Prof. Dr. Sohan Raj Tater
Introduction
With the tremendous advance in medical sciences in the recent centuries, man’s longevity has increased as well as health care sciences have taken new shape. For example, medical and pharmacologic advancements have made it possible to transplant organs successfully and thereby to save the lives of many persons who otherwise would die from irreversible end stage organ disease. The existence and distribution of organ transplantation procedures in developing countries, while almost always beneficial to those receiving them, raise many ethical concerns. Both the source and method of obtaining the organ to transplant are major ethical issues to consider, as well as the notion of distributive justice.
Similarly, what if, parents could have specified which gender child to have? Pre implantation genetic diagnosis technology, a testing process that costs thousands of dollars and is offered to couple using in vitro fertilization, allows today’s parents to choose whether to have a boy or girl.
Embryos also can be tested for hundreds of fatal congenital anomalies, childhood diseases and even some diseases that don’t occur until well into adulthood. Doctors can test to ensure that an embryo’s umbilical cord blood or bone marrow will be a match for a sibling who needs a donor. And just as physicians can use PGD (Pre - implantation genetic diagnosis) to help deaf parents avoid giving birth to a deaf child, so theoretically, doctors could use it to help them to avoid having a child who is like them. Physicians working in this field face a seemingly overwhelmingly array of demands from different stakeholders - parents, bioethicists, anti - abortion critics, disabled - right groups. As the field advances, individual doctors from now must determine where and how to draw the line between the craft of medicine and the specter of eugenics fears of so - called designer - babies. No U.S. law specifically restricts the uses for which doctors and patients can use embryo screening, though several European countries ban or severely restrict PGD.
All this and in many more branches of medical science, technological advancements have raised many questions of ethics which involve human existence. Though not going into very detail of the branch of medical sciences, ethical issues related to it will be dealt with as follows:-
(1) Some ethical issues peculiar to psychiatry
The practice of psychiatry is different from other medical specialties in two significant respects. First, one deals with certain groups of patients whose judgment may be impaired at times due to their mental illness or who are unable to refuse any medical help. In such situations, therapeutic intervention or even detention in a psychiatric facility against the patient’s wishes may become necessary. This raises various ethical and human rights issues that have been debated extensively without arriving at a consensus.
Second, in no other medical speciality do patients share with their doctor so many intimate details about their personal, emotional, social or even sexual life. As a result, a special kind of relationship, both positive and negative develops between the patient and psychiatrist. This particularly happens during prolonged treatment. This raises many ethical issues depending on how the psychiatrist handles it.
(2) Ethical Issues in personalized Medicine
As these issues are much more difficult, I have tried to limit myself to three different classes of issues:
- Protecting patient privacy.
- Protecting patient autonomy.
- Allowing access to personalized medicine.
Protecting patient privacy is one of the most important things that must be done before ordinary people will be willing to take advantages of individualized medical care, and just about everyone agrees that patients have a right to keep details about their health private from most people (even if not from, say, their insurance company or in some cases state or local governments). But how far does that right extend? Does it cover person’s genetic make - up? That is something that undeniably influences health. And a fair amount of information about what diseases a person has or is at risk can be extracted from genotype and gene expression information like what would be collected for personalized medicine services. How do you keep that information private and what uses are OK?
For example, if a person has this information collected for use in risk profiling or diagnosis, should then automatically commit them to allowing their data to be used for diagnosing and profiling others? While this can be done without identifiers, this information is, in effect personally identifying, so it can never be truly anonymous. Additionally, what about the privacy of other family members? Families share genetic information, and by knowing something about their risk, a person also learns about the relatives’ risks.
(3) Ethical Considerations in Rural Health
Within rural medicine, there are a number of ethical challenges that clinicians face. Many of the ethical challenges that develop in rural areas arise simply because of the large distances separating patients from medical resources. Other barriers to providing quality care in rural settings are due to changing demographics of these regions. Immigrant workers are being drawn to the numerous agricultural jobs found in these areas. This creates an environment where both cultural and linguistic differences cause difficulties when providing care.
(4) Informed Consent
Informed consent is another pertinent issue related to medical science and health care. Informed consent is no more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. In the communication process, the physician providing or performing the treatment and or procedure not a delegated representative should disclose and discuss with his patient:
(5) Ethical Issues Transfusion Medicine
The practice of transfusion medicine involves a number of ethical issues because blood comes from human beings and is a precious resource with a limited shelf life. In 1980, the International Society of Blood Transfusion endorsed its first formal code of ethics, which was adopted by the World Health Organization and the league of Red Crescent Societies. A revised code of ethics for donation and transfusion was endorsed in 2000. Blood donation as a gift donor confidentiality, donor notification and donor consent, consent for transfusion, the right to refuse blood transfusion the right to be informed if harmed and ethical principles for establishments are discussed in the international and Indian contexts.
