Hippocrates dealt with issues of medical ethics. The evolution of traditional medical ethics. Features of Percival's medical ethics

Medical ethics is a part of general ethics concerning moral, moral standards, which should be guided by health workers in relations with patients and fellow professionals. With a concept medical ethics closely related medical deontology, which should be considered as a set of principles and rules of conduct medical workers aimed at achieving the maximum benefit for the patient in treatment and prevention, to fulfill the medical duty, the duty of the health worker.

The work of a physician refers to those types of activities that require mandatory knowledge of various (mainly characteristic only of this profession) moral rules of behavior in relationships with others and, first of all, with sick people. The activities of medical workers, including middle ones, due to their complexity and diversity, do not always fit into the framework of the official prescriptions of the law, instructions and guidelines. Often a physician has to act in conditions that exclude the possibility of obtaining qualified advice or guidance. In such cases, the doctor or other health worker finds justification for his actions not only in existing laws and instructions, but also in existing moral rules their profession, as well as in the understanding of medical (medical) duty. Medical ethics is largely a reflection of these established professional medical rules and existing ideas about medical duty (medical duty). The experience of numerous generations of doctors and the best representatives of medical ethics crystallized in the rules of medical ethics. medical profession.

The outstanding physician of antiquity, Hippocrates, not only advanced the art of treatment, but I developed for the first time a coherent system of definite rules for the conduct of a doctor in relation to a patient. For doctors, according to Hippocrates and his followers, the basic rules should be: do not harm, do not disclose the secrets of the patient, do not deceive the patient, do not despair to the end in the possibility of saving the patient, etc. These and other statements became known as the “Hippocratic oath »; they were reflected in the so-called faculty promise, or doctor's oath, a solemn commitment signed by doctors upon graduation. The content of the faculty promise was to a large extent the code. The development of the main humane features contained in the Hippocratic oath and the faculty promise, and a reflection of the moral code of the builder of communism, is the oath of a doctor in the Soviet Union, which is taken by citizens of the USSR who graduated from higher medical educational establishments USSR and received the title of doctor [Fundamentals of the legislation of the USSR and the Union republics on health care (Article 13)].

Ethical ideas, including those related to medicine, always have a class character. In the conditions of capitalism, in which the basis of medical care is private practice, a significant part of doctors and other medical workers seek, first of all, to achieve individual well-being and recognition, often at the expense of the interests of the patient. In capitalist countries, the right to "freedom" to prescribe drugs is often used by doctors to collude with pharmacists and pharmaceutical firms, which give "bonuses" to doctors for prescribing expensive drugs, sometimes unnecessary or even harmful.

Between patients and doctors in the capitalist countries there are insurmountable barriers, mainly economic. The doctor is interested in increasing his clientele, so that there are more patients, since his budget depends on the fees that he receives from patients.

The relationship between physicians in our country and other socialist countries is fundamentally different from the relationship between physicians in the capitalist countries. There, private practice gives rise to competition between them, the struggle for clientele. In the USSR and in other socialist countries, publicly accessible and free medical care creates the conditions for truly comradely relations between medical workers, respect and mutual assistance.

The Hippocratic Collection contains five essays on medical ethics and the rules of medical life in ancient Greece. These are "Oath", "Law", "On the doctor", "On decent behavior" and "Instructions". Together with other works of the Collection, they give a complete picture of the training and moral education of healers and the requirements that were placed on them in society.

In the process of learning, the future healer had to educate in himself and constantly improve “contempt for money, conscientiousness, modesty ... decisiveness, neatness, abundance of thoughts, knowledge of everything that is useful and necessary for life, aversion to vice, denial of superstitious fear of gods, divine superiority ... After all, the doctor-philosopher is equal to God ”(“ On Decent Behavior ”).

The healer must learn to keep in mind the medicines, the methods of their preparation and correct application, not to get lost at the bedside of the patient, visit him often and carefully observe the deceptive signs of change. “All this should be done calmly and skillfully, hiding a lot from the patient in his orders, ordering with a cheerful and clear look what should be done, and turning the patient away from his wishes with perseverance and severity” (“On Decent Behavior”). However, when treating a patient, it is necessary to remember the first commandment: "first of all, do no harm." Later this thesis will appear in Latin literature: "Primum non pose-ge".

