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HISTORICAL VIEWS OF THE LIMITS OF MEDICINE

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					HISTORICAL VIEWS OF THE LIMITS OF
MEDICINE
"Doctor, I have an ear ache."
2000 B.C. - "Here, eat this root."
1000 B.C. - "That root is heathen, say this prayer."
1850 A.D. - "That prayer is superstition, drink this
potion ."
1920 A.D. - "That potion is snake oil, swallow this pill."
1975 A.D. - "That pill is ineffective, take this antibiotic."
2006 A.D. - "That antibiotic is artificial. Here, eat this
root!"
MEDICAL HISTORY

The Ancient Egypt
2600 BC
The Egyptian Imhotep described the diagnosis
  and treatment of 200 diseases.
It is suggested that he was the first one who
  enreached the mummification about
  evisceration.
1550 BC
The important source of information is the Ebers
  papyrus. There is written about 878 medicinal
  drugs and different kinds of tumors, infestations,
  dysentery, cranial injury or bone fractures.
Examples of remedies in the Ebers Papyrus
Include:
Cancer  - recounting a "tumor against the god Xenus", it
   recommends "do nothing there against„.
Death - half an onion and the froth of beer was considered
   "a delightful remedy against death.
Ancient Greece
First doctors question about ethical limits of
  medicine.
The father of Medicine was Apollo.
The most famous work were written by
  Hippocrates in the third century BC.
Hippocrates quote:
Wherever the art of Medicine is loved, there is
  also a love of Humanity.
HIPPOCRATES
Doctor has a duty to heal the sick but he also
 refuse those who are completely overcome by
 disease.
If someone is overcomes by illness then medicine
 is powerless.
Knowing the limits of medicine is part of the skill
 of the doctor
Doctor who thinks he can heal someone who is
 beyond the limit of medical care is actually making
 an error known as „hubris“.
Who is the
 „hubris“?
A doctor who thinks he can
   heal someone who is
beyond the limit of medical
           care.
HIPPOCRATES
 The real doctor should be reliable, discreet, moderate,
  respectable and hard-working.
 Diagnosis had to be based only on careful observation
  or testing of disease symptom.
 During the treatment the doctor was obliged to write
  careful medical report.
 He emphasized that a cause of disease is inappropriate
  food, inadequate hygiene, unfavourable climate and
  risks connected with certain professions.
 Surgery should be used only if it mean effective
  treatment.
RULES OF HIPPOCRATIC MEDICINE
To understand the body to be subject to different
 forces or humours.
In a healthy person there is balance between them.
If person has an extreme imbalance of these
 forces it must be due to the nature of the person
A doctor can be of no help.
(except perhaps in helping the person die as
 painless as possible).
HIPPOCRATIC OATH

The doctors were obligated to follow the
 Hippocratic oath (it is Code of Ethics of medical
 profession containing moral principles of
 medical practice).
HIPPOCRATIC OATH
I swear by Apollo Physician and Asclepius and Hygeia and Panaceia and all the gods and goddesses,
making them my witnesses, that I will fulfill according to my ability and judgment this oath and this
covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with
him, and if he is in need of money, to give him a share of mine, and regard his offspring as equal to
my brothers in male lineage, and to teach his art – if they desire to learn it – without fee and
covenant,; to give a share of precepts and oral instruction and all the other learning to my sons and to
the sons of him who has instructed me and the pupils who have signed the covenant and have taken
this oath according to the medical law, but to no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will
keep them from harm and injustice.
I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.
Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and
my art.
I will not use the knife, nor even on sufferers of stone, but will withdraw in favour of
such men as are engaged in this work.
Whatever houses I visit, I will come for the benefit of the sick, remaining free of all intentional injustice,
of all mischief and in particular of sexual relations with both female and male persons, be they free or
slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the
life of men, which on no account one must spread abroad, I will keep to myself holding such things
shameful to be spoken about.
If it fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored
with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of
all this be my lot.
HIPPOCRATIC OATH

1. Where in the text you can find the relation to
   the teacher?
2. Where is in the text described the principle of
   maleficence?
3. Where is in the text described the need of
   confidentiality?
INTERNATIONAL CODE OF MEDICAL ETHICS OF THE
WORLD MEDICAL ASSOCIATION – 1949
Compare with Hippocratic oath:
1. Any act, or advice which could be weaken
   physical or mental resistance of a human being
   may be used only in his interest.
2. The requirement to be „loyal“ to his patient.
3. Doctors must not use „medical knowledge
   contrary to the laws of humanity.
4. The requirement that a doctor must practice his
   profession uninfluenced by motives of profit.
MEDIEVAL MEDICINE

The body was considered as a temporary
 physical box and the development of scientific
 medicine was neglected.
Monastic orders founded charity hospitals all
 around Europe.
LEONARDO DA VINCI (1452–1519)




           He anatomized human bodies
           and he painted several anatomic
           schemes.
ANDREAS VESALIUS (1514 – 1564)
MODERN TIMES