Ethics is basically a set of moral values or a code of conduct. The role of ethics in developing clinical practice guidelines and recommendations for health care providers is to ensure values that may not be adequately incorporated into the law are given reasonable consideration. The framers and the users of guidelines must be aware of the potential ethical conflicts inherent in many medical decisions and the guidelines must reflect a thoughtful consideration and balancing of issues.
The practice of transfusion medicine involves a number of ethical issues because blood comes from human beings and is a precious resource with a limited shelf life. It involves a moral responsibility towards both donors and patients. Decision must be based on four principles- respect for individuals and their worth, protection of individual’s rights and well being, avoidance of exploitation and the Hippocratic principle of premium “first do no harm.”
(6) Ethical Issues in Maternal Fetal Medicine
The clinician who developed technologies for assisting human reproduction had a double motivation. Parentalistic concern to help women experiencing difficulties with reproduction was coupled with a utilitarian ethic that assumed that such innovations would result in more benefit than harm. Current techniques- donor insemination, the induction of ovulation, invitro - fertilization, antenatal screening for fetal abnormality, antenatal diagnosis (with the option of abortion), and fetal treatment in uterus were accepted because of their obvious benefits. They became routine practice long before adverse effects were quantified and before it became apparent that clinicians assumptions of the benefits to women and their children had been simplistic. In vitro fertilization has resulted in the birth of children disabled by the prematurity associated with multiple pregnancy; after normal conception, the notion of pregnancy as a natural and rewarding process has been undermined by pressures to accept antenatal diagnosis and fetal monitoring.
Discussion of ethical issues and legal regulations has followed rather than led the developments in maternal fetal medicine. The autonomy of the woman and the moral status of the fetus are central to this debate. Western secular ethics gives priority to personal autonomy, but in matters of sex and reproduction society persists in assigning more autonomy to men than to women. Man often coerces their partners into undesired sexual activity. Unintended pregnancy is disproportionately harmful to women yet their default behavior is expected to be acceptance both of the pregnancy and the obligation to care for the child. Full autonomy for women means equality in sexual behavior and complete personal authority over the fetus.
(7) Organ transplantation
Organ transplantation is the moving of a organ from one body to another, or from a donor side on the patient’s own body for the purpose of replacing the recipient’s damaged or absent organ. The emerging field of Regenerative medicine is allowing scientists and engineers to create organs to be regrown from the patient’s own cells (stem cells, or cells extracted from the failing organs). Organs and/or tissues that are transplanted within the same person’s body are called auto grafts. Transplants that are performed between two subjects of the same species are called allografts. Allografts can either be from a living or a cadaveric source.
Organs that can be transplanted are the heart, kidneys, liver, lungs, pancreas, intestine and thymus. Tissues include bones, tendons (both referred to as musculoskeletal grafts), cornea, skin, heart valves and veins. Worldwide the kidneys are the most commonly transplanted organs, while musculoskeletal transplants outnumber them by more than tenfold.
Organ donors may be living, or brain dead. Tissue may be recovered from donors who are cardiac dead upto 24 hours past the cessation of heartbeat. Unlike organs, most tissue (with the exception of corneas) can be preserved and stored for upto five years, meaning they can be “banked”. Transplantation raises a number of bioethical issues, including the definition of death when and how consent should be given for an organ to be transplanted and payment for organs for transplantation. Other ethical issues include transplantation tourism and more broadly the socio - economic context in which organs harvesting or transplantation may occur. A particular problem is organ trafficking.
(8) Ethics and Cloning
Discussion of ethics at the UN level, often brings to mind the notion of deep, profound, commonly held principles to guide human actions in accordance with some higher purpose. It may emanate from belief of a religious nature, or from concern for human, animal, environmental welfare. Definition of the boundaries and scope of any ethical principle and the measures necessary to adhere to it faithful is however not an exact science, especially when recognizing that there are several thousand different ethnic groups in the world and their cultural ethos vary. While general ethical principles such as the principle of doing no harm in medical practice are widely respected the question of what amounts to harm is less easily defined. The debate on reproductive and research cloning has demonstrated the fluidity and diversity of ethical beliefs in this area. It is interesting for instance to note that while there is an almost complete consensus amongst countries with regard to the need to ban reproductive cloning, a number of academics and some religious groups do not necessarily believe that such cloning is unethical.
References
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- Truog RD, Cochrane TI: ‘The Truth about “Donation after Cardiac Death”, Journal of Clinical Ethics 2006, 17(2): 133 - 136
- Childress, JF: ‘Practical Reasoning in Bioethics’, edited by Childress, JF Bloomington, Indiana University Press, 1997: 385
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- Centre for Genetics & Society (2003), Preimplantation Genetic Diagnosis (PGD) and Screening, http://www.genetics and society.org/technologies/other/pgd.html (accessed 23rd Jan 2007)
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