Worried about the patient's health, the healer should not start by worrying about his fee (remuneration), since "paying attention to this is harmful to the patient." If she presents herself to help a stranger or a poor person, then in particular it should be delivered to such people ”(“ Instructions ”).

Along with high professional requirements great importance was attached appearance healer and his behavior in society, "for those who themselves do not have a good appearance in their body, the crowd is considered unable to have the right care for others." Therefore, it is appropriate for a healer to “keep himself clean, have good clothes and rub himself with fragrant ointments, because all this is usually pleasant for patients ... He must be fair under all circumstances, because in many cases the help of justice is needed” (“About the Doctor”).

At the end of his studies, the future healer took the “Oath”, which he inviolably followed throughout his life, for “he who succeeds in the sciences and lags behind in morality is more harmful than useful.”

When the "Oath" was first composed is not known. In oral form, it passed from one generation to another and in its main features was created before Hippocrates. In the III century. BC e. "The Oath" was included in the "Hippocratic Collection", after which in wide circles it began to be called by the name of Hippocrates.

Along with the medical "Oath", in ancient Greece there were legal "Oath", oaths of witnesses and many others. All of them assumed the assistance of the gods who consecrated the "Oath" and punished perjurers (in the case of the medical "Oath" these are the gods Apollo, Asclepius, Hygiea and Panacea). Thus, the "Oath" given by the healer upon graduation, on the one hand, protected patients, being a guarantee of high medical morality, and on the other hand, provided the healer with the full trust of society. The laws of medical ethics in ancient Greece were strictly enforced and were the unwritten laws of society, because, as they say in the "Instructions", "where there is love for people, there is love for one's art."

Today, each country has its own “Oath” (or “Oath”) of noach. Preserving the general spirit of the ancient Greek "Oath", each of them corresponds to the modern level of development of medical science and practice, reflects national characteristics and general trends in world development. An example of this is the latest addition that was made to the text of the Oath of a Doctor of the Soviet Union" in response to the call of the III Congress of the movement "Physicians of the World for the Prevention of Nuclear War", held in Amsterdam in 1983. Here are these lines:

Conscious of the danger posed by nuclear weapons, fight tirelessly for peace and for the prevention of nuclear war.

This call today unites the eyes of all continents of the earthly sha-ea and reminds us with renewed vigor of the great wisdom laid down in antiquity: high professionalism has the right to life only on the condition of high morality.

A. A. Stabredova

Medical ethics of Hippocrates and modern medicine

Ethics (from other Greek τὸ ἦθος ‘custom, custom’) is the doctrine of morality. Medicine is a field of science and Practical activities aimed at preserving and strengthening people's health. Medical ethics is an integral part of ethics. The sciences that are currently involved in medical ethics are bioethics (from the ancient Greek ὁ βίος 'life' and τὰ ἠθικά 'the doctrine of morality, ethics') and medical deontology (from the ancient Greek τὸ δέον, οντος 'duty , duty' and ὁ λόγος 'teaching').

In ancient Greece, a doctor who gave Special attention ethical standards healing, was Hippocrates - the famous healer, who came from the island of Kos. It was Hippocrates who in his treatises reflected the inextricable link between medicine and ethics. The name of Hippocrates is associated with the idea of ​​a high moral character and ethics of a doctor's behavior. The ethical views, requirements and prohibitions of Hippocrates are set forth in the books of the Hippocratic Corpus: Oath, Law, On the Doctor, On Decent Behavior, Instructions.

Having studied the above-mentioned treatises, we have identified eight ethical principles of Hippocrates related to the relationship of a doctor with patients, colleagues, and his moral qualities.

These principles are:

1. The principle of non-harm, concern for the benefit of the patient, the dominant interests of the patient.

2. The principle of careful informing the patient, allowing him to be misinformed.

3. The principle of respect for life, a negative attitude towards euthanasia, complicity in suicide, and abortion.

4. Commitment to renounce intimate relationships with patients.

5. The principle of medical secrecy and confidentiality.

6. Obligations to teachers.

7. Commitment to transfer knowledge to students and to consult with colleagues.

8. Obligations of professional and moral self-improvement and decent behavior.

In our article, we will compare the medical ethics of Hippocrates with modern ones and consider how the ethical principles in medicine.

