What is ethics in medicine definition. Questions of medical ethics and deontology. Nurse Patient Interaction

Medical ethics and medical deontology... Bioethics

The term "ethics" comes from the Greek "ethos", i.e. custom, disposition. Another term has almost the same meaning - "morality" (from the Latin "morbus"). Therefore, "ethics" and "morality" are usually used together. Ethics is often qualified as a science, theory, doctrine of morality and ethics, i.e. as a science about the forms of social consciousness. Prof. A.A. Grando in study guide for students of medical institutes, with good reason, writes: "Ethics is a science that deals with the determination of the moral value of human aspirations and actions." There are hundreds of definitions of ethics (as well as morality, morality). There are even more discrepancies in the understanding of the term "deontology". At the I All-Union Conference on the Problems of Medical Deontology (1969), organized on the initiative of the Minister of Health of those years, Acad. B.V. Petrovsky and acad. USSR Academy of Medical Sciences A.F. Bilibin, who devoted a lot of effort and attention to the problems of ethics and deontology, in his opening remarks BV Petrovsky defined deontology as "the doctrine of the doctor's duty not only to the patient, but also to society." This term came into use, and, above all, in scholarly works and speeches as a doctrine about what should be, about duty. In fact, the author of the term, the English jurist I. Bentam, in his well-known book "Deontology or the Science of Morality" (early 19th century) considered deontology as a teaching about what should be done (hence the origin of the term itself) in human behavior. He contrasted deontology with ethics as the science of morality or socially proper behavior of people. This understanding of deontology opened up scope for all kinds of individualistic and not always humane activities, could justify selfish morality and ethics. The author of the term gave him an antihuman orientation, but he became the embodiment of behavior that meets the high purpose and humane activities of a physician. I. Bentam gave his teaching certain normative features, i.e. considered deontology not so much as a theory, teaching, but as a justification for a certain (including pragmatic, egocentric) activity, human behavior as achieving a personal, personal goal.

There are still debates about, for example, which concept is more capacious - ethics or deontology, and many are inclined to believe that deontology is broader than ethics, since it includes teaching, the theory of proper behavior, and the implementation of moral and ethical rules, norms, i.e. behavior itself, and ethics is limited only by theory, the development of scientific moral and ethical norms, rules, concepts, etc.

Ethics reflects the attitude of people not only to each other, but also to facts, events, phenomena in the life of mankind, including to science and the application of its achievements in practice. The ethical component arises immediately, as soon as the question is raised about the goals of this or that action, deed, action, about the interests of a person or a group of people. In this regard, it is possible and necessary to talk about the ethical aspect of each field of activity and knowledge, including the ethical value of science. Progressive scientists are concerned about the possibility of using the greatest achievements of science to the detriment of themselves and people's health. The most striking example is the use for military purposes of discoveries in the field of nuclear physics and the creation of thermonuclear weapons. Equally justified is concern about the use of the achievements of genetic engineering for inhuman purposes. The same can be said about robotics, bacteriology, immunology, etc.

What has been said about ethics and deontology is entirely related to medicine. It is impossible not to note the blood connection of medicine with the general properties of ethics and deontology, first of all with the universal norms of morality and ethics, which are valid for all political, class and other categories and for various socio-political and economic structures. These are the so-called simple norms of morality and morality - good, love, compassion, respect, mercy, resistance to evil, violence, anger and other phenomena and features of human relations that divide people and destroy the human community. They are often associated with Christian virtues.

Medical ethics and medical deontology, as they are most often designated, is an expression of high duty, universal humanity in specific conditions of professional activity.

Unlike all other professions, a doctor or other medical worker deals with a sick person. It should be added - either with a practically healthy person, whom we must protect from diseases, as well as with a healthy person, whom we must not only protect from diseases, but also preserve his health, strengthen and improve this health.

There are other specific points as well. In medicine, unlike other specialties, human affairs and knowledge, only the ethical maximum is admissible, from the standpoint of which you need to be both a good doctor and a good man... There are bad doctors, but the very notions of "bad doctor" and "bad person" are excluded from medical ethics and deontology, although public consciousness fully admits such a situation in other professions.

