T

he extraordinary pro- guish traditional medical ethics from The most important obligations of
gress of biomedical ethical issues that arise from recent the physician toward the patient are
sciences and medical progress in biology and medicine. fidelity to the patient's interest, truth-
technology during the Health policy ethics concerns ethical telling of physicians and confidentiality
last three decades and issues relevant to the organizing, finan- of patient information. In a physician-
its application in medical practice con- cing and delivering of health care patient relationship where there are
front our societies with new ethical services. emotional and physical intimacies,
dilemmas. The numbers of articles in patients often entrust their bodies and
daily and professional journals bear Medical ethics sometimes even their lives to physi-
witness to the importance of the The central role of ethics in the cians, and therefore trust must exist.
subject and society's preoccupation practice of medicine cannot be too Medical ethics provides the basis for
with it. The terms "medical ethics," highly rated. Medicine presupposes this trust. To assure patients that their
"bioethics" and "health policy ethics" certain fundamental values such as the interests are the most important, to
appear more and more often - and preservation of life and the relief of promise to keep their confidences, and
usually in confusing contexts. Before suffering. These values distinguish to deal honestly with them are fun-
going further, it may be useful to medicine from other sciences and damental values of medicine to which
provide some definitions. imply some special responsibilities, physicians must adhere.
Health is a state of complete physi- particularly for the physician and other Ethical problems arise when these
cal, mental and social well-being and members of the health professions. values conflict with one another or
not merely the absence of disease or with other interests. For example, there
infirmity. may be conflict between fidelity to the
Ethics is a set of principles of right Dr Zbigniew Bankowski is patient's best interest and the physi-
conduct, such as those governing the cian's financial interests, or conflict
actions of an individual or of a profes- ·Executive Secretary of the between the obligation to tell the truth
sional group, or the philosophy under- Counci I for International and the obligation to protect the
lying such principles. Organizations of Medical patient's well-being - in a case where
Medical ethics deals with those ethi- Sciences (CIOMS). In colla- the physician fears that an honest
cal principles that govern professional boration with WHO. CIOMS description of a hopeless prognosis
conduct in medicine. Medical ethics has conducted a series of would seriously upset the patient.
implies obligations of the physician international conferences Because of the physicians' central
toward the patient as well as some dealing with ethics. human role as decision-makers about the
obligations towards other physicians. values and he-alth pol health and welfare of their patients, the
Bioethics is the term used to distin- dilemmas they face are the primary

2 WoRLD HEALTH, April 1989

concern of medical ethics. This role of Society, together with the medical
decision-maker has created a degree profession, is developing measures Cover: Co ll aborat ion
of paternalism, in that the physicians aimed at protecting against possible or confrontati on? -
are qualified by their expertise and are abuses. Thus, immediately following the "little theatre"
obligated by this relationship to their the Second World War, the judge- w here eth ics and the
patients to take the responsibility for ments passed by the Nuremburg Tribu- heal th p rof ess ions
meet. as see n by Peter
decision-making. The patient expects nal on those who ran the Nazi Dav ies. lt~-.............,_-'l' ~
his physician to possess both technical concentration camps articulated the
knowledge and ethical wisdom. standard for carrying out human
experimentation , emphasising the
Bioethics subject's voluntary consent. Repre-
Recent progress in biomedical sented by the World Medical Associa- IX ISSN 0043 - 8502
science, the resulting development of tion, the medical profession took an World Health is the official illustrated
magazine of th e World Health Orga nization .
new medical technology and the grow- important step further to reassure
ing possibility of its applications pro- society: the Helsinki Declaration of Editor:
voke a certain anxiety. In order to 1964, elaborated and revised in 1975
J oh n Bland
explain society's concern it may be and 1983, provides ethical principles
useful to describe briefly the methods for research involving human subjects. Deputy Editor:
of biomedical experimental research It adheres entirely to the concept of Christian e Vi edma
and their application. Investigation voluntary informed consent and
begins with the construction of imposes other protective measures Art Editor:
hypotheses which are tested in a such as a review of research protocols Peter Davies
laboratory and with experimental by independent ethical review com-
animals. For the findings to be clinically mittees. News Page Editor:
useful, experiments must be done on These issues were further expanded Philippe Stroot
human subjects and, even when by the Council for International
World Health appears ten times a year in English.
carefully designed, such research Organizations of Medical Sciences French. Portuguese. Russian and Spanish. and
entails some risk to the subjects. This (CIOMS) and WHO, which published four times a year in Arabic and Farsi. The German
edition is obtainable from: German Green Cross.
risk is justified not by any personal international ethical guidelines for such Schuhmarkt 4. 3550 Marburg. FRG .
benefit to the researcher or the institu- research. Besides prior review of Articles and photographs not copy righted may
tion at which research is conducted, research protocols, the ethical review be reproduced provided credit is given to the
Wo rld Health Organization. Signed articles do
but by its benefit to the human subject committee at the hospital, university or not necessari ly reflect WHO's views .
involved, its potential contribution to other facility where the research is World Health. WHO.
human knowledge, to the relief of conducted may only approve research Av. Appia. 1211 Geneva 27. Swi tzerl and.
suffering or to the prolongation of life. when the expected ratio of benefit is
Long-term, the benefits are likely to be favourable compared with the risk to
collective. the subjects, and when the subjects'
informed consent has been obtained. Contents
New and very complicated bio- Ethics and Health
ethical questions arise today. For by Zbigniew Bankowski 2
In the remote Tunisian countryside or in example, the resuscitation of patients
a crowded hospital in Sri Lanka, whose hearts and respiration have Family planning and the law
wherever people gather to talk health, stopped functioning. Is an unconscious by Anne-Marie Dourlen Rollier . . . 7
certain fundamental values hold true body in which respiration and blood
about the preservation of life and the Medical confidentiality . . . . . . . 9
circulation are artificially maintained
relief of suffering.
still a living person or merely a corpse Health ethics and the law
by Susan Scholle Connor and
Hernan L. Fuenzalida - Puelma 10
AIDS and discrimination
by Jonathan M . Mann ......... . 14
The doctor's dilemma . . . ... 16-17
Research in human
reproduction
by Jose Barzelatto .. . ..... . .. . .. 18
Islam and family planning
by Maher Mahran . . . . . . . . . . . . . . 22
They condone tortune
by Cesar A. Chelala . . . . . . . . . . . . . 24
The Ethical Grid . . . . . . . . . . . . . . 25
World's 2nd No-Tobacco Day
by Peter Ozorio . . . . . . . . . . . . . . . . . 26
Food irradiation - scientists'
toy or everyman's joy?
by Valery Abramov . . . . . . . . . . . . . . 28
News Page .... ... .. . ...... . 30-31
WHO / J Mohr