The main principle both in modern medicine and in the ethics of Hippocrates is the principle of non-harm, concern for the benefit of the patient, the dominant interests of the patient. The Hippocratic Oath says: “I will direct the regime of the sick to their benefit ...<…>Whatever house I enter, I will enter there for the benefit of the sick ”(“ Oath ”). The Code of Medical Ethics of the Republic of Belarus states: “In the work of a doctor, a rude and inhumane attitude towards a patient, humiliation of his dignity, expression of hostility or preference for other patients is unacceptable. The doctor is obliged to give preference to the interests of the patient, if this does not cause harm to the patient himself or to those around him.

In Hippocrates, the principle of careful informing the patient, which allows him to be misinformed, plays an important role. The treatise “On Decent Behavior” says that the doctor has the right to hide all the details of the course of the disease so as not to worsen the situation of the patient: “Everything ... should be done calmly and skillfully, hiding a lot from the patient in his orders ... and not telling the patients what will come or has come, because many patients for this very reason ... were brought to an extreme state ”(“ On Decent Behavior, XVI). However, in modern medical ethics, in contrast to the ethics of Hippocrates, the patient has the right to have complete information about the diagnosis, the purpose of the proposed treatment, its possible consequences, and the prognosis in case of refusal of treatment.

One of key principles Medical ethics of Hippocrates can be called the principle of respect for life, a negative attitude to euthanasia, to complicity in suicide, to abortion. The “oath” reads: “I will not give anyone a lethal agent asked of me and will not show the way for such a plan ... I will not give any woman an abortion pessary” (“Oath”). In the modern medical society, there are different points of view on the problem of euthanasia and abortion, but most doctors adhere to the point of view of Hippocrates. For example, the Code of Medical Ethics of the Republic of Belarus states: “Euthanasia as an act of deliberate deprivation of the life of a patient at his request or at the request of his relatives is unacceptable.” And the right of a doctor to refuse to perform an abortion is enshrined in the Geneva Declaration of the World Medical Association: “I will show the highest respect for human life from the moment of its conception and never, even under threat, use my medical knowledge to the detriment of the norms of humanity.” As for our country, in June 2014, changes and additions were made to the Belarusian law on health care, which also touched upon the issues of artificial termination of pregnancy. Now the right of Belarusian doctors to refuse to perform an abortion, if it is contrary to their beliefs, is enshrined in law, but the new provisions have not yet come into force.

Of particular note is the principle of the obligation to renounce intimate relationships with patients. The "Oath" says: "Whatever house I enter, I will enter there ... being far ... from love affairs with women and men, free and slaves" ("Oath"). Nowadays, it is also considered incorrect to have intimate relationships with patients. Thus, this principle in modern medical ethics is fully consistent with the teachings of Hippocrates.

In our opinion, one of the most important principles in medical ethics is the principle of medical secrecy. The “Oath” says: “Whatever during the treatment ... I see or hear about human life ... I will keep silent about that, considering such things a secret” (“Oath”). In modern society, this principle is somewhat modified. For example, one of the articles of the Code of Medical Ethics of the Republic of Belarus states: “A doctor may disclose information about the patient’s health status to close relatives ... as well as health authorities and law enforcement agencies in cases provided for by the legislation of the Republic of Belarus.”

An important principle is the principle of obligation to teachers. The “Oath” says: “I swear ... to consider the one who taught me the art of medicine on an equal footing with my parents, share my wealth with him and, if necessary, help him in his needs” (“Oath”). In today's medical society, future doctors also promise to show respect to their teachers, as enshrined in the Geneva Declaration of the International Medical Association: "I will give my teachers the respect and gratitude they deserve."

Also important is the principle of obligation to transfer knowledge to students and consult with colleagues. The “oath” reads: “I swear ... instructions, oral lessons and everything else in the teaching to communicate to my sons, the sons of my teacher and students” (“Oath”). The treatise "Instructions" says: "There is nothing shameful if a doctor who is difficult in any case with a patient ... asks to invite other doctors with whom he could jointly find out the situation of the patient" ("Instructions", VIII). The Code of Medical Ethics of the Republic of Belarus states: “If a doctor has professional difficulties, he must immediately seek help from competent specialists.”

