Letters to the Editor
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"Ethical issues often have no clear-cut answer, and faced with them, it is most improtant to reason out the issues at hand and identify the basic ethical principles involved." - Dr Peter Loke
"Mini Course on Medical Ethics"
The SMA Mini Course on Medical Ethics was held on Sunday morning, 15 November 1998. This was in conjunction with the SMA Ethics & Practice Convention held over that weekend.
Considering the early Sunday morning start at 8.55 am, the turnout of a hundred doctors was tremendous and quite unexpected. It only goes to show that much as the profession has been maligned for being increasingly mercenary, there are still many in our ranks who do care about being able to justifiably preserve the high esteem doctors are generally held in.
After being taken through the basic principles that underpin medical ethics by Dr David Chan from the Department of Philosophy, NUS, and A/Prof Goh Lee Gan, the highlight of the morning was the four case studies looking at very real life scenarios. It was most enlightening to see how to apply the theoretical parts which we have learnt at the course to the difficult situations we have faced or could one day encounter ourselves.
The first case centred on an outstanding 18-year-old sportsman who was facing a life-saving amputation for which he refused to consent to because he felt that life would be meaningless without his sport. Even though the exact facts may vary, it is a kind of situation we have faced or could one day encounter ourselves.
The audience was reminded that all the medical issues need to be explored fully first, especially the psychological aspects of the boys decision. It was just a pity that there was no psychiatrist among the crowd to contribute to the discussion of a possible grief reaction. Thereafter, the central issue to resolve is whether such a case calls for justified paternalism on the doctors part or if we should respect the patients autonomous choice. Questions were raised on whether accepting patient autonomy over all else in such a situation is actually abetting suicide, and whether a boy at that age is capable of an authentic decision. The utilitarian decision was that this case called for justified paternalism, as to allow the boy to die would be to lose a valuable member of society and have a devastating effect on his family.
The lively discussion this case provoked clearly illustrated a most important point made that morning. Ethical issues often have no clear-cut answer, and when faced with them, it is most important to reason out the issues at hand and identify the basic ethical principles involved. The ultimate decision might differ, but a good suggested end-point is the course chairmans "mirror test". This simply invites us all to look at ourselves in the mirror and ask if we have been true to ourselves and know we have made our decisions in the best interest of the patient. Often we can only resolve such dilemmas at this intuitive level, as principles of ethics and even the law often serve only as guidelines.
The second case discussed revolved around an old man found to have annular carcinoma of the oesophagus. The son who was aware of the diagnosis wished to keep his father in the dark about it, and the principle issue was whether the patient should be told of his condition against his sons wishes.
Here, everyone was reminded to refer to the flow charts shown earlier by A/Prof Goh Lee Gan to see if there is an ethical issue, and if so, to identify its components. That settled, the ball was back in the audiences court, and the opinions came thick and fast. A general consensus did come out of this case that the old man should be told of his diagnosis. Of prime importance here is the need to break the news gently and gradually to the patient, and of treating the bigger patient comprising the sick mans family.
The last two cases discussed mainly involve intra-professional etiquette and ethics. The first of these examined the problems that can arise when a doctor leaves a group practice. Patients are not given the new practice address of the doctor, and the group accuses the doctor of enticing patients away. In addition, the ownership of the patients notes is in question. Here, the legal aspects have to be addressed first. The contractual relationship between the doctor and group needs to be looked at, and it is at the pre-contractual stage that the doctor must look at the ethical issues that may exist in signing for the group. As for patients notes, ownership technically lies with the group, whereas the information inside is the right of the patient who thus must be able to have access to them.
The last case looked at the use of ones clinic to sell products, be it skin beauty treatments and cosmetics, health insurance policies or even lucky draw tickets for charity. The underlying concern with this is a tacit endorsement of the product the doctor is selling, which may not be in the best interest of the patient. It represents unfair pressure, whether actual or implied, for the patient to buy the product in question. Here again, the aim of the doctor is the crux of the issue. If stocking or selling a particular product is principally for the benefit of the patient, then it is justified. Otherwise, we would be wise to apply the "mirror test" and adjust our practice accordingly.
The morning ended with A/Prof Goh looking at the challenges we will be facing in the next millenium, and attempting to see how ethical issues debated upon since time immemorial can be applied to this increasingly complex world, both of medicine and at large, that we live in.
All in all, it was a thoroughly enlightening and enjoyable morning. Everyone was left hungry for the such a convention next year and it is hoped that even more doctors will make the effort to attend the next time around.
DR PETER LOKE