Introduction
Cultural factors
have influenced the definition of health and mental health. In ancient Greece
Plato suggested, those who do not accept beliefs in Gods as laid down by the
State be designated as deviant and mad and be isolated. He believed, a healthy
State makes the ‘psyches’ of its citizens healthy. Bhagavd Gita created by
Vyasa had a profound influence in Indian thinking since centuries. Gita is an
ancient document on the affairs of the minds of men, their temperaments,
behavior, frailties and strengths which guided ancient Indian physicians in
their ethical practice. Ethics have also formed an important part of medical
practice since the time of Hippocrates. Though the current concept of medical
ethics has come from the Western medicine and is also applied in the modern
medicine in other countries, role of local cultural influences can’t be
ignored. The cultural factors play an important role in acceptability of
medical treatment, and have also implications in further development, research,
and growth of medical science. In recent years, a lot of transnational
collaborative research is taking place in poorer countries of South Asia. This
has raised concerns about the protection of rights of the human subjects in
biomedical research [1]. Hence it is important to review the ethical guidelines
prevalent in South Asian countries in medical practice and understand the
cultural influences, so as to protect the rights and prevent exploitation of
the vulnerable patients of the poor countries. This paper discusses the
influences of culture on medical ethics mainly from South Asian perspective.
What are ethics and their relevance to medicine?
Ethics have an important role to
play in medical practice, where a doctor while treating a patient by different
means, may have to perform different diagnostic or therapeutic procedures. Ethics
basically refer to the principles of conduct that govern the
behaviour of medical professionals, which includes moral duties, obligations
and responsibilities towards the patients. The medical ethics differ
from the clinical practice guidelines in form that they provide only some
general guidance for the doctor in terms of medical practice and research,
broadly referring to respect for autonomy,
beneficence, non-malfeasance and justice [2].The guidance is generally
in form of what is good vs what is bad or what is right vs
what is wrong.
Respecting people’s autonomy means taking a
person’s consent before anything is done to him or her, after providing
adequate information and ensuring that a person has understood the process.
Autonomy also includes medical confidentiality, as the doctors have a general
obligation to keep other people’s secrets confidential, disclosed during the
professional interactions. This is important
because, without such assurance, patients are less likely to divulge the often
highly private and sensitive information that is needed for their optimal care.
Principles of beneficence and non-malfeasance refer to the traditional
Hippocratic moral obligation of medicine to provide net medical benefit to
patients with minimal harm. The medical professionals need to ensure that they
provide the benefits they profess to be able to provide. The obligation to
provide net benefit to patients also requires the professional to be clear
about the risks and probable benefits associated with a particular treatment or
procedure, when assessments of the expected benefits and possible harms are
made. A low probability of great harm such as death or severe disability is of
less moral importance in the context of non-malfeasance than is a high
probability of such harm. Similarly, a high probability of great benefit such
as cure of a life threatening disease is of more moral importance in the
context of beneficence than is a low probability of such benefit. Justice, the
fourth ethical principle, refers to the moral obligation to act on the basis of
fair adjudication between competing claims. The obligations of justice include
fair distribution of scarce resources, respect for people's rights and respect
for morally acceptable laws [2].
Historical perspective
History of medical
ethics in the modern medicine can be traced back to the time of Hippocrates,
the famous Greek physician of 5th century BC, on whose teachings the
Hippocrates Oath is based. It states “…Except for the prudent correction
of an imminent danger, I will neither treat any patient nor carry out any
research on any human being without the valid informed consent of the subject
or the appropriate legal protector thereof, understanding that research must
have as its purpose the furtherance of the health of that individual. Into
whatever patient setting I enter, I will go for the benefit of the sick and
will abstain from every voluntary act of mischief or corruption and further
from the seduction of any patient…”. The Hippocratic
tradition, however, is not the only option for resolving medical ethical
dilemmas. Some other frequently referred to texts on the subject include the
Declaration of Geneva, the Principles of Ethics of the American Medical
Association, or the national guidelines of the country of practice [3].
