Ethics through the looking glass [CMAJ

Ethics through the looking glass

Peter S. Craighead

CMAJ 2000;162:1147-8

See also:

Vigilance is needed [Letter]
Ethics and human rights in South African medicine [Review]

The report by John Williams¹ on ethics and human rights in South African medicine in this issue (see page 1167) is a good reminder to all of us who practise medicine that we are accountable to the communities we claim to be responsible for. Williams outlines the many serious failings of the professional organizations and individual physicians who practised during apartheid. These include the provision of inferior health care to nonwhite South Africans by way of reduced funding and compromised access to care, the involvement of physicians in practices that harmed "enemies" of the government and the failure of the medical profession to oppose unethical policies of the government. Williams also describes the transformation of the country's medical organizations since apartheid was dismantled and the steps being taken to integrate the teaching of ethics into medical education programs. Since the cornerstone of Canadian medicare is the provision of high quality care for all citizens regardless of race, culture, language or religion, we might assume that as far as medical ethics goes all is well in this country. In fact, there is much in Williams' report to challenge our complacency.

The history of the 20th century teaches us that complicity between governments and medical professionals is nothing new. Examples include the Kremlin's use of Soviet physicians to commit political refugees to psychiatric institutions,² the involvement of Nazi physicians in the attempt to build a pure Aryan nation and the history of eugenicist policies and programs within Canadian health care jurisdictions.³ The report on South African health care ethics, rather than make us sanctimonious about our own record, should cause us to ask whether physicians in Canada have the skills they need to grapple with ethical problems. For it seems that we humans are capable of making unethical choices fairly easily. Whether based in human rights, utilitarianism or some other framework, the essence of ethical thinking is to lead us to make more good decisions than bad ones.

We are fortunate to live in a country with strong democratic philosophies. Nevertheless, ethical issues are likely to become more pressing in the daily practice of medicine as time goes on. The conflicts that are bound to arise between new technological innovations and the survival of publicly funded health care will bring immense pressure to bear on our health care system. The coding of the human genome, new reproductive technologies, the surgical manipulation of organs in utero and genetic therapies among other innovations will challenge physicians' attitudes significantly. Unless we adopt ethical approaches to weighing potential benefits and the harm of treatment options, our profession will fall into the trap of expediency in dealing with weighty issues.

How are we positioned to deal with the significant ethical issues that will besiege us in the 21st century? The promotion of comprehensive ethics teaching as a statutory requirement in medical education programs in South Africa is a huge step forward, one that promises to integrate ethical principles and clinical practice in that country. Can our medical ethics education claim to be as comprehensive? Are ethics and practice sufficiently integrated in Canada? Furthermore, do ethicists have any involvement in setting undergraduate medical curricula in Canada? One gathers that even in Canadian medical schools with a strong track record in bioethics teaching, there is little ethics involvement in setting undergraduate curricular priorities and infrastructural support for such teaching is suboptimal.

So what should be done? At a minimum, each medical school should have a strong bioethics infrastructure to assist health care professionals in their decision making and to force us to view issues from an ethical standpoint. Will this mitigate the coercive tactics of corrupt governments and safeguard ethical medical practice? Experience tells us that societies in such countries generally are unable to mount resistance to strong governments and need at least a few individuals with strong ethical beliefs to focus attention on the moral weaknesses of a system. If education in ethics trains at least some physicians to advocate for their patients in active ways, this would be sufficient justification for a greater emphasis on ethics teaching, to my mind.

Finally, we should ask ourselves whether the health care provided to the diverse cultures represented in our society is optimal, and whether the longer waiting times for diagnostic and treatment facilities indicates a reluctance of physicians to act as advocates for their patients. I suspect that most of us recognize the advantages of our health care system; any problems are generally unrelated to prejudicial government policies and are not directly linked to the failure of physicians to become involved in advocacy. Nevertheless, we would do well to ensure that our clinical practice is based on as strong a moral and ethical code as possible and that we don't make unethical decisions simply because we don't know what wrong and right are.

Competing interests: None declared.

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Dr. Craighead is Director of the Department of Radiation Oncology, Tom Baker Cancer Centre, Calgary, Alta.

Correspondence to: Dr. Peter Craighead, Director, Department of Radiation Oncology, Tom Baker Cancer Centre, 1331 29th St. NW, Calgary AB T2N 4N2; fax 403 283-2809; peterch@cancerboard.ab.ca

References

Williams J. Ethics and human rights in South African medicine. CMAJ 2000;162(8):1167-70.
Solzhenitsyn AI. The Gulag Archipelago 1918-1956: an Experiment in Literary Investigation [Translated from Russian by Whitney TP]. New York: Harper & Row; 1974.
Government of Alberta. Institutional Confinement & Sexual Sterilization Compensation Act Introduced. Government of Alberta News Release 1998 Mar 10. Available at: www.edt.gov.ab.ca/pab/acn/199803/5962.html (accessed 2000 Mar 13).