Professional Ethics in Polish Medicine

S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 Professional ethics in medicine Representatives of professions boasting of having their own professional ethics do not question their existence in general. Its justification is usually looked for in traditions of the profession and moreover humanistic sense and even culture-forming character of this ethics are shown. What is important, with such attitude, professional ethics is treated as a part of all mankind output, and its teaching turns out to be an important element of preparation for taking part in culture. However, it is thought-provoking that in these discussions there are nearly not arguments concerning usefulness of such ethics taking decision directly bound with performing a profession. Relations ethics and medicine Taking into account cultural meaning of professional ethics one should notice that all discussions on the character of relations of medicine and ethics exceed the very health care system. As an example American magazine “Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine” dedicated one of issues in 2001 to discussion about sources of ethical reflection in medicine. Among participants of this exchange of thoughts there predominated an opinion that sources of ethics in medicine must have an external character because medical art is a part of culture and realizes service tasks in favour of society in which it is performed. Therefore there must exist an external reason deriving from social environment which decides about the fact that some defined values are connected with medicine and which later play a crucial role in it. Many outstanding representatives of philosophy of medicine took part in this discussion, including Tom L. Beauchamp, the coauthor of the book known in Poland “Rules of medical ethics” (Beauchamp – Childress, 2006). . Therefore, an outlined dilemma dealt with the problem if existence of medical ethics requires external regulations or this is also a creature of the very representatives of medicine and only they can formulate it. If we assumed the second solution, ethics in medicine would have to be independent of other detailed ethics and it would not have to be included in any other more general theory. In the first solution medical ethics is becoming a part of general ethics and therefore it would be justified to include it in more general theory – bioethics.. Participants of discussion were trying to also decide the problem if medical ethics requires some external justification of its existence. John D. Arras of Virginia University in 1 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 his speech made an attempt of generalizing attitudes appearing in the course of discussion. Considering the matter from the point of view of possibility of existence in medical professions so called internal morality (medical internalism) distinguished its four variants. The first one was called essentialism because it assumes that fundamental standards of medical ethics can be directly derived from the idea of medicine and point of its performing. He included Edmund D. Pellegrino, co-author of the book „Virtues in Medical Practice” (Pellegrino – Thomasma, 1993) into representatives of this variant. Second variant constitutes the concept of “necessary practical conditions” in which moral standards are derived from conditions of performing the profession of a doctor. The third variant is “historical professionalism”, according to which both standards of performing this profession as well as standards of ethics might be settled exclusively by doctors for doctors. The last variant Arras called “internalism of evolution perspective” because in accordance with it professional standards in the field of medicine with time are subject to progressive evolution in interactions with outer standards of morality. Other participants of symposium were included into followers of this attitude: Franklin G. Miller and Howard Brody (Miller – Brody, 2001). According to Arras in these variants internal estimation of medicine for making attempts to solve the biggest dilemmas of modern bioethics, like curing of HIV carriers, approval or disapproval of aided suicide, etc. (Arras, 2001, p. 645) is not used. At the same time he was of the opinion that medical ethics alone cannot be a sensible offer to solve modern dilemmas afflicting humanity. This kind of hope is already given by bioethics which is a part of culture in which it is formulated. Obviously, there also exist some competitive approaches which appeal to liberalism thereby assuming functioning of relation between medical staff and patients following the example of market regulations. Depending on political option having power at the moment we have therefore contradictory attempts of reforming medical service in pro-social or market direction. Neither science nor political practice have enough data yet to unequivocally point at rightness and rationality of the choice of these outlined options. It seems, however, that considering the problem from the point of view of ethics more rights speak for pro-social solution. Therefore, the attitude of John Arras seems to be enough justification for including all issues, which until now had been considered by particular