Historically, need for medical ethics was felt following the
shocking behaviour of the German medical practitioners post Second World War
in conducting experiments on human subjects without their consent and exposing
them to grave risk of death or permanent disability. Thereafter, concerns were
raised internationally over regulating medical research. Nuremberg Code, the
first international statement on the ethics of medical research using human
subjects was formulated in 1947. The Code highlighted the essentiality of
voluntary consent. Subsequently, the Universal Declaration of Hunan Rights,
which was adopted by the General Assembly of the United Nations in 1948, expressed
concern about rights of human beings being subjected to involuntary
maltreatment. Based on the preliminary efforts of the Council for International
Organisations of Medical Sciences (CIOMS) in 1964 at Helsinki, the World
Medical Association formulated general principles and specific guidelines on
use of human subjects in medical research, known as the Helsinki Declaration,
which has been revised from time to time. The most recent revision was
adopted by the 56th World Medical Association Assembly in Seoul in
October 2008.
Medical Ethics in South Asia: Role of cultural factors
Culture can be
broadly defined as a common heritage or set of beliefs, norms and values, and
refers to the shared attributes of the particular group. Since cultural values
affect the medical beliefs, health seeking behavior, acceptability of a
particular treatment, cultural factors are also likely to influence medical
ethics. The modern medical ethics mainly refer to the modern medical practice,
or more specifically the Western medical model. Even in the Western culture,
the traditional Hippocratic model or the modern ethical principles may not be
fully compliant with major Western religious systems like Judaism, Catholicism
or Protestantism or the Western secular philosophical options like Kantianism,
utilitarianism or libertarianism, and a conflict is possible between ethics and
cultural values [3]. Here, we
will refer to influences of the traditional cultures of the South Asia, which
includes ancient Indian system of medicine, Hinduism, Buddhism and Islam.
Medical ethics in India are embedded in its ancient and diverse
medical and cultural traditions. India is a multicultural,
multilingual and multiethnic society. Variations in the traditional health
related beliefs may thus be seen across different parts of the country, which
also follow a number of medical systems (Ayurveda, Siddha, Unani, Homeopathy,
etc.) embedded under the Indian Systems of Medicine [4]. Indian history and
the ancient treatise on Indian medicine provide a framework for
understanding Indian medicine and for understanding ethical action within medicine.
The ancient medical texts of India, especially the Charak Samhita [5] have
wide references to medical ethics. The Indian understanding of the importance
of progeny, especially male progeny, provides a framework for understanding
Indian views on conception, pregnancy, abortion, and sex selection. A Hindu,
who sees death as a transition to a new and potentially better life is likely
to have difficulty communicating with a secular Western physician for whom death
is the end of all that is [6].
The value systems in India have been influenced by all the prevalent
religions, predominantly by Hinduism, the major religion (82.64% of the
population), contributing to the philosophy and ethics of the people of’ the
country7. Closely allied to Hinduism are Jainism
and Buddhism. Ayurveda (the ancient science of life), the ancient system of
medicine in India, lays down the principles of management in health and disease.
It also has a code of conduct for the physician. Charaka, a famous Indian
physician of the ancient period, has described the objective of medicine as two
fold; preservation of good health and combating disease [5]. Charaka
Samhita prescribes an elaborate code of conduct. The medical profession has to
be motivated by compassion for living beings. Charaka’s humanistic ideal
becomes evident in his advice to the physicians, that “He who practices not for
money nor for caprice but out of compassion for living beings, is the best
among all physicians”. Charaka also advises the physician to take into confidence
the close relatives, the elders in the community and even the State officials,
before undertaking procedures which might end in death of the patient. The
physician is to proceed with the treatment only then.
Islam, the other dominant religion in many South Asian
countries, also had its own influences on medical ethics, which were inspired
by a dual set of sources. The first was scriptural and historical, embodying
the Islamic message, revealed to the Prophet Muhammad and recorded in the Qur'an.