A physician deals not simply with the object of his activity - a sick person, in his hands health and life.

A physician (of course, a good, real one) must be ready for self-sacrifice, forget the personal in the interests of another person, his condition, his health. Everyone who has written about medical ethics has emphasized this. A.P. Chekhov said that the profession of a doctor is a feat, and not everyone is capable of it.

One of the most important principles of Hippocrates - "do no harm" calls not for self-elimination in difficult situations, not for passivity, but obliges to apply all knowledge and experience to save the patient, for his good, but always so that his actions do not worsen his condition. This is prudence based on high professionalism, caution and at the same time activity.

The universal moral and moral categories of honor, dignity, duty, guilt, duty, responsibility and others, passing through the crucible of medical practice, acquire peculiar qualities characteristic only of this specialty and giving rise to problems inherent only in medicine, for example, the problem of medical secrecy, intervention without consent of the patient, euthanasia, experiment on oneself and on other people, etc.

The relationship of professional medical ethics with general ethics is reflected in its definitions. Out of hundreds of definitions, we cite the one proposed by A.M. Izutkin back in 1968: "Medical ethics is a section of science about the role of moral principles in the work of a doctor, about his highly humane attitude towards a patient as a necessary condition for successful treatment and strengthening of human health." 1 ... A broader and, so to speak, socially oriented definition - in the collective monograph by Yu.P. Lisitsyna, A.M. Izutkina and I.F. Matyushin (1984), which says that medical ethics considers "... the entire set of moral factors that guide health workers in all spheres of material and spiritual activities aimed at meeting the needs of society and individuals in maintaining and strengthening health" 2 .

Before we talk about specific problems, the structure of ethics and deontology, it is proposed not to separate these concepts, but to consider them as one direction, one doctrine - medical ethics and deontology. Medical ethics and deontology, as organically related concepts, deal with moral and ethical norms and the principles and rules of behavior based on them for medical workers performing their civic and professional duties.

These concepts are close, but not identical. From this perspective, ethics (as a science) is a more methodological concept, and deontology (as principles and rules of behavior) is a rather methodological concept.

The importance of medical ethics and medical deontology is increasing at the present time, during the period of changes in socio-economic relations, the introduction of market, marketing processes that directly affected health care. Proud reports about free medicine for the entire population at the expense of public funds and the right of every citizen to free medical care are a thing of the past. At the expense of the state and the currently introduced compulsory medical insurance, only a part of medical services is provided under the so-called program of state guarantees (most of outpatient and outpatient medical care and part of inpatient medical care, and even far from all types of preventive services). Due to the reduction of the state budget, this compulsory program is increasingly limited. At the same time, medical institutions received the legal right to paid services, moreover, they became the financial basis for the so-called voluntary medical insurance. Already today, the majority of the population, whose material capabilities have fallen sharply, are not able to receive all the necessary medical care, including medication, due to the extremely increasing cost of drugs.

In such a situation, the postulates about the doctor's freedom from commercial relations with patients, about the absence of grounds for business in medicine, about free ethical and moral relations with patients not polluted by commercial interests have lost their foundation. In fact, the position of a physician in our country at the present time in principle (except for the still much lower salary) does not differ from that in other (capitalist) countries. "Communist", "socialist" medical ethics have sunk into oblivion. This circumstance has brought the universal problems of medical ethics and deontology closer to our society, to our health care and more broad sense- to social policy in the field of public health protection.

In connection with the reform of health care, state regulation of paid services and, in general, the tariff for medical care, the creation of public organizations (associations, unions), the definition of the rights of patients, doctors, insurance bodies and trade union representatives to control the work of insurers, doctors, medical organizations are becoming practically important. ... Of particular importance are the so-called ethical commissions provided for by law (Fundamentals of Legislation on the Protection of the Health of Citizens of the Russian Federation).

Such organizations operate abroad, and their experience is useful for us as well. Codes are especially important medical ethics, which are discussed later.