WORLD HEALTH, April 1989

 Ethics and health
with the appearance of life? Likewise,
methods of artificial reproduction offer
the possibility of child-bearing to infer-
tile couples. But who are the parents
of a child resulting from in vitro
fertilisation of the egg taken from Mrs
A and sperm from Mr B, implanted
into the uterus of Mrs C and then
offered to Mr D and Mrs E upon birth?
The sperm and the ovum, and the
fertilised ovum resulting from their in
vitro union, can be manipulated to a
hitherto unknown extent. Artificial
insemination by donor other than the
husband is an established procedure; a
~ husband's sperm can be frozen and
~ stored for future use, even after his
~ death; similarly, the fertilised ovum can
~ be frozen and stored for later use; and
women "lease" their wombs to carry
other women's embyros. Genetic
The doctor-patient relationship has required patients to entrust their engineering is already capable of
bodies and even their lives to the physician. Medical ethics prollidf:?S the changing some inherited characteris-
basis for this trust. tics, and genetic selection is feasible,
based on prenatal diagnosis.
Research at present under way on
molecular genetics, and particularly on
human genome mapping and
sequencing (as described in the
December 1988 issue of World
Health) , presages a new scientific era,
perhaps a revolution, in the medicine
of the 21st century. It opens up the
possibility of changing the ways in
which certain genes function in order
to prevent or to treat many diseases
and disorders. The particular dilemmas
raised by genetic screening and
counselling are: the ownership of gen-
etic information, and the advantages
and pitfalls associated with genetic
counselling and engineering.
Who owns genetic information? The
traditional moral viewpoint has been
that professional secrecy is in both the
patient's and the doctor's interests. But
today, ought we not to be concerned
to make genetic information available
to the relatives (or the potential
spouse) of the patient? If the health
and well-being of relatives or of future
offspring are at issue, does the obliga-
tion to keep a secret then turn into an
obligation to tell? It now seems that the
totality of one's physical existence
exceeds the limits of one's body, and
consequently the traditional right to
secrecy may turn into a duty to share
information with the family or even
with others in society.