medical professions, into the area of bioethical considerations. In traditional division of bioethics, offered once by Daniel Callahan, culture bioethics is distinguished – which task is to tackle known and newly born bioethical problems in social, 2 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 historical and culture contexts. In this measure it constitutes the object of interest also of study of science, sociology, anthropology and history. This state of matters results directly from the system of organization of our society which is often called “the culture of risk” . For risk is a consequence of our natural tendencies which results in the fact that culture constantly threatens itself (Sennet, 2010, p. 8). At the same time there must exist in it some criteria defining limits of acceptable risk. Therefore, in every culture there have been elaborated subtle rules of tolerated treatment of a man by a man. They obey everybody but for some groups consents and prohibitions are specially defined because it is not indifferent to anybody how representatives of a given group treat others. Because everybody, without exception, is or may become a patient, it is understandable that society it trying to eliminate unwanted risk connected with compulsory contacts with representatives of medical service. Doctors, nurses or pharmacists are included in the list of potential patients and thus one may assume that they as people who are most aware of the range of a risk, care, first of all, about the fact that records of ethical codes would protect the patient. Even if it may seem that some records protect e.g. only doctors, it is always a patient who will finally be a beneficiary. Pragmatic meaning of professional ethics In the case of professional ethics it is all about practical aspect, for it is to help to solve not typical situations which happen during work which cannot be predicted and decision, once taken, influences health or one’s life, patient’s or co-workers’. Education in the scope of ethics of one’s own profession is therefore also a kind of necessity to diminish the field of committing possible mistakes. When for the first time I was teaching classes of nursing ethics they took place on two levels. The first level, let’s call it theoretical, was to introduce students into problems of philosophy in general, specially taking into account ethical theory. The second level was conducted by experienced nurses who were conveying records of nursing code enriched with their own experience at the work posts. From the perspective of many years of didactic experience am willing to acknowledge that such model of education in the scope of nursing ethics was probably the best and certainly the most sensible. A disadvantage of such two-level education was separation of theoretical and practical classes. The first ones were mostly conducted by philosophers and the second ones by representatives of medicine, and they were not connected by no more than common work in this institution. In this way theory has been separated from practice. In spite of this, this model of students’ education seems to me very 3 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 sensible for many reasons because during classes of history of ethics they were introduced to different ways of estimating health and life and solving of the most important problems which human can face in his/her life. These propositions of estimation and justification of making decisions in the matters of health and life in overwhelming majority maintain relevance until today. The sense of making such an education amounted to offering possibilities to choose such offers which would not be contradictory to individual view of life and hierarchy of student’s values. It is not about any indoctrination because higher education, as assumed, does not change the system of student’s values in a direction desired by lecturer or school. For in philosophy it is assumed in advance that there doesn’t exist any timeless and unchangeable solution, which should only be mechanically introduced in life to be able to act well. This is a student alone who is to choose the foundation to which he will refer in doubtful and extreme situations. It might be the system of ethics elaborated by John Paul II or John Stewart Mill or somebody’s else. None of ethical systems, established in philosophical tradition, recommends taking up activities morally wrong or contradictory to common sense. Everybody, though, points at the source to justify one’s behaviour- at first one needs to be honest to oneself to be useful to others. The essence of first stage of ethical education amounts to shaping of a motivating system and abilities to independent deciding in difficult situations. In this way representative of every medical system is becoming or strengthens inside oneself dispositions to decide about other people’s health and life and, what is important, they are not contradictory to the system of humane values, common sense and science. It allows to reach indispensable certainty and trust to oneself, which is necessary to move incentives constituting the foundation to make a decision also to one’s place of work. To reach this it is indispensable to contact a real environment, in which decisions of moral