The last of the principles we have identified is the obligation of professional and moral self-improvement and decent behavior. The "Oath" says: "Pure and blameless I will spend my life and my art" ("The Oath"). The Code of Medical Ethics of the Republic of Belarus states: “The main condition for successful medical activity is the professional competence of a doctor and his high moral qualities. The doctor is obliged to improve his qualifications throughout his professional activity.

Thus, in modern medicine, some of the principles of Hippocrates' medical ethics have not changed, others have undergone some changes, and still others are controversial both among physicians and in society. They are united by the fact that they did not cease to exist with the end of the era of Hippocrates, but continue to some extent retain their relevance and develop along with the evolution of society.

Literature

1. Hippocrates. Selected books / Hippocrates; per. from Greek prof. V. I. Rudneva; ed., entry. articles and remarks prof. V. P. Karpova. - Moscow: State. ed. biol. and honey. liters, 1936. - 736 p.

2. Code of Medical Ethics of the Republic of Belarus [ Electronic resource]. - 1999. - Access mode: http://www.beldoc.by/documents//. - Date of access: 04/01/2015.

3. Shamov, And. BUT. Bioethics: textbook. guide to ethical and legal documents and regulations/ I. A. Shamov, S. A. Abusuev. - Makhachkala: Publishing House of the DSMA, 2001. - 446 p.

About the author(September 2015): Stabredava Alyaksandra Anatolyeva - 2nd year student of the specialty "Classical philology" of the philological faculty of the Belarusian Dzyarzhaўnaga University (Minsk).

Output: Philalagical studies = Studia philologica: sb. navuk. art. / pad red. G.I. Shauchenka, K. A. Tananushki; editorial staff: A. V. Garnik [i insh.]. - Issue. 8. - Minsk, 2015. - C. 75–78.

Bioethics is a significant point of philosophical knowledge. The formation and development of bioethics is closely connected with the process of changing traditional ethics in general, as well as medical and biological ethics in particular. It can be explained primarily by the significantly increased attention to human rights (in particular, in medicine, these are the rights of the patient) and the creation of the latest medical technologies, which give rise to a lot of problems that require urgent solutions, from the point of view of both law and morality.

In addition, the formation of bioethics is determined by colossal changes in the technological support of modern medicine, great achievements in medical and clinical practice, which have become acceptable due to the success of transplantology, genetic engineering, the emergence of new equipment to support the patient's life and the accumulation of practical and relevant theoretical knowledge. All these processes have made the most acute moral problems that are now facing the doctor, relatives of patients, nursing staff.

Are there limits to the provision medical care, and what should they be in maintaining the life of a terminally ill person? Is euthanasia acceptable in modern society? From what time should the onset of death be counted? Since when can a human fetus be considered a living being? Are abortions allowed? These are some of the questions that confront the doctor, as well as society at the present level of development of medical science.

Bioethics is an interdisciplinary research area that emerged around the late 1960s and early 1970s. The term "bioethics" itself was introduced by W. R. Potter in 1969. Today, its interpretation is very heterogeneous. Sometimes they try to equate bioethics with biomedical ethics, limiting its content to ethical problems in the doctor-patient relationship. In a broader sense, bioethics includes a number of social problems and problems that are associated with the health care system, the attitude of man towards animals and plants.

And also the term "bioethics" suggests that it focuses on the study of living beings, regardless of whether they are used in therapy or not. Thus, bioethics is guided by the achievements of modern medicine and biology in substantiating or solving moral problems that arise in the course of scientific research.

In the past there were various models, approaches to the issue of morality in medicine. Let's consider some of them.

Hippocratic model ("do no harm")

The principles of healing, which were laid by the "father of medicine" Hippocrates (460-377 BC), are at the origins of medical ethics. The famous healer in his well-known "Oath" formulated the obligations of the doctor to the patient. Its main position is the principle of "do no harm." Even despite the fact that centuries have passed since then, the “Oath” has not lost its vitality; moreover, it is the standard for the construction of many modern ethical documents. In particular, the Russian Doctor's Oath, which was approved at the 4th Conference of the Association of Russian Doctors in Moscow in November 1994, contains positions that are close in spirit and even in wording.

Paracelsus model ("do good")

Another model of medical ethics was formed in the Middle Ages. Most clearly, its postulates were set forth by the physician Paracelsus (1493-1541). In contrast to the Hippocratic Oath, when a doctor wins the patient's social trust with his attitude, in the Paracelsian model, paternalism is of paramount importance - the emotional and spiritual contact between the doctor and the patient, on the basis of which the treatment process is built.

