies 5, (Editör Nil Sari), İstanbul 1999, pp. 11-68; Sari N.: “Ottoman Medical Practice and the Medical Science.” Selected Papers on Turkish Medical History. (Ed. A. D. Erdemir), Ist International Congress on the Turkish History of Medicine. İstanbul 2008, pp. 5-89.
[26] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[27] Sari, N.: “Osmanli Hekimliǧi ve Tip Bilimi.” Yeni Tip Tarihi Araştirmalari-The New History of Medicine Studies 5, (Editör Nil Sari), İstanbul 1999, p. 11-68; Sari N.: “Ottoman Medical Practice and the Medical Science.” Selected Papers on Turkish Medical History. (Ed. A. D. Erdemir), Ist International Congress on the Turkish History of Medicine. İstanbul 2008, pp. 5-89.
[28] Akdeniz (Sari) N.: Osmanlilarda Hekim ve Hekimlik Ahlaki (Ottoman Physician and Medical Ethics), İstanbul, 1977.
[29] 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.
[30] Ajzen, I.: Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 1991, pp. 179-211; see online Theory of Reasoned Action / Theory of Planned Behavior and Theory of Planned Behavior (Azjen).
[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. 3rd National Congress of Medical Etihcs With International Participation, Congress Proceedings Book (vol. 1), Bursa 2003, pp. 1-13.
[36] See online: Careers in Health Psychology.
[37] See online ibidem: Careers in Health Psychology.
[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.
[40] Dinççaǧ A.: Can Suyu. İstanbul 2006.
[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. 3rd National Congress of Medical Etihcs With International Participation, Congress Proceedings Book (vol. 1), Bursa 2003, pp. 1-13.
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*Professor Nil Sari, Ph. D., from Istanbul University Cerrahpasa Medicine Faculty, Department of Deontology and History of Medicine, is a world expert scholar in the history of medicine, Islamic medicine and culture and Ottoman science and medicine. Professor Sari is also a key FSTC associate. Presently Professor Nil Sari is Head of the Medical Ethics and History Department, Istanbul University, Cerrahpaşa Medical School. This essay was presented during the International Bioethics Meeting on 14-18 December, 2005, in Urfa, Turkey.
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