The second set of sources consisted of combination of influences resulting from
the Muslim conquest and expansion from the seventh to the eleventh centuries
into domains, whose cultural and scientific heritage were selectively
appropriated by Muslims, and were then refined and further developed. The
elements in the early moral environment refer to healing within the larger
world-view of the Qur'an, which were later modified in terms of intellectual
and cultural adaptation. These subsequently integrated the new values and
practices that were not directly derived from the Qur'an, Prophetic practice or
Arab. The traditional notion of adab, another related concept from
Islam, refers to the integration of human learning and knowing of the
right and appropriate human conduct into a conception of criteria for
excellence. While the traditional Hippocratic medicine lacked any full theory
of justice or the duty of physicians to treat those in need, Islam has, with
its sister traditions, Judaism and Christianity, historically provided a
special commitment to treat the poor [3,8].
Buddhism, the third major religion of the
South Asia, follows the virtue based system, as also the other religious
systems, which is in contrast to the Western medical ethical systems in its
emphasis on equal treatment. There is also a relative lack of interest in the
Western notions like privacy and confidentiality. Veracity is always a
duty for people in general and medical personnel in particular. Falsehoods and
deception cannot be morally justified simply on the grounds that we think it is
good for another. Buddhism also prohibits killing. The doctrine of Kamma holds
that joys and sorrows are the result of one's own past actions. Kamma must
run its course or will be manifest in a future life. Compassion goes beyond
justice to self-giving and self-denial. It is central to the path to the
attainment of highest human fulfilment [9].
Thus the principles of duty, justice, equality and do good,
as professed in major religions and cultures of the South Asian countries have
an important influence on the practice of medical ethics here.
Medical Ethics in the modern medicine as practiced
currently in South Asia
The professional
medical associations and the national research bodies of many countries of
South Asia have generally made their ethical guidelines, based mostly on the
Western model. The countries as members of the United Nations Organization are
signatories of the Declaration of Geneva, International Code of Medical Ethics,
and Declaration of Helsinki. In India, there
is an exclusive journal on Medical Ethics by the name Indian Journal of Medical
Ethics, which is being published in India since 1993.
As an example, the Medical Council of
India, the professional licensing medical body of the Government of India and
the Indian Council of Medical Research, Union Government’s advisory council on
medical research have framed their own code of ethics on medical practice and
research respectively. [10,11] In additional, various other professional
societies of different medical or surgical specialties have also framed their
own ethical guidelines for medical practice and research. This section briefly
discusses about the ethical guidelines generally followed in India.
All medical institutions in India now have
to adhere to the research guidelines as issued by the Indian Council of Medical
Research and have also to constitute an Institute Ethics Committee as per the
guidelines suggested by the Council.
The Medical Council of India gave its
latest regulations on the professional conduct, etiquette and ethics in
2002, called Code of Ethics Regulations, 2002 [10]. The code is very elaborate.
It has 8 chapters, referring to duties
and responsibilities of the physician in general, duties of physicians to their
patients, duties of physician in consultation, responsibilities of physicians
to each other, duties of physician to the public and to the paramedical
profession, misconduct, punishment and disciplinary action. Each chapter has
further sections and subsections giving details of the guidelines. Some of the salient features are further detailed in
the following paragraph.
A physician is expected to uphold
the dignity and honour of his profession. The principal objective of the
medical profession is to render service to humanity with full respect for the
dignity of profession and man. Physicians should merit the confidence of
patients entrusted to their care, rendering to each a full measure of service
and devotion. The Code gives some standard guidance on maintenance of medical
records, prescribing medications by generic names, guidance regarding referring
to other doctors and display of fees. A physician is free to choose whom he
will serve. He should, however, respond to any request for his assistance in an
emergency. Physicians are expected to behave like good citizens and should
disseminate advice on public health issues. They have an important role to play
in enforcing the laws of the community and in sustaining the institutions that
advance the interests of humanity. The physician shall not aid or abet torture
nor shall he be a party to either infliction of mental or physical trauma or
concealment of torture inflicted by some other person or agency in clear
violation of human rights. A physician can conduct clinical drug trials or
other research involving patients or volunteers as per the guidelines of the
Indian Council of Medical Research (ICMR), provided ethical considerations are
borne in mind. Violation of existing ICMR guidelines in this regard shall
constitute misconduct. Consent taken from the patient for trial of drug or
therapy which is not as per the guidelines shall also be construed as misconduct. Any complaints with regard to professional misconduct can
be brought before the appropriate Medical Council for disciplinary action [10].