Now on the most important problems of medical ethics and deontology, one of which - the payment for medical care - has just been mentioned. The problem remains invariably the main one the relationship between doctor and patient, doctor and patient... Around this pillar of medical ethics and deontology, the problems of the relationship between the doctor (physician) and the people surrounding the patient (relatives, friends, acquaintances, etc.) revolve; doctors with each other and other medical and paramedical personnel (i.e. relationships within the medical environment); physicians (doctors and other medical personnel) with various strata and groups of society, in essence, the problem of the position of a doctor (physician) in society. Medical ethics and deontology also include the problems of medical secrecy, medical error, euthanasia, the right to experiment on oneself (doctor, physician), medical intervention without the consent of the patient, experiment on humans, organ and tissue transplantation, genetic engineering, witchcraft, paramedicine, etc. , which today are usually referred to as bioethics.

The annals of the history of medicine have accumulated numerous statements on the main issue of medical ethics and deontology - the requirements of a highly moral, spiritual, careful, merciful, sympathetic, of course, highly professional, masterful attitude of a doctor (physician) to a patient. Perhaps there is not a single scientist or practitioner who would not emphasize the imperativeness of such an attitude. From such judgments and orders, edifications, instructions and advice, whole volumes can be compiled, the content of which comes from the origins of medicine. The appearance of a doctor in them appears morally, mentally and physically clean, modest, restrained, confident, courteous, friend, advisor and mentor to the suffering person. In the ancient manuscripts of Ayurveda ("Knowledge of Life", India), the outstanding physician of antiquity Sushruta wrote: "A doctor must have a pure compassionate heart, calm temperament, truthful character, be distinguished by the greatest confidence and chastity, a constant desire to do good. You can be afraid of your father, mother, friends. , teachers, but should not feel fear of the doctor. The latter should be kinder, more attentive to the patient than the father, mother, friends and mentor. " 25 centuries ago in the famous treatise of Tibetan medicine "Chzhud-shi" it is said: "The basis of a good doctor is 6 qualities, according to which he must be completely wise, straightforward, vowed, skillful in appearance, diligent in his activities and wise in human sciences. ".

Undoubtedly, the well-known Hippocratic Oath, as an example of subsequent oaths, oaths, professional ethical medical promises, etc., has become the quintessence of highly humane moral and ethical requirements for a doctor since ancient times. In different translations and interpretations, its individual elements sound differently, but the essence is the same. Its main provisions:

Serve the triumph of life.

To direct the regimen of patients to their benefit in accordance with the available forces and understanding.

Observe medical confidentiality.

Live and work blamelessly.

Consult with teachers and mentors, read them.

To remain faithful to the oath.

Excerpt from the original text translated by prof. V.P. Rudnev: "I will direct the regime of the sick to their benefit in accordance with my strengths and my understanding, refraining from causing any harm and injustice ... Whatever house I enter, I will enter there for the benefit of the patient, being far from everything intentional, unrighteous righteous and pernicious ... Purely and immaculately I will spend my life and my art ... Whatever during treatment, as well as without treatment, I see or hear about human life from something that should never be disclosed, I I will not say that, considering such things a secret. "

One of the founders of epidemiology, the famous Danila Samoilovich, in a speech to students of hospital schools (1782) said: those who are preparing to become a doctor should be "merciful, sympathetic, helpful, love their neighbor as themselves, not be stingy ... a word. to become a doctor, you have to be an impeccable person. "

All authors who brightly, figuratively, sincerely, strongly urge the doctor to be noble, skillful, decisive, calm and compassionate, like the father of medicine Hippocrates (M.Ya. Mudrov, I.E.Dyadkovsky, N.I. Pirogov, M.Ya. Mukhin and others), emphasized one fundamental quality in the relationship between a doctor and a patient - humanism in its fullest expression. Humanism, according to the famous French surgeon L. Leriche, takes as its object the whole person "in the creation of his mind, in the movement of his intellect, his heart, his anxiety, in his hopes, in his despair. This flow of thought should permeate all medicine. It is that humanism that the doctor should awaken in himself when he comes into contact with human grief. "

It is especially useful to recall the high requirements in the spirit of medical ethics and deontology to the doctor in his relationship with the patient at the present time, when, in the context of the transition to market relations, it is necessary to revise the requirements of medical ethics and deontology.