~-~r---~~
~
_The burden of knowledge
There is also a right not to know.
For one reason, false-positive test
:ii results give inaccurate predictions.
•---.---.'l._-l ~ Then, some people are unable to cope
~ with the burden of knowledge. Thirdly,
~r;..._....l..,__ _..Jiw._.....J §information obtained from predictive
~testing can be misused. A fundamental
s principle of patient autonomy would
WORLD HEALTH, April 1989
WHO / T Farkas

seem to be that it is the basic right of answer the questions about the moral Laboratory in Singapore specialising in
the person to be tested or not to be status of human germinal material, sexually transmitted diseases. The tradi-
tested, and to choose to be informed eggs, sperm and embryos, whether in tional right to medical secrecy may turn
fully or only in part. Here is an area of the human body, in the laboratory test into a duty to share information with
interaction between the developments tube or even frozen in laboratory the family.
in biomedical science, ethics and containers?
health policy-making that cries out for Society is largely unprepared for,
further elaboration. and unconcerned about, such rapid decisions raise ethical questions. Poli-
What are the advantages and pitfalls scientific and technological develop- cies having to do with who shall
of genetic screening and engineering? ments. The ethical issues to which they receive health care, what resources
Both geneticists and the public must give rise need to be examined should be allocated, what criteria
know clearly that prenatal diagnosis, as thoroughly in the light of social norms, should be used in setting priorities,
one of the options in genetic counsel- legal codes and human values. what constitutes an acceptable form of
ling, does not lead to a "handicap- health care, when should health care
free" society; and that, even when used Health policy ethics begin or end, and even the matter of
to the maximum, there would not be a The ways in which health policy, who should be involved in making
significant reduction in the percentage ethics and human values interrelate policy decisions, all have inherent
of congenital handicaps and diseases. are described by the American physi- ethical components. Different national,
Predictive screening is warranted cian and philosopher, Edmund Pelle- cultural and religious traditions yield
only if a free and informed decision is grino: "The health policy of a nation or different ethical value-systems, and
possible, and if adequate facilities are a community is its strategy for control- their interaction with health policy-
available for long-term follow-up of ling and optimising the social uses of makers will therefore vary from country
those identified as disease-gene its medical knowledge and resources. to country.
carriers at an early age. Another Human values are the guides and Three general considerations should
reason for concern is the risk of social justifications that people use for motivate health policies: First, to
discrimination by employers, insurance choosing the goals, priorities and attempt to control the social and
companies and so on against someone means that make up that strategy. economic impact of the unrestrained
known to have some genetic pre- Ethics acts as the bridge between use of advanced medical technology in
disposition. health policy and values. It examines treating individual patients; second, to
These and similar questions seem to the moral validity of the choices that achieve a more equitable distribution
go beyond the terms of reference of must be made, and seeks to resolve of the benefits of medical knowledge;
the medical profession alone. Can we conflicts between values which inevit- and third, to use the medical know-
consider that the neurologist or the ably occur in making those choices. ledge in an anticipatory way for the
cardiologist is the only person to Ethics, therefore, orders human collective good of present and future
decide who is alive and who is dead? choices in accordance with normative generations.
Are the geneticists, obstetricians and principles." Let us try to identify the levels of
embryologists the only people to Many, perhaps most, health policy moral responsibility that physicians
WOR LD HEALTH, April 1989 5
Ethics and health

The poor man's medicine; a street-

vendor offers drugs in Nepal. One goal
of health policies should be to achieve a
more equitable distribution of the bene-
fits of medical knowledge.
should exercise in making the judge-
ments and choices essential to policy
formation and operation:
- The physician as the patient's advo-
cate. The physician who offers to
treat or help a sick person is
bonded in a special way with the
patient. He (or she) invites the
patient's trust that he will be
competent and will place that
competence at the patient's
disposal.
- The physician as technical expert
When not locked into a trust
relation with a particular patient,
the physician is obliged to partici-
pate in policy formulation as a
person with the technical know-
ledge which policy-makers need to
make rational choices among alter-
natives. This is an obligation owed
to society since that knowledge is
not proprietary.
- The physician as citizen. The duty
to act as a technical witness in
policy formation does not exempt
the physician from obligations as a
citizen. Thus, he must favour poli-
cies that are morally sound, and
oppose those that are immoral.
- The physician implementing health
policies. Sooner or later, health
policies must be applied to the care
of individual patients. It is here that
the physician faces the most diffi-
cult moral conflicts and the most
direct challenge to the traditional
ethic of beneficence.
- The physician as moral agent. The
physician, like any other person, is
morally accountable and therefore
cannot carry out a health policy -
for example, mandatory sterilisation
of carriers of genetic disorders, or
refusal of care because of inability
to pay - that he considers fun-
damentally immoral.
The complexity of these role rela-
tionships illustrates the urgent need for
careful reconstruction of professional
ethics so as to address the new

, dilemmas and conflicts that medical

technology and evolving health poli-
cies introduce into the physician's role.

,~
' Today, it is possible, and indeed
necessary, to examine these questions
not only as the ethics of care but much
more extensively as the ethics of health
policy and biotechnology as a whole.
The intention is not to under-value
moral and ethical aspects at the indi-
vidual level, but rather to view them
within a wider frame of reference. •
Photo W HO/J Schytte

6 WORLD HEALTH, April 1989