A number of researchers have
also studied ethical practices in South Asia. In one of recent analysis of
original research publications from Sri Lanka, spanning over 1985-2005,
Sumathipala et al [12] found that only about
one third of the publications had mentioned having taken approval of the Ethics
Research Committee and procurement of informed consent. However, the authors
noticed a positive trend in local postgraduate research and in local medical
journals.
Ethics in medical practice have also
been a focus of discussion in the Muslim world. Kuwait declaration on patient
safety of 2004 was a step in this direction. The meeting was attended by
experts and health professionals from many Islamic countries including Bahrain,
Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman,
Qatar, Pakistan, Saudi Arabia, Sudan, Tunisia, United Arab Emirates and Yemen
on the initiative of the WHO Regional Office for the Eastern Mediterranean in
2004. The meeting deliberated on the health situation in developing countries
and countries in economic transition with specific focus on the Eastern
Mediterranean Region., The poor state of infrastructure and equipment,
unreliable supply and quality of drugs, lack of or poor pre-qualification of
medical supply factories, inadequate application of good manufacturing practice,
shortcomings in waste management and infection control were some of the
important areas of discussion. These are also relevant to various South Asian
countries. Issue of patient safety especially how best to prevent harm
occurring to patients through learning from errors and incidents, and
advocating the culture of learning from mistakes was an important agenda. The
declaration is a call upon the regional scientific community and civil society
to join the efforts of WHO and ministries of health to attain the better care
that all are striving to achieve.
Goals of declaration included developing integrated national
patient safety programmes with clear targets in all countries of the Region to
ensure the safety of patient care at all levels, facilitating a culture of
safety through better reporting and information systems which assists the
systematic monitoring, analysis and improvement of patient outcomes. There was
also emphasis on consumer involvement in improving health care safety. Improving
communication between patients and physicians, enhancing and supporting the
research activities for patient safety and developing centres of excellence at
national levels, and facilitating coordination of national efforts to improve
patient safety through effective networking and collaboration with regional and
international centres involved in patient safety were some other goals. Proposed
strategies for patient safety included establishing continuous training
programmes on patient safety for different categories of health care providers,
and developing, updating and disseminating universal protocols and guidelines
on evidence-based practices to health care team providers for different aspects
of patient safety. Capacity building activities need to be undertaken by
increasing resources allocated to patient safety programmes. Similarly, there
is a need to ensure high level commitment for patient safety and patients
rights through enactment of legislation, development and enforcement of
regulations and allocation of financial and human resources, and so on [13].
Specific needs of the countries of South Asia
A number of issues like informed
consent, patient rights, confidentiality, conflict of interests, unnecessary
investigations, treatment and hospitalization and unethical advertising need
special discussion.
In South Asian countries, traditionally, the patient and the
general population often reposes great trust on the treating doctor. The
patient often comes with the notion that the doctor knows the best and expects
the doctor to make a decision about the treatment. A paternalistic view had
been the norm over a long period, though the trends are changing now, and this
is starting being questioned now [7]. Trust based on goodness of the doctor is
slowly giving way to the concept that making the decision is the patient’s
right. Introduction of the consumer rights movements, increasing costs of
medical treatment, increasing privatization of medicine, introduction of
medical insurance have brought the change1. Similarly, with the
introduction of the West sponsored multinational drug trials in the South Asian
countries, the issue of informed consent has become more important, as many
times an untried drug may be brought for trial here. Concerns about this have been
raised in the lay press as well as the medical journals. In informed consent,
how much is actually understood by the patient has also been a focus of study.
In a study on informed consent from Bangladesh, Lynoe & Hyder [13] examined
participants' understanding of iron supplementation in a community-based study.
