Bulletin der Schweizerischen Akademie der Medizinischen Wissenschaften最新文献

Rules of medical ethic bid since the times of antiquity to respect the patients dignity. Today to respect the dignity of any man is a general legal rule. In the same way other rules of the traditional medical ethic became legal norms as for instance the command forbidding to do harm to someone. The law intends to limit the possibilities to exercise power. Therefore it does not compete to the doctor alone to decide that a medical treatment has to be applied. The legal base of a medical treatment lies in the consent of the patient who has been duly cleared up on his state, the necessary treatment and its risks. If it has to be decided if a doctor has given the right treatment in a special case it does not suffice to consult the general rules of the law; the circumstances of the case have to be considered as well. The doctor has to decide, according to the actual medical knowledge and the rules of his professional art what the appropriate proceeding is. Legal and medical considerations are closely connected if one judges a doctor handling a special case. If the patient consents, the doctor is not obliged to treat him, but he is entitled to do it, cases of emergency excepted. If and in what way he treats the patient has to be decided by the doctor according to medical criterias. If a patient, sound of mind, who is suffering heavily by an incurable illness asks the doctor to restrain treatment to alleviating the pains and to the absolute cares to preserve life, the doctor is bound by his patient's wish. In analogy the legal construct of "conducting business without mandate" allows the doctor to proceed in the same way if the patient who lost consciousness is not able to decide upon the treatment and whose death is inevitable and imminent if this is the only wise to respect the dignity of the patient.

The psychological aspects of medical ethics are described and analysed in terms of the doctor-patient relationship. Analysing the patient's needs, the doctor ceases to regard him as an "object" for his diagnostic and therapeutic procedures and makes him the "subject"; this implies respect for his person and his rights. From this psychological and ethical perspective, questions of patient information, professional secrecy, therapy transfer and the doctor's authority are discussed. Psychiatry poses specific problems both in practice (admission of patients to hospital although their illness prevents them from giving their consent) and in its theory (is mental illness real?). Ethical problems force the practitioner to reconsider his concept of man and his options in respect of freedom.

As a professional organization, the Federation of Swiss Physicians must make sure that generally admitted rules of ethics as well as professional regulations in this matter are recognized and observed by its members. In its statutes, it asserts itself for a high level medical care of the population; it requires not only a permanent renewal of professional aptitude as a duty in the widest meaning of the word, but also a great sense of responsibility for patients and society. Axioms on professional ethics are unfit as arguments for material requirements to fulfil the best possible all these duties. Credibility is only granted if ethical rules are really observed.

A series of situations and decisions involving medical ethics in a prison medical service are discussed. The doctor's independence is considered in relation to his contract with administrative authorities. In contrast with most private doctor-patient relationships, there is usually no possibility for prisoners to choose their doctor and vice-versa. Freedom of consent on the part of the patient may also imply a right to no-treatment. Medical care in prison is not easy to delineate, also because patients often try to involve the doctor in non-medical demands. A prison doctor should avoid taking part in decisions which ought to be made by the judiciary or by administrative authorities. Programmes involving preventive medicine and sociotherapy imply collaboration between therapeutic and security staff. The continuous interplay and readjustment between powers based on public authority, on the rights of each individual prisoner and on the medical programmes makes it possible for some sort of therapeutic freedom to exist in the prison.

The Federal Office of Public Health is a governmental administration in charge of control and coordination measures related to the field of health protection. A rough 20% of the 220 officials and employees have university education prevailingly in medicine or natural sciences. Any government is working for the benefit of the general public and ought not to end in itself. Although there is a potential danger of abuse of official authority and power and of corruption, such deviations have proved to be quite rare in Switzerland. The safety guarantees are sufficient and we furthermore dispose in general of a professionally and morally well qualified staff. A governmental institution is as good or as bad as the humans working for it. A careful selection of the civil servants is therefore of utmost importance. On the whole, the quality of our civil service is quite superior to its reputation. Negative global judgements are to be declined. The Federal Office of Public Health aims at respecting the principles of the medical ethics in all its activities.

Specific examples illustrate that biological research and its medical applications often contain, besides known risks, also hidden risks, which may become apparent with delay. Scientists are expected to carefully watch for such risks in order to limit their possible undesirable effects.

In his treatment of the patient, the doctor must be guided not simply by concern for the patient's biological existence but ultimately by concern for the dignity and integrity of his person. These qualities are founded in the patient's innate human freedom, which equally underlies his entitlement to life and to proper treatment without sacrifice of his right to self-determination, his inviolability and his human dignity. Self-determination presupposes the right to information and communication, and this in turn an obligation on the part of the doctor to talk in terms which the patient understands and to devote sufficient time to his needs. Respect for the inviolability of the patient's person implies not only his right to the security of confidentiality and discretion, but also his right, when receiving any form of treatment, to be acknowledged as a physiological, psychological and social entity with a concrete individuality. Human dignity, finally, implies the right of each individual to be the real "raison d'être" for any treatment to which he is subjected. Beyond this, a right to health can only exist in the negative sense of the right not to be made avoidably ill by the social order, and a right to sickness only in the restricted sense of not being put at a social disadvantage as the result of a medically diagnosed illness.

The guidelines of medical ethic are recommendations of the Swiss Academy of Medical Sciences to the medical doctors to overcome the difficulties of medicine and modern technics and social problems. In an introduction the duties of the physician and his behaviour in the hippocratic mind are exposed, without asking for an oath. The recommendations give I. essential rules of international health organisations and II. Medical-ethic guidelines regarding different questions: 1. research examinations on men 2. euthanasia 3. transplantation 4. artificial insemination 5. sterilisation, especially the operative sterilisation of mentally handicapped persons, without acceptation of the so-called forced sterilisation 6. medical-ethical committees. The newly founded medical-ethical commission of the Swiss Academy of Medical Sciences and its organisation with physicians and laymen is explained. Its different functions are: a) answers to inquiries of international or national organisations and of individual persons b) formulation of principal ideas for medical-ethical questions, which will arise also in the future, not only on research, but also on diagnostic, therapeutic or prophylactic problems. These medical-ethical guidelines are formulated in few words to help the medical doctor for a quick consultation. They give a legal ethic. The Swiss Academy of Medical Sciences considers this as one of her tasks: to guard and to guard and to advance ethical devices in medicine.