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Medical ethics

"TO CURE sometimes, to relieve often and to comfort always" is quoted as the duty of physicians. But a cursory survey of patients often conveys a different picture. Many physicians are often perceived as rude and patronising, which then begets the question `why.'

The answer to this question is not simple. The genesis of this behaviour among many doctors lies in their training in medical colleges, rather the `absence' of education about medical ethics. The subject of medical ethics is given prime importance in all western medical schools, but is surprisingly shelved away by the Indian medical curriculum. It is included under Forensic Medicine, which essentially deals with the legal aspects of medicine. I still fail to see the connection, as FM is essentially more about corpses, rather than living beings! In any case, medical ethics is a subject, which ought to be taught by clinicians, which is seldom done in most medical colleges.

To the common man (who is incidentally the patient), medical ethics is a topic, which deals with the following: duty of a physician, his limitations, the rights of patients and physician-patient issues like confidentiality, etc. At the outset, it might all sound like a lot of common sense, but then common sense isn't that common a commodity either!

Four principles

The cornerstones of Medical ethics are the four principles — autonomy, beneficence, justice and non-maleficence. Autonomy essentially means that the physician is merely an advisor, and not a dictator. The physician can opine and suggest, not `force' any form of therapy. The physician is obligated to help patients attain their own interests and goals as determined by the patient, not the physician. The time-honoured principle of `do no harm, prevent harm and remove harm' should guide doctors while suggesting a treatment plan. Every patient deserves and must be provided optimal care as warranted by his underlying medical condition. In certain conditions, physicians are not required to provide treatment that has no patho-physiologic rationale. Such futile interventions that cannot achieve the goals of the patient need not be performed. Every physician should know the above principles. Patients should also know their rights, and should question doctors about their options.

Coming back to the issue of medical education regarding ethics, it is lamentable that it is not taught in classrooms. Most textbooks in medicine begin with a section on ethics and physician-patient relationships, but they are seldom read and never tested in examinations. Even clinical medicine examinations do not assess a medical student's communication skills with the patient. A medical student only learns how to diagnose diseases, but never learns `what to tell the patient.' When these important issues are trivialised during training, the results are but obvious. The issue of child abuse and spousal abuse are also not given sufficient attention and as a result of this neglect, physicians in practice are clueless about their options when dealing with such cases. Many physicians are unaware of social support services for such cases. Guidelines, if available, are useless unless the practitioners put them in action.

A patient is foremost a human, who has a physical condition which has necessitated medical care. The physician is merely a qualified advisor, whose duty is to make an honest assessment of the patient's condition, and suggest a treatment plan based on the patient's needs and values. The patient is the one who endures the disease; he takes the hits on the field. The physician is like a coach, he can only encourage and support the patient, he cannot bear his pain. Kind words, compassion and empathy have an equal hand in cure as much as medical competence does. Medicine is primarily a relationship and medical ethics is a set of principles that guides this sacred relationship.

Ethics should be taught to medical students actively and must not be relegated to a ritual recital of the Hippocratic oath. Going further, CME (continuing medical education) programmes must also focus on such issues, as a failure of adherence to medical ethics erodes the very roots of the physician-patient relationship.

RAJESH VENKATARAMAN

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