In the spirit of the Middle Ages, the relationship between a doctor and a patient can be compared with the relationship of a spiritual mentor and a novice, since the concept of “pater” (lat. - father) in Christianity also applies to God. The essence of the relationship between the doctor and the patient is determined by the good deed of the doctor, and the good, in turn, has a divine origin, for every good comes to us from above, from God.

Deontological model (principle of "observance of duty") Formed later. It is based on the principle of "observance of duty" (from the Greek. deontos - "due"). It is based on the strict observance of the prescriptions of the moral order, the observance of a certain set of rules that are established by the medical community, society, as well as the doctor's own mind and will for their mandatory implementation. Each medical specialty has its own "code of honor", non-compliance with which is punishable by disciplinary action or even exclusion from the medical class.

Bioethics is also understood as the principle of "respect for human rights and dignity". Modern medicine, genetics, biology, relevant biomedical technologies have come very close to the problem of managing and predicting heredity, the problem of life and death of organisms, the control of many functions of the human body, even at the tissue, cellular level.

For this reason, the question of respecting the rights and freedoms of the patient as an individual has become more acute than ever. Compliance with the rights of the patient (the right to information, the right to choose, etc.) is entrusted to ethical committees, which actually made bioethics a public institution.

The considered historical models can be considered "ideal". Today, in practice, there are more realistic models that include some legal aspects of the described relationship.

Sometimes most of the problems appear in medical practice where neither the condition of the patient nor the procedures prescribed to him by themselves generate them. In daily contacts with patients, morally extraordinary situations generally do not arise.

The most important problem in modern medical ethics is that health care should be the right of every person, and not a privilege for a limited circle of people who are able to afford it. Today, as, indeed, in the past, medicine does not follow this path. Although this norm as a moral requirement is gaining more and more recognition today. Two revolutions played an important role: biological and social. Thanks to the first revolution, health care became the right of every person. All members of society are to be regarded as equal in that which is united with their human qualities—dignity, freedom, and individuality. According to the human right to health care, historically established models of moral relationships "doctor-patient" and the state modern society, the following synthetic models of the relationship between doctor and patient can be considered acceptable.

Model "technical" type

One of the results of the biological revolution is the rise of the medical scientist. Scientific tradition commands the scientist to be "impartial". His work must be based on facts, the doctor must avoid value judgments. Only after creating atomic bomb and medical research of the Nazis, when no rights were recognized for the test subject (we are talking about experiments that were carried out on prisoners of concentration camps), humanity began to realize the danger of such a position.

A true scientist cannot be above universal human values. When making important decisions, he also cannot avoid judgments of a moral and other value character.

Sacred type model

The paternalistic model of the doctor-patient relationship has become polar to the model described above. Sociologist Robert N. Wilson has characterized this model as sacred.

The main moral principle, which formulates the tradition of the sacred view, says: "Helping the patient, do not harm him."

In the works of medical sociology, one can find the position that images of the child and the parent invariably arise between the patient and the doctor.

Although paternalism in the range of values ​​deprives patients of the opportunity to accept own solutions, shifting it to the doctor. Thus, for a balanced ethical system, it is necessary to expand the range of moral norms that physicians must adhere to. Here are the basic principles that a doctor must follow in this model.

1. Benefit and do no harm. No one can remove a moral obligation. The doctor should bring only benefit to the patient, avoiding completely causing harm. This principle is taken in a broad context and constitutes only one element of the whole mass of moral obligations.

2. Protect personal freedom. The fundamental value of any society is personal freedom. The personal freedom of both the doctor and the patient must be protected, even if it seems to someone that this could be harmful. The judgment of any group of people should not serve as an authority in deciding what is beneficial and what is harmful.

3. Protect human dignity. The equality of all people according to their moral principles implies that each of us has the main human dignity. Personal freedom of choice, complete control of one's body and one's own life contribute to the realization of human dignity.

4. Tell the truth and keep promises. The moral duty of the physician to tell the truth and to keep promises made is as reasonable as it is traditional. But one can only regret that these grounds for interaction between people can be made minimal in order to comply with the “do no harm” principle.