Although consent had been obtained after detailed explanation of the study,
many participants did not understand that they were free to decline to
participate, or they could choose to leave the study, and about half believed
that the participation was part of routine health care. This raises important
question about the use of doctrine of informed consent in research.
Issue of confidentiality of the information shared by the
patient during the therapeutic interaction is another important concern.
Patients are frequently accompanied by family members, who would often be
present while clinical history is taken and examination is conducted. The
patients often may not object to the family members being told about the
medical details. Many times, the information shared may be of sensitive nature,
where it may not be in interest of the patient to share the information.
Sometimes in cases of serious or life threatening illnesses like malignancy,
the family members may desire the information about diagnosis not to be
disclosed to the patient [14,15].
Conflict of interest is another issue needing attention.
Sometimes, there may be an inherent interest on the part of the doctor
recommending a particular treatment or ordering for an investigation or
hospitalization. Kickback practice for referrals to diagnostic centers or to
the big hospitals for advanced treatment or unethical promotional favours by
the pharmaceuticals for prescriptions is not uncommon. These issues have been a
focus of discussion in recent years [16].
Pharmaceutical companies may try to induce doctors in
different ways. Iinducements can range from seemingly small
gifts such as pens and writing pads with drugs’ names inscribed to gifts and
free meals, financial support for travel, lodging and dinners to all expenses
paid participation in seminars, symposia and medical conferences, and lavish
trips and entertainments [16]. The Medical Council of India has taken
some initiative to curtail this practice [10]. The drug firms also generally
don’t follow the WHO’s ethical criteria for drug promotion. In
a recent direction, the Government of India asked the pharmaceutical companies
to self-regulate rather than have a legislation to tackle the menace [17].
Recently, the Organisation of Pharmaceutical Producers of
India (OPPI), an association mainly of multinationals which is estimated to
account for 70% of the drug market in India, came out with some regulations to
check the practice. But the move is questionable, since more than a quarter of
the members of the OPPI are subsidiaries of companies that have been penalised
in the US for illegally promoting various drugs through inducements for doctors
[18].
A desire to have a male child in India as well as some other
South Asian countries has led to rampant practice of pre natal determination of
sex and then resorting to medical termination of pregnancy if the foetus is
female. Female infanticide is also not uncommon. This has led to disturbing the
male/female sex ratio in the population, not a healthy trend. The Government of
India has even brought a law by the name the Pre-Natal Diagnostic
Techniques Act
and Rules
in 1994 to regulate this practice.
There has been a massive increase in recent years in
recommendations of unnecessary investigations like imaging of different body
parts, ultrsonography, endoscopies or cardiac procedures or other surgeries in
the absence of proper indication or in the name of safe practice, which is
probably a fallout of mushrooming of private sector in medicine and opening of
corporate chains of hospitals. This has increased the cost of medical care many
fold, and has been a matter of serious concern in term of medical ethics [19].
Advertisements of deceptive nature with false claims of
success with some treatments are also not uncommon. In fact, many times such
misleading advertisements are given by unqualified quacks or lay
practitioners.
Though there have been many initiatives by different
organizations including the Medical Council of India, professional
associations, human rights groups and media, and there is some improvement in
maintenance of ethical standards in medicine, still much is to be achieved.
Doctors also have their own limitations. In the state owned
hospitals, they are often over worked. They are often criticised because they are
the most visible and senior members of the health professions and therefore hold
a major responsibility for the failings of the system. State-funded health
services throughout the world are imperfect, over pressured and
under-resourced. In spite of the best intentions, they sometimes damage and
dehumanise the people that move through them [19]. Many patients may perceive
that the health professionals are more interested in sickness than in them and
more interested in biological faults than the people who experience them.
Conclusion
The modern medical
practice in various South Asian countries though predominantly follows a
Western model cultural factors have an important influence on the application
of the accepted ethical standards in medical practice and research. The
traditional system of medicine, socio religious factors and overworked medical
profession sometimes act as impediments.
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