meaning are made. Second level of ethical education is thus connected with performing professional duties and comprises of proper professional ethics. In my opinion, without coming through this first generally philosophical stage, education of disciples of medical professions is imperfect and in the future it results in cases of offending the rules of social cohabitation by representatives of medical professions, and worse still, avoiding of making necessary decisions in extreme and unusual situations. Rising specialization of medical professions also causes the fact that unified medical ethics doesn’t exist, common to representatives of all professions. To me, the moment in which different medical specializations have been extracted in systems of education is only 4 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 sanctioning of this state of affairs. Yet, no one will say that pharmacist is not a representative of medical professions, the same refers to a nurse or dentist. It would be of no sense to expect that a dentist will be guided by the same reasons in his/her decisions as for example surgeon oncologist. Therefore, one should admit that every medical specialization of which representatives “serve” patients should have their separate professional ethics and its basis should be taught during specialization. At this level it should take place via studying medical cases which happened or are happening at the moment in the frames of a given specialization and which are very often quoted in separate publications or handbooks for medical ethics (See: Szewczyk, 2009, pp. 151-415; Kaczynska, 1996; Beauchamp – Childress, 2006, pp. 528-542). This is really important to realize what rights representatives of medicine, law and philosophy are guided by deciding in the matters of life and death of concrete people. Issuing general judgments, not directed at a concrete man, is not difficult, every one can make it. There is a totally different situation when one has to decide in the matter of somebody who can be easily localized and recognized and, what is more important, to bear personal responsibility for one’s decision in front of the whole world. It seems to me that representatives of medical professions in Poland are not prepared enough for this, which are testified of evading from making even prosaic and obvious decisions as for example in the case of ante-natal examinations. Is professional ethics indispensable for medical professions? It is a justified conviction that having one’s own professional ethics is social distinction of a given professional group. For society is vitally interested, first of all, in these professional groups which are guarding values constituting a given culture. It has also been assumed in ethics that this is an indicator of social prestige of a given profession. Now it is considered as indispensable to establish codes of professional ethics, if representatives of a given profession “every day deal with values particularly appreciated socially, as e.g.:  health and life (doctor’s ethics)  freedom (barrister’s and judge’s ethics)  shaping of personality (teacher’s ethics)“. Moreover, one points at the need of ethical codes in professional groups, “of which activity has gained more social meaning (e.g. ethics of scholar) or in which the question of moral qualifications is at least as important as the matter of professional qualifications” (Jedynak, 1990, p. 72). 5 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 However, there are a lot of postulates and expectations put forward in relation to medical professions. Medical representative must thus present not only high professional qualifications but also social and moral, therefore as a rule there are no opinions negating the need of developing professional ethics in medical specialities. In these professions one can notice the need of human work particularly of special ability to foresee both results of one’s own actions as well as behaviour of a patient and getting on well with other people. It results straightforward from a special character of work of representatives of medical professions, and especially:   “ irreversibility of consequences of doctor’s decisions and doctor’s actions, necessity of entrusting secrets to the doctor, discussing most personal and intimate matters,  necessity of being subject of unpleasant and dangerous treatments and allowing to perform similar treatments at the closest people”,  social authorization to “decide about human life, along with the right to inflict pain (surgery) and restriction of personal freedom (infectious and mental illnesses) ” (Kielanowski, 1970, pp. 174-175). These conditions show distinctly how wide range of life practice must embrace regulations of medical ethics. No wonder that there is always dispute over the scope of such regulations. On the one hand we deal with willingness to regulate, with the help of expanded ethical codes, all possible moral dilemmas which one can meet while working in institutions of health and on the other hand with the conviction that such a well-educated social group as representatives of medicine does not need external suggestions and knows what to do in such situations. Thus, there is no certainty if it is not enough to refer in the codes only to the