5. Observe justice and restore it. The social revolution increased public concern about the equality of the distribution of basic medical services.

Thus, if health care is a right, then this right should be for everyone. The negative feature of such a model is that the observance of all these principles is entrusted only to the doctor, which requires the highest moral qualities from him.

Unfortunately, now a similar approach in the provision of medical services is very difficult to implement due to the high level of discrimination on various grounds (material, racial, sexual, etc.).

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The first part of the "Oath" contains a description of the relationship within the medical profession, in particular, between teacher and student. The one who enters the profession actually becomes an adopted member of the teacher's family, and his strongest obligations are precisely to the teacher and the teacher's family. Important are the requirements forbidding the disclosure of medical knowledge to those who have not taken the oath, and protecting the ranks of the profession from the penetration of the unworthy. The medical community thus appears to us as a highly closed social organization, which could be denoted by such words as “order” or “clan”.[ ...]

Doctoring, which in certain situations implies the need for visual and similar examinations of the patient by a doctor of the opposite sex, as it were, destroys the corresponding moral barriers, “neglects” the cultural context of gender relations in society. It is this side medical practice, as well as the special depth of spiritual contact, the influence of the doctor on the patient (and even power over him) contain the possibility of abuse.[ ...]

The problem posed by Hippocrates retains its practical relevance for modern medicine. For example, in 1991, the Committee on Ethical and Legal Affairs of the American Medical Association, having considered the ethical aspects of the relationship between doctors and patients, made a special decision: intimate contacts between a doctor and a patient that occur during treatment are immoral.[ ...]

Perhaps none of the ideas of Hippocratic ethics attracts today, at the turn of the 21st century, more interest (not only in the professional medical environment, but in society as a whole) than the idea of ​​respect for human life. All the huge modern literature devoted to the problems of euthanasia and abortion, in a certain sense, comes down to the polemic of supporters and opponents of the position of Hippocrates: “I will not give anyone a lethal agent asked of me and will not show the way for such a plan; likewise, I will not give any woman an abortion pessary.”[ ...]

Although the term “euthanasia” is not found in the texts of Hippocrates, the given provision of the “Oath” obviously does not allow such a moral choice of a doctor in relation to a dying patient, which in modern literature on bioethics is called “active euthanasia”; the tactics of “assisting with suicide”, also extremely widely discussed in last years(for more on this, see chapter X).[ ...]

As we can see, many essential features of the “paternalistic model” of the relationship between the doctor and the patient were developed back in the time of Hippocrates. The fatherly-patronizing style of behavior of the doctor is also inherent in many other advice and instructions of the Hippocratic Corps.[ ...]

An integral part of the Hippocratic ethics are moral prescriptions regarding the relationship of doctors with each other: “There is nothing shameful if a doctor who is difficult in any case with a patient ... asks to invite other doctors.” At the same time, "doctors examining the patient together should not quarrel with each other and ridicule each other." It is not appropriate for doctors to be likened to “neighbors by trade in the square”, “the judgment of a doctor should never arouse the envy of another”. Faced with the mistake of a colleague, you must at least keep in mind that you are also a person and you can also make mistakes, “for in every abundance there is a lack.”[ ...]

The moral and ethical instructions of Hippocrates instruct the doctor to keep under ethical control not only the professional activity but also your whole lifestyle. Yes, this is such a high ethics that the question arises - is it possible for a person-doctor who takes an oath: “I will spend my life purely and blamelessly”? Here, in particular, at what price is given "good fame" in medicine: "To me, who inviolably fulfills the oath ... let it be given ... glory to all people for eternity." This is the real meaning contained in the words (only at first glance arrogant): “Medicine is truly the noblest of all arts.”[ ...]

The problem of the authority of medicine in Hippocrates has another very important aspect- this is an assessment and criticism of the activities of "pseudo-doctors". The author of the book “The Law” states about doctors: “there are many of them by rank, but in reality they are as few as possible.” The book "On Decent Conduct" speaks of those who, "possessing professional dexterity, deceive people ... Everyone can recognize them by their clothes and other ornaments." As for true doctors, then, having many positive qualities (“demanding to debaters, prudent in making acquaintances with others like themselves”, etc.), they also “give in general information everything that has been accepted from science.” However, in the light of the text of the “Oath”, this “for general information” most likely includes only a limited circle of the elite.