Context and Narration
Ethics is a discipline of philosophy which guides on the notions of good and bad, right and wrong. Bioethics is the application of ethics to the field of medicine and healthcare. My journey in bioethics started with a workshop in India and the journey progressed with training in a postgraduate diploma in Bioethics from PSG Institute of Medical Sciences and Research, Coimbatore, India. I was exposed to various topics/aspects of bioethics; medicine as a profession, history and evolution of bioethics, theories of moral reasoning, professionalism and ethics, law and ethics, autonomy, privacy and confidentiality, communication in health care, pharmaceutical industry and physician, research ethics, beginning of life issues, end of life issues, organ donation and transplantation.
During this journey, I have learnt tremendous lessons which are significant not only for my professional role, but in personal life as well.
The following monograph is a reflective narrative of my journey in bioethics. Reflecting on my journey, I have attempted to capture my learning and the essence of certain topics/aspects of bioethics in the form of a rhyme.
The purpose of writing this reflective narrative and rhyme is multifold. One is to develop the deeper understanding of my learning, going by the maxim given by John Dewey that “We do not learn from experience...we learn from reflecting on experience.” Second is to invite the readers to engage with the creative expression of some aspects/lessons of bioethics. Third, the rhyme can also be used by the medical teachers to sensitise their students on bioethics and on reflective writing.
Along the journey, I internalised that medicine is a vocation, not just a profession. It can be best put in the words by Sir William Osler “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head”. When, I learnt about the history and evolution of the codes of ethics and principles of ethics, I found that the history of mankind is quite painful with a number of instances when moral principles were violated [1]. While learning about the history, i understood the hidden warning in the words of George Santayana “those who don’t learn from the history are doomed to repeat the mistakes of it” and realised that whatever we possess today, the mankind has paid the price for it! I learnt about the theories of moral reasoning with the help of classical scenarios; Heinz dilemma [2] and Run way trolley [3]. Doctrine of double effect [4] was understood with the help of another real case scenario of conjoined twin children “Mary and Jody Siamese twins,” in which one child had to be sacrificed in order to save another [4,5]. It was a tricky case where certain principles of ethics; beneficence and non-maleficence were in conflict with each other. In such situations, doctrine of double effect [4] helps in resolving such conflicts. It is fundamental to understand that the Health Care Professionals (HCP) owe fiduciary duty to their patients and their relation with them rests on loyalty and trust. A fiduciary duty is an obligation to act in the best interest of another party. The law and ethics are inseparable; the law sets minimum standards of what must be done whereas ethics set highest standards of what ought to be done. I learnt about the first systematic use of the informed consent by Major Walter Reed for yellow fever experiments during Spanish American War [6]. Respect of patient’s autonomy is of paramount importance; it is important to note that many cases of litigation are due to errors in informed consent. Therapeutic privilege is a privilege of withholding information from the patient when the physician believes that the disclosure may have an adverse effect on the patient’s condition or health. Empathetic communication and compassionate care are essential for better health outcomes. The protocols [7] for communicating the medical errors and bad news are of little value if the communication lacks empathy. It is known that the prescribing behaviour of a physician is influenced by the promotional strategies and tricks played by the pharmaceutical companies, which leads to conflict of interest situations. However, a solid foundation of ethical principles will usher the way forward for HCPs. Consequentialism and deontology [8] are theories of morality, which consider the “ends” and “means” respectively to determine the morality of action. While performing research studies, a researcher may find himself in dilemma as whether to put the science first or the participants, So, in these situations, following the basic principles the guidelines and law will help. Further, I learnt the ethical aspects related to beginning of life, organ donation and transplantation. It was very painfully realised that in spite of the so-called technological advancements, societal progress, with the laws in place, female feticide is still prevalent in some parts of the world.
Medicine an art or science, a profession or a vocation, at the outset this was contemplated,
Atrocities of Nazis, deception of Tuskegee, sacrifice of mankind, Hippocratic oath…. We all were acquainted.
Heinz dilemma, Run way trolley, Mary and Jody’s separation triggered a number of dilemmas with a profound effect,
Deontology, Principlism, Consequentialism…answered many of them and then came the rescue with the Doctrine of Double Effect.
Fiduciary’s duty is resting on honesty, loyalty and trust,
For a doctor in relation with his patient being professional is a must.
Law and ethics are integral to each other and have a natural intimacy,
Civil, Criminal liabilities, Knowledge of law is must but it is full of intricacy.
Informed consent was first attempted by Major Walter Reed,
Respecting patient’s autonomy is utmost hence for informed consent every HCP* should pay heed.
Respecting privacy and truthful disclosure are essential but it is also of good knowledge,
HCP may withhold information in patient’s best interest in exceptional instance under the principle of therapeutic privilege.
Breaking bad news and communicating medical errors are challenging and are my dislikes,
Empathy and compassion are imperative to practice the protocols of CONES and SPIKES.
Gifting authorship, free lunches to foreign tours, pharma industry will play all the tricks,
But following the principle of ethics a fiduciary can annul all the gimmicks.
I am often in doubt that in research whether its consequentialism or deontology which is right,
Adherence to guidelines and law will protect the participants, and hold their rights and dignity upright.
I am a zygote on day first, my heart beats on thirty first and I become a soul on one forty first,
Natural, ART** or surrogate, I am a blessing from the heavenly abode, at times I am not of preferred gender then this blessing becomes a curse and I end up in dust.
As I sense my end, I want to cry out loud ...so that you can hear me Maa***,
I know you are aware, but helpless...but where else do I share my pain Maa.
Life and death with dignity is a human right,
But euthanasia/physician assisted suicide can be a slippery slope hence its indication should be water tight.
There is a special part (organ) of me that will help someone to live,
I will do something, by which, even after death I will find a way to live.
Medicine is a life calling.... Ethics is a way of life.
It is a soul of science ...as it deals with humane side of medicine and human life.
Let’s promise that the price paid by the mankind will not go in vain,
We will practice ethics and make it count time and again...!
Footnotes:
*HCP: Health care professional, **ART: Artificial reproductive technology
***Maa: means Mother in Hindi language
Disclaimer/disclosure: The author does not claim the topics and the rhyme to narrate the complete picture of bioethics. The rhyme is neither meant to be prescriptive nor an absolute interpretation of ethical principles. Some words may seem crude, since they have been used for creative expression and rhyming. In the narration the pronouns “I” and ‘We” have been used to deliver the perspective in first person, with hope that the readers would relate better and would go in self-reflection! The expression “Do you hear me Maa” is inspired from another poem [9].
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