conscience of representatives of medical professions, restricting oneself exclusively to their appellative message. Then, one can confine oneself to showing the virtues which should be characteristic to every representative of medicine. For example, according to T. L. Beuchamp and J. F. Childress, a total message of doctor’s ethics might be restricted to shaping of hardly four virtues:  sympathy – that is concern about other’s good and ability to empathize in the situation of others (patient’s)  deliberation – that is constant and penetrating insight into a situation, understanding and sound judgment which lie at the bases of making decisions. “Deliberation in itself 6 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 consists of the ability of judging and deciding with the exception of personal liking, extravagance and fears”,  ability to return confidence – this is a virtue which experiences a real crisis nowadays. “The reasons of collapsing of trust we can comprise in the loss of close contact between doctors and patients, coming specialization of health service, higher fees for medical service, conflicts of interests during competing for patients, investments of doctors in medical centers, the increase of large impersonal and bureaucratic institutions of health care”,  integrity – that is in a wide meaning “healthy, consolidated, responsible and integrated moral character and in a narrow meaning – “loyalty to declared norms” (Beauchamp – Childress, 2006, p. 493). Perhaps, creating of ethical codes and wide professional ethics is of no sense if one can be limited to awaken conscience and grounding such virtues in it. However, tradition of many centuries speaks against such attitude - tradition according to which the best way to keep high level of morale of representatives of medical professions is to obey and adjust codes to the requirements of changing life. For it’s obvious that someone deprived of basic sympathy should not perform none of these professions. Control function of professional ethics Many people think that everybody who graduated from university is a man who can direct his/her own life independently and does not need any external regulators of their own behaviour. However, common ignorance of industrial safety rules at the workplace or set of rules in crisis situations tells us that this not true. And nobody is able to foresee all possible events in one’s life and therefore is not prepared in advance for unexpected threats. Regulative function of ethics seems to be sometimes useless because it is quite commonly thought that we do not need to read learned ethical treatises to know how to act towards our own children, patients, or co-workers. In the life of every man, however, there are situations where conventional rules of behaviour do not give any clue as to the choice of proper or the best way of behaviour. Such situations are dealt with emergency medicine every day, where human life has to be assessed “ad hoc”. Then it turns out that it was worth studying ethical dilemmas so that modeling oneself on these solutions one can solve their own dilemma. No one wants to make a mistake which will shorten or take patient’s life. An average man does not deal with such situations in his/her life at all, and representatives of medicine deal with 7 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 them every day sometimes. But even multitude of unusual events does not give a man the ability to manage in every situation because at simultaneous specialization of medical staff they deal with typical events in this area. It can even happen, for example, that prosaic procedure of making an injection, once learned in the past in a medical school, has been just forgotten and ordinary syringe may become the most dangerous tool. At the moment when performing of a given profession starts to be a subject to, except from requirements concerning qualifications, also regulations of moral character there appears a problem in codifying them. The term ‘ethical code” means “non-contradictive system of norms regulating a moral sphere of social life and solving problems of the individual resulting from her/his attitude to a social group, to other man, to oneself and, in the case of religious and ethical code (e.g. Decalogue), first of all to God” (Jedynak, 1990, p. 120). For a long time, among ethicists there has been a dispute over the need of existence of professional ethics codes. The followers of ethics of rules consider codifying of moral norms as indispensable, whereas followers of situational ethics negate the need of functioning of the codes, regarding conscience as the only authority solving moral dilemmas. In the area of situational ethics, deliberations on ethical codes are considered as unjustified. Opting for the ethics of rules or indirect solutions, one regards the existence of ethical codes as useful and even socially indispensable. Thus, one can reasonably assume that professional ethics does not limit working freedom but it gives a special opportunity to use it. Records constituting its contents are mostly standardized by a professional group which sets criteria of recruitment on its own and general duties resting on their members. Also, only within the framework of a group decisions about changes