Modern science tried to dominate nature, to
 understand the way nature works.
Medical science began to adopt the same
 attitude towards medicine that science had
 adopted towards nature.
Sickness was no longer seen as a change in
 the balance of forces in the body.
 With development of bacteriology and germ theory of
  disease, it was decided that specific microorganisms were
  responsible for specific diseases          modern medical
  science felt it could dominate and destroy disease by
  destroying the microorganism.
MODERN TIMES
 There is complete belief in scientific progress.
 The doctors assume that their duty to the patient and
  society is to use every possible known medical method
  in every situation.
BUT it can lead to the ethical problems – for example:
1) How much medical care should be given to a patient
    who is dying?
2) Who would only benefit very slightly from medical care?
3) Why did these ethical questions or problems appear?
MODERN TIMES

Answers:
1. In most situations there are only limited
   resources available: medicines, staff,
   equipment.
2. An individual patient may be given health care
   which he or she doesn´t want.
What about the Hippocratic oath today?
What function does it fulfill today?
What does the Hippocratic oath mean to you?
HIPPOCRATIC OATH TODAY
Today the Hippocratic oath reminds students
 the importance of their profession, the need to
 teach others and the obligation to never
 knowingly harm a patient or divulge a
 confidence.
The principles state in the oath are found today
 in many of professional codes of ethics.
Do you know any of them?
What does the shortcut AMA mean?
WHAT IS THE SUBJECT OF ETHICAL CODES IN MEDI
PROFESSION TODAY?
   Abuse
   Accepting patients
   Allocations of health resources
   Confidential care of minors
   Euthanasia
   Fee spliting
   Financial incentives for organ donation
   Gene therapy
   Ghost surgery
   HIV testing
   Mandatory parental consent to abortion
   Physician-assisted suicide
   Quality of life
   Withholding or withdrawing life-prolonging treatment.
MEDICAL ISSUES RELATING TO BIOETHICS
 Abortion.                  Organ donation and
 Allocation of scarce        transplantation.
  health resources.          Quality-of-life-issues.
 Cloning.                   Random clinical trials.
 Euthanasia: active and     Stem cell research.
  passive.                   Sterilization.
 Fetal tissue research.     Surrogate parenthood.
 Genetic counseling.        Withdrawing treatment.
 Harvesting of embryos.     Withholding lifesaving
 HIV, AIDS and ARC.          treatment.
 In-vitro fertilization.
THREE STEP ETHICS MODEL
 Is it legal? When applying this three-step model, if the situation is clearly illegal, such as inflicting

    bodily harm on another, then matter is also clearly unethical, and you do not even have to progress to

    the second question. However, if the action is not against the law, then you should ask yourself the

    second question.

 Is it balanced? This question helps to determine if another person or group of people is negatively

    affected by the action. In other words, is there now an imbalance so that one person or group suffers

    or benefits more than another as a result of your action? For example, in the case of a scarce

    resource such as donor organs, does one group of people have greater access?

 How does it make me feel? This final question refers to how the action will affect you emotionally.

    Would you be hesitant to explain your action to a loved one? How would you feel if you saw your name

    in the paper associated with the action? Can you face yourself in the mirror?
EXAMPLE 1

  A patient in your hospital needs costly long
  term therapy to survive and the hospital will
  have to bear the cost. Should you authorize
  continued treatment if doing so would mean
  forgoing either needed emergency room
  renovation or a salary increase for the nursing
  staff?
  What should/would you do?
EXAMPLE 2
A severely defective newborn is delivered at your
hospital. The infant might survive for six months to a
  year with advanced medical technology. Attending
  physicians and invited medical consultants
  support the parents request to let the baby die
  without further medical intervention. You, the
  administrator, are aware of recent federal
  regulations („Baby Doe“) requiring treatment of
  handicapped infants.
What should/would you do?
EXAMPLE 3
 You have patient in your hospital whose upper brain is
 irreversible total loss of all upper brain function activity. A
 person can be upper brain dead, but have a fully
 functioning brain. Such a person is unable to chew or
 swallow, but his/her lungs and heart function without
 a machine. He/she can be kept alive for many years
 (e.g.30) by means of artificial nutrition and hydration. Total
 loss of upper brain function is not always irreversible, but no
 one has ever recovered full function after total loss for many
 years. There have, however, been a few cases of partial
 recovery of the function after total loss for a year.
 Do you think this person is alive?
THERE ARE THREE QUESTIONS
1. Do human beings with no capacity for future
   consciousness (e. g. Upper brain dead people)
   have right to live?
2. Do human beings for whom it is virtually, but
   not perfectly, certain that they will never have
   the capacity for consciousness (e. g., PVS
   patients) have a right to life?
3. Who has the right to decide whether a PVS
   patient will go on living? (a) God, (b) only a
   patient, (c) only the family, (d) only the state,
   (e) some other set of people?
WHAT IS THE SOLUTION?

It may be useful to consider the idea of futility.
Futile medical care would be when resources
 are used for a patient who has actually reached
 the limit of medical care.
REVISION
1. What does the word „hubris“ mean?
2. How did the Hippocratic medicine understand
   the processes of health and illness?
3. Why is the question of how much medical care
   should be given to a dying patient an ethical
   problem?
4. What is the difference between Ancient Greek
   and modern medicine?
5. What is futile treatment?

				
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posted:6/8/2014
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