The decline in the level of ethical and deontological requirements is also confirmed by sociological studies. So, only 30% of the 6th year students of the evening department of the Russian State Medical University answered that they have a clear idea of medical ethics and deontology, 35% have an indefinite, vague idea, and 15% could not answer the question of what it is.

According to R.V. Korotkikh, who defended her doctoral dissertation on medical ethics and medical deontology in 1990, 61% of doctors violate the moral norms of relationships with patients and colleagues, 30% do not observe medical secrets, constantly, regardless of the situation, talk about patients, calling their names ... Among the moral reasons that cause dissatisfaction with medical care, 37% of the respondents complained about the inattention of doctors, 6% - about rudeness. Patients are very sensitive to the psychological climate in the team of the medical institution, to the relationship of the medical staff, a significant part of the patients negatively assesses these relationships. In total, according to R.V. Short, 60% of the population is dissatisfied with the relationship with doctors and other medical personnel. Insufficient attention to the problems of medical ethics and deontology in educational institutions and the indifferent attitude towards them of many senior comrades in the team leads to difficulties in communicating with patients, especially among novice doctors. It turned out that 11% of the surveyed doctors experience difficulties in taking anamnesis, in contacts with patients, 14% in determining prescriptions, 52% in monitoring and fulfilling prescriptions. As rightly noted by R.V. Short, this indicates insufficient psychological and moral preparation for communicating with the patient, which is the most important content of the doctor's activity.

The rules of medical ethics and deontology in the relationship between a doctor and a patient follow from centuries of professional experience and universal human qualities.

Violations of these or similar ethical, moral rules often lead to iatrogenism, self-perceived diseases, exacerbation of diseases, mental breakdowns, depression, and sometimes tragic events. The influence of the word on a person, especially on a patient, is generally recognized. The word heals, but it can kill. V.M. Bekhterev said that if after talking, communicating with the doctor, the patient did not feel better, then this is a bad doctor.

Among other problems of medical ethics and deontology, we will call the ratio of moral and moral and legal, legal, those. included in the legislation, making a number of rules for the conduct of physicians into law.

There is no insurmountable wall between moral and ethical rules and norms that are developed and regulated by society, and legal, legal, regulated by laws, the state, for violation of which the perpetrators are subjected not only to public censure, but also to various punishments determined by legislation, including imprisonment and etc. Moreover, the rules and norms that arise and spread as ethical, moral and ethical, often become juridical, legal categories, enshrined in legislation.

The most demonstrative example is the requirement of medical confidentiality. This rule has existed since ancient times as one of the important provisions of the Hippocratic Oath, was included in all codes of ethics and other documents on the principles and rules of medical conduct. After many centuries, the observance of medical confidentiality began to be included in legislative acts. In 1969, the Supreme Soviet of the USSR adopted a law, or rather a set of legal provisions "Fundamentals of Legislation of the USSR and the Union Republics on Health Care", which included the observance of medical secrecy (Article 16 "Obligation to maintain medical secrecy"). The regulation on medical secrecy is included in the "Fundamentals of legislation on the protection of the health of citizens of the Russian Federation" (1993). Art. 61 of this law reads: "Information about the fact of seeking medical help, the state of health of a citizen, the diagnosis of his disease and other information obtained during his examination and treatment, constitutes medical secrecy. The citizen must be confirmed the guarantee of the confidentiality of the information transmitted by him." The legislation also included other rules that were considered ethical, moral and ethical, for example, the production of surgical interventions without the consent of the patient (Article 34). Art. 43 on biomedical research involving a human being as an object, i.e. on experiments on humans, subject to the written consent of the citizen.

However, perhaps the most striking example of the legislative consolidation of moral and ethical principles was the inclusion in it of the so-called Oath of the Doctor (Article 60), which for many centuries was taken as a moral and ethical obligation. The tradition of such promises, oaths, oaths was renewed in the 60s in a number of medical institutes of the USSR upon receiving a diploma. In 1971, by a decree of the Presidium of the Supreme Soviet of the USSR, the text of the doctor's oath was approved, and subsequently a new text of the oath was approved.

