298

Medical EthicsTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 7, NO.6, 1994

THE STARTING POINTSYou will recall that we decided to use Johnson's text! as abasis for initiating a discussion on the subject in this journal.Johnson explains, 'the study of medical ethics is the studyof values in the care of sick people and values must bederived from somewhere or someone'. In addition to thesevalues, we also have an obligation to apply what is goodand right.

CLASSIC PHILOSOPHY: ATHEIST AND THEISTJohnson harked back to classic philosophy. Plato definedmoral good as a harmony of all the virtues under the ruleof reason, the virtues existing independently of any person.This implies a higher authority responsible for these virtues.At once we face a problem. If the virtues exist independentlyof a person, it is upto that person to choose or reject them.Jean-Paul Sartre, whilst rejecting the existence of God,insisted that values are innate, man-made and self-imposed.

The scientific humanists, descendants of Charles Darwin,Thomas Huxley, Bertrand Russell and Julian Huxley, amongothers, affirm that moral values derived their source fromhuman experience. Ethics stem from human need andinterest. Whatever promotes the survival and improvementof the species is good. Actions follow the general opinionsand values of mankind.

Apologists for the current medical morass put fortharguments apparently based on the following tenets:

1. The twin goals of mankind at present appear to be wealthand power. Acts enabling us to reach these goals areethical.

2. Since ethics and obligations are often derived fromexamples set by the leaders among mankind, it is correctto follow the examples of a Narasimha Rao, Sharad Pawarand Bill Clinton.

3. When, in the words of a previous Prime Minister, corrup-tion is a universal phenomenon, how can doctors remainuntainted?

The fallacies inherent in such logic are obvious. To choosea path is to affirm the value of what is chosen. The choiceof an act destined to promote self-interest over the interestsof mankind cannot fall within scientific humanism. There isa distortion of values inherent in such a choice.

The ideals laid down by religious philosophers are simple.Good is what corresponds to the acts of the saints-basedon the concepts of God's ultimate motive of self-sacrificinglove. 'Love is patient. Love is kind. It does not envy, itdoes not boast. It is not rude, it is not self-seeking, it is noteasily angered, it keeps no record of wrongs. Love ...rejoices with the truth'. 2

All religions espouse similar ideals-honesty, humility,kindness, charity, service and self-abnegation.

ETHICAL COMPONENTS OF MEDICAL CAREThe goals of preventing and curing disease are basedeverywhere on traditional principles.

Primum non nocereFirst of all, do not harm. The final outcome of any measuretaken on behalf of the patient must be beneficial. Whenpotential damage outweighs possible benefit, the measureshould be avoided.

Beneficence'A doctor will do what is good for the patient, not what isgood for the doctor', always.' The glaring misdeed runningcontrary to this adage is the unnecessary operation.Removing normal organs (such as the tonsils, appendix anduterus) may not do the patient much harm but certainly dono good.'

To cure sometimes, relieve often, comfort alwaysThis fifteenth century statement of intent inscribed on thestatue of Edward Livingstone Trudeau (justly famed for hiscare of patients with tuberculosis in the era before the dis-covery of drugs against the tubercle bacillus) holds at theclose of the twentieth century. It exhorts us to improve thelives of our patients. It also emphasizes the need for eachof us to bear in mind constantly that medicine has not andnever will be the answer to all the ills of mankind nor willit ever transcend death. Heaven will not wait.

This principle, taken together with that of beneficenceprovides the logic behind the exhortation against strivingofficiously to keep alive. When the quality of life hasdeteriorated irrevocably to a subhuman level, the use ofordinary (leave alone extraordinary) means to prolong itruns contrary to respect for life.

Medicine must, in the words of Sir Peter Medawar,progress towards scientific meliorism, turning away fromscientific messianism.

The greatest good for the greatest numberHere, we encounter difficulties. 'Good' can be variouslydefined. 'The patient's well being' offers itself to less mis-understanding. If, however, we attempt to cater to the wellbeing of the premature neonate struggling to breathe andthe octogenarian attempting to cope with the failure ofseveral organs, we will end by benefitting neither.

This difficulty forced the United Nations to advocate thatminimum health care should be considered a basic humanright. As Johnson points out, even the provision of accessto 'Health for all by the year 2000' appears to be a Quixoticideal.