introduced into such ethics are taken. It’s true that is difficult freedom because one needs to know how to use it. It is not a coincidence however that only representatives of medical professions requiring high qualifications and imposing special requirements in the area of professional improvement may make use of it. Undoubtedly, such requirements are met by all health service, in which taking a decision requires not only substantial qualifications but also, and maybe first of all defined personality predispositions. Conclusion Out of these considerations there result premises enforcing formalization of moral requirements imposed on representatives of some socially important professions. However, a duty of compiling of such requirements in the shape of ethical code does not result from them. 8 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 Neither theory of morality nor social practice impose such duty. However, in the case of “distinguished” professions there is a social expectation for such codes. It mostly results from historical premises and the willingness to eliminate degenerations present in a given professional group and which are most painfully felt by the society. Nihil volitum nisi praecognitum – we can only want things which we have already known. The more I know the more and better I can choose (Szostek, 1996, pp. 22-23). Therefore, there is no doubt that some norms and rules of ethical character obligatory in a given profession have to be passed on to students of medical art. Contrary to appearances the field of room for manoeuvre is very small here: for we either decide for verbal transmission of the contents or for reading of a written code. In the first case a student introduced in the secrets of profession is doomed to good memory or good will of the one whose honour is to introduce him/her in the ethics of a given profession. However, in the other case one can always come back to the reading and doubts can be clarified in any time even with more experienced co-workers. On the one hand we have ready solutions, in the shape of a code passed on verbally or in a written version from generation to generation, and on the other hand we have a vision of a free man, not confined to any dictated in advance orders and bans, who, by his/her nature, aims at the good. Such a man needs no codes. Both of these variants have a long tradition in the ethical thought. Both of them also have its followers as well as staunch opponents. Ethics of codes, as followers of postmodernism want, is anachronism of past modernist epoch, where everything was normalized, totalized. “Great narrations” also included formalized morality. Today, as they say, ethics of codes does not match social needs. However, all the same, codes still exist and even there is a visible tendency to widen the number of areas of life normalized by them. By virtue of quite common agreement regarding functioning of professional ethics formulated in the shape of a code there is usually adopted a solution assuming that the rules of professional ethics are just taught during teaching of a profession. So, the student gets the knowledge of basic moral requirements which will be placed in front of him during future work already at school or university. This situation causes that representatives of medical professions do not have a comfortable “way out” which would allow to avoid also moral responsibility for the effects of their actions. Therefore, careful studying of the contents included in their own codes of professional ethics and following discussions about moral dilemmas in medicine is just inscribed in the rules of performing of the profession. One 9 S. Konstanczak, B. Choinska) Professional ethics in Polish Medicine, "Ethics and Bioethics (in Central Europe)" 2011, vol. 1 (1-2), s. 14 -20 cannot renounce such responsibility, it is just a part of a social role fulfilled by representatives of health service. References ARRAS, J.D. (2001): A Method in Search of a Purpose: The Internal Morality of Medicine. In: “Journal of Medicine and Philosophy” 26(6), pp. 643-662. BEAUCHAMP, T.L. - CHILDRESS, J.F. (2006): Zasady etyki medycznej. W. Jacorzynski (trans.). Warszawa: Ksiazka i Wiedza. GLUCHMAN, V. (2003): Human Being and Morality in Ethics of Social Consequences. Lewiston: Edwin Mellen Press. JEDYNAK, S. (ed.) (1990): Slownik etyczny, Lublin: UMCS. KIELANOWSKI, T. (1970): Zawodowa etyka lekarska. Rozwazania na temat kilku aktualnych zagadnien. In: A. Sarapata (ed.): Etyka zawodowa, Warszawa: Ksiazka i Wiedza, pp. 174-191. KACZYNSKA, I. (ed.) (1996): Medycyna a prawa człowieka. Normy i zasady prawa miedzynarodowego, etyki oraz moralnosci katolickiej, protestanckiej, zydowskiej, muzulmańskiej i buddyjskiej, Warszawa: Wydawnictwo Sejmowe. MILLER F.G. - BRODY H. (2001): The internal morality of medicine: An evolutionary perspective. In: Journal of Medicine and Philosophy” 26(6), pp. 581-689. PELLEGRINO E.D. - THOMASMA D.C. (1993): Virtues in Medical Practice. Oxford: University Press. SENNET R. (2010): Etyka dobrej roboty. J. Dzierzgowski (transl.). Warszawa: Muza. SZEWCZYK, K. (2009): Bioetyka: Medycyna na granicach zycia, vol. 2. Warszawa: PWN. SZOSTEK, A. (1996): Etyka dziennikarska. In: Przeglad Uniwersytecki 6(44), pp. 22-23. 10 View publication stats