An important moral and at the same time legal, legal issue is represented by medical errors although medical errors were not mentioned in the Criminal Code. However, their

the consequences are often close to criminal acts. Medical errors are usually understood as the consequences of delusions without elements of negligence, negligence, dishonesty, professional ignorance. A number of errors depend on the imperfection of research methods and equipment, atypical, unusual clinical case, i.e. features of the course of the disease, which the doctor did not know or did not recognize, and most often from little experience and insufficient competence of the doctor. Iatrogenies often become the causes of medical errors, unprofessional behavior of a physician. To overcome and prevent mistakes, a self-critical, open analysis of their causes and circumstances is required at clinical, clinical and pathological conferences, in a professional environment. Self-criticism, public admission of one's mistakes is an important criterion for the moral and ethical qualities of a physician; sometimes it takes personal courage.

N.I. was especially strict about his mistakes. Pirogov. There are even known cases of his mistakes being made public. Unfortunately, there are frequent examples of concealment of mistakes, moreover, cover, protection of doctors who have made such mistakes, sometimes criminal acts prosecuted by law. There is even a special type of insurance - payment for claims for mistakes that led to adverse consequences for the health of patients, or for unjustified medical (most often surgical) interventions.

In the United States, for example, more than 98% of doctors are insured for medical errors. A detailed register of conditions and examples of errors and an insurance premium rate have been developed. The largest contribution is for surgeons and especially for neurosurgeons (from several thousand to tens of thousands of dollars). But insurance policies are issued up to 300 thousand dollars, and sometimes up to 1 million dollars.

The growing social (and economic) importance of medicine, the non-decreasing number of medical errors and other violations of medical ethics and deontology up to crimes, the high responsibility of doctors and other representatives of our profession to people and society, led to the development of a special type (section) of law - medical law, which included the legal aspects of the rights and obligations of physicians. Such a proposal was considered in 1977 at the IV International Medical and Legal Conference in Prague. Today, medical law, the 16th in a row, is recognized along with other types of law (criminal, administrative, civil, labor, etc.).

From the standpoint of medical law, moral and ethical norms and regulations are also carefully considered. Particularly difficult in practical terms (execution) and complex in theoretical, legal terms (i.e. from the standpoint of medical law) is the problem euthanasia, i.e. voluntary death of the patient (usually doomed) at his request and demand. In 1952, an appeal was sent to the UN with more than 2.5 thousand signatures, among which were the names of famous doctors, scientists, cultural figures from the USA and Great Britain. The appeal spoke of the need to supplement the Universal Declaration of Human Rights with the right of a terminally ill person to demand an easy death for himself. The appeal was rejected by the UN, which recognized it as inhuman. In response, associations were formed to push for the adoption of the right to euthanasia. One of these organizations (New York) even drew up a sample of a patient's will with a request for an easy death: "If there is no reasonable hope that I can recover from a physical or mental illness, then I will bequeath any artificial or other measures were taken to keep me alive. "

Naturally, the right to a voluntary, easy death caused and still causes discussion due to a complex set of legal and moral problems. A number of US states have nevertheless passed legislation allowing euthanasia. Its implementation under this law requires compliance with many formalities: a statement signed by the patient, certified by three doctors, the right to refuse this request, the exclusion of the use of the law by relatives or medical personnel for mercantile purposes, etc. Although such laws have been adopted, there is practically no information in the press about their application on practice. Our legislation excludes the decision on euthanasia, considering this, like the UN, to contradict the requirements of humanity (Article 45 of the Legislation on the protection of the health of citizens of the Russian Federation prohibits euthanasia).

No less controversial and acute are decisions on transplantation of unpaired organs (heart, liver) from a donor who is considered dead. The complexity and severity of the problem is associated with the determination of the biological death of the donor. The law allows the removal of organs or tissues from a person for transplantation (Article 47) and has developed national and international criteria for death, which are mainly reduced to stating the death of the brain. However, these provisions are not always convincing for all specialists. For example, the heart should be taken as early as possible, when it shows signs of functioning, with the belief that the brain has already died irrevocably.