LEITER FROM MADRAS

Criteria for selectionSince resources are limited and needs infinite, how shouldwe select a beneficiary? The champion of the free marketeconomy will argue for the wealthy and politically powerful.Is this ethical? Should we not, instead, concentrate on theone who most needs help? Should not a young bread-winnerbe given preference over a decrepit head of state? Is it notjust and fair to help one who cannot help himself ratherthan one who will not help himself? Should the thoracicsurgery theatre be reserved for the youth with rheumaticheart disease rather than the chronic smoker with. coronaryartery disease?

Letter from Madras

299

You will have noted that we encounter almost as manyquestions, as facts and principles. It is upto us to offerreasoned answers. This is possible only after dispassionatedebate.

REFERENCE1 Johnson AG. Pathways in medical ethics. London:Edward Arnold, 1990.2 The Bible. 1 Corinthians: 4-7 (quoted by Johnson).

S. K. PANDYA

Most of us do not know why we take up medicine. We willtalk about the pleasures of doing good to people and thelack of dull routine. It is better than sitting at a desk, pushingfiles. It came therefore as a surprise that the Tamil NaduGovernment Doctors' Association (TNGDA) objectedstrongly to the appointment of officers from the IndianAdministrative Services (IAS) as heads of some healthrelated projects. The Government appointed these IASpersonnel to lead the AIDS Control Society, the Tamil NaduMedical Services Corporation and the Directorate of FamilyWelfare. The professionals rose up in arms. The StatePresident of the Association, Dr S. Krishna Kumar, saidthe family welfare programme had been run efficiently bydoctors in the past and there was no need for bureaucratsto take over. The grouse of the Government doctors is thatthey have only two ranks in the State service--civil assistantsurgeon and civil surgeon. They want to be directors andcomplain that if these posts are given to bureaucrats theiravenues for advancement will be reduced. The Governmentsaid it appointed trained administrators only to those postswhich needed such people. If a post called for a skilleddoctor, an appropriate professional would certainly beappointed. The TNGDA would have none of this. In anearlier letter, I mentioned the current readiness to indulgein labour union tactics with strikes and other forms ofagitation. This was another such occasion and the doctorsin the North Arcot district refused to perform eye operationsor family planning procedures. While the Health Ministerdecried this approach, it seems to have paid dividendsbecause ultimately the Government made a compromise ofsorts. While the IAS would continue to head the AIDScontrol programme, there would be a new post of technicaldirector which would be held by a medical person. In otherwords, the work which had earlier been done by one personwould now be shared between two at considerable expenseto the public exchequer. The prime aim of the government,it appears, is to create jobs. The government also agreed tohave a doctor to head the family welfare department andto consider the demands of doctors with regard to the otherposts.

The Tamil Nadu Village Health Nurses Association hadwelcomed the government proposal to have an IAS officerat the helm of health projects saying they could solve internalproblems more amicably. They seem to have lost this round.

In university circles in the West, it is widely held thatwhen an academic is no longer productive, he yearns to gointo administration as the only way to remain in the limelight.Is this the case with our doctors as well? If what they wantedto do was to warm chairs and push files, why did they notopt to do that from the beginning, instead of taking a placein the medical college which could have been filled by some-one more interested in healing the sick?

The Supreme Court issued a directive to all states to limitreservation in educational institutions to 50%. Tamil Nadu,which has kept 69% of its seats reserved for years, wishedto continue to do so. The further developments in this case,the passage of a bill by the state legislature to exemptTamil Nadu from this limit and the Central Government'sacquiescence, are common knowledge, and the matter is inthe courts again. I wish to draw your attention to twointeresting phenomena that Tamil Nadu demonstrated inthis connection.

The first was the state sponsored bandh (strike). Thefreedom struggle led to the general adoption of this tacticas a means by which an organization could protest againstauthority. We Tamils have improved on this. In our state,it is no longer a protest against, but a protest by, authority.How much more effective this is. Our Government with-draws all transport services, including trains and buses, andcrowns it all by declaring a holiday under the NegotiableInstruments Act. Even the airlines join in the fun and theirflights avoid our state. No one can go to work anyway, forthe mobs take over the road, and halt the movement ofprivate transport. The few taxis and auto rickshaws whichply take the opportunity to make a killing and demandtwenty times their normal fares. Everyone must perforcestay at home and the Government then declares that clearlythe mass of the people are in agreement with its policies