Solving the problems of medical ethics and deontology is not always indisputable and often daunting. For practical application summaries of the rules of conduct for physicians, codes of medical ethics and deontology are compiled. Compliance with these codes is considered mandatory for physicians and their corporations. In fact, the Hippocratic Oath can already be considered a code of conduct for a doctor, i.e. a kind of code of medical ethics and deontology. Since the creation of the UN and the adoption of the Universal Declaration of Human Rights (1948), international medical codes of ethics have been more actively and systematically developed. Among them: "Geneva Declaration" (1948), supplemented by the World Medical Association in 1968 and 1983; The Ten Nuremberg Rules (1947) Declaration of Helsinki-Tokyo (1964, 1975), International Code of Medical Ethics, adopted in 1949 and amended in 1968 and 1983; 12 principles for the provision of medical care in any health care system, adopted in 1963 and amended in 1983, and a number of subsequent additions, revisions of these and other documents. The International (World) Medical Association has assumed a kind of coordinating role for such codes. The Geneva Declaration, for example, states that the doctor solemnly promises to "devote himself to the service of humanity" and vows "to maintain gratitude and respect for his teachers for life; to fulfill his professional duty with conscience and dignity, the patient's health will be the first reward; to respect trusted secrets. even after the death of the patient; do everything to maintain the honor and noble traditions of the medical community, colleagues will be my brothers; do not allow considerations of a religious, national, racial, party-political and social nature to come between me and my patients. "

ETHICS MEDICAL(Greek ethika, from ethos, custom, disposition, character) - a kind of professional ethics that concretizes general ethical principles and norms in relation to the specifics medical activity.
Ethical medical principles are aimed at protecting the rights and interests of the patient, and, it would seem, they should be absolutely humane. However, in real life things are not so simple. Physicians are often put in a situation where they have to make decisions that are contrary to the rules of medical ethics. In this case, the doctor tries to make a decision that will cause less harm.

There are a lot of life examples. For example, emergency medicine or military field medical assistance, when triage of the wounded is carried out. According to the rules, all the wounded are divided into three groups: light wounds, severe wounds and hopeless ones. Lightly wounded are bandaged and sent to the rear. The seriously wounded are first provided with the greatest possible assistance on the spot, and then also sent to the rear. The "hopeless" are relieved of suffering, but not transferred to the rear.

In fact, some of the wounded who have fallen into the "hopeless" category can still be saved if they are attended by highly qualified doctors with specialized medical equipment. To do this, they will urgently need to be evacuated accompanied by medical staff. In this case, lightly wounded and severely wounded, whose condition will worsen, may remain without the necessary medical assistance.

This raises a medical ethical problem: on the one hand, one cannot leave a person without a chance of salvation, on the other hand, one cannot be saved, forgetting about dozens of people. There is no ethically ideal way out of this situation. Therefore, each doctor takes responsibility for himself and decides for himself how to act in this situation. Most doctors are of the opinion that it is necessary to save the lives of as many people as possible.

Also, a medical ethical problem is teaching a student on living people. Students, through their inability, can inadvertently hurt the patient, which is contrary to medical ethics. However, how can a highly qualified specialist be trained without practice on living people ?! Neither dummies nor practice on corpses will be able to prepare a specialist in the same way as working with a person. This ethical problem is insoluble.

On the one hand, it is quite understandable that a young doctor needs to practice in public, but few would agree to provide themselves "for experiments." The ambiguity of this situation is confirmed by the results of surveys in the United States, according to which more than 80% of volunteers who agreed to provide their bodies for experiments, and about 70% of donors agreed to medical manipulations, being in a difficult financial situation. Another question arises: is it ethical to take advantage of people's material hardships?

The question of clinical experiments on animals remains unsolvable. Hundreds and thousands of animals die in experiments in order to subsequently save human life. Without such experiments, which entail huge sacrifices, it is impossible to test a new technique or medicine on humans. This is another medical ethical issue.

Today, medical practice is governed by many ethical and legal norms. The rights of volunteers are protected. Compulsory participation in clinical trials is illegal and unethical. However, society has come to this relatively recently. In ancient Alexandria, it was allowed to use convicted criminals for experiments. In Germany, studies have been published by Nazi doctors who conducted their experiments on prisoners in concentration camps. These are examples where a physician rejects the principles of medical ethics.

Professional honey. ethics as a set of specific norms and assessments that determine the behavior of a health worker has deep historical roots. As early as 1500 BC. NS. Hindu doctors took a professional oath. At the heart of numerous professional oaths, to-rye doctors in many countries of the world, is the Hippocratic Oath. The most important principles of Hippocratic ethics: "Primum nоn nosere" - first of all, do not harm the patient; enter the patient's house solely for his benefit, and in relations with him refrain from everything malicious and immoral; consider human life an unconditional value, never give a sick person a lethal means; keep medical secrets; do not drop the authority of the noble medical profession, etc. Since the time of Hippocrates, the mercy of medicine was manifested primarily by the recognition of the life of every person as an unconditional and highest value, the struggle to preserve and strengthen health, for the longevity of people. One of the manifestations of the humanism of doctors is a compassionate attitude towards a person in pain. NI Pirogov, one of the first to apply anesthesia in surgical practice, spoke about the obviousness of the moral influence of anesthesia on suffering humanity.

Since the middle of the 20th century. the development of E. m. was greatly influenced by the scientific and technical revolution and the increasingly widespread use of honey. knowledge. The campaign of the world community to condemn the crimes of fascist anti-medicine had a significant impact. In the same period, new ethical honey appeared. codes both in individual countries and international. In 1948, the World Medical Association formulated the "Geneva Declaration", and in 1949 - a more detailed "International Code of Medical Ethics".

In the second half of the 20th century. the humanistic mission of medicine has expanded thanks to the role that honey. science and doctors play in solving problems of environmental pollution and especially in preventing a world thermonuclear war (see "Doctors of the World for the Prevention of Nuclear War").

At the heart of e. M. In socialist society are the principles of communist morality. Since 1971, in all Soviet medical centers. universities, graduates take the "Doctor's Oath Soviet Union", and in many medical schools, graduates give a" Solemn Promise. "These oaths reflect the following requirements for a physician: constantly strive for professional improvement, observe collegiality standards, keep medical secrets. Medical workers should not disclose information about the diagnosis, the severity of the prognosis , latent physical disabilities and mental defects, peculiarities of the patient's anamnesis. real threat society or people around the patient. Embarking on an independent professional activity, the Soviet physician solemnly vows that he will work conscientiously where the interests of society require it, that he will cherish and develop the noble traditions of domestic medicine, and that he will always remember about responsibility before the people and the Soviet state.

In socialist honey. ethics, the principle of humanism is the original. One of the requirements of medical humanism is that every physician should take good care of the patient's personality, take into account the peculiarities of his mental state. The professional duty of a medical worker is his moral responsibility to the patient, to society. The concept of duty is inseparable from selflessness.

Honey. ethics is a developing area of knowledge. Within its framework, the real customs that exist in honey are studied. environment, in particular the relationship of doctors with their patients, possible contradictions between them, conflicts. E. m. Pays more and more attention to the study of moral and ethical positions of patients. A modern patient is, as a rule, an active patient, whose attitude to his health is becoming more and more responsible, he increasingly seeks to participate, together with the doctor, in making decisions concerning his health. At the same time, the behavior of a certain part of the patients has moral deviations. All this was the reason for raising a new question - about the "patient's ethics".

There is also such a thing as medical deontology:
Deontology(from Greek . δέον - due) - the doctrine of the problems of morality and ethics, a section of ethics. The term was introduced by Bentham to designate the theory of morality as a science of morality.

Subsequently, science narrowed down to characterizing the problems of human duty, considering duty as an inner experience of coercion, given by ethical values. In an even narrower sense, deontology was designated as a science that specifically studies medical ethics, the rules and norms of the interaction of a doctor with colleagues and a patient.

The main issues of medical deontology are euthanasia, as well as the inevitable death of the patient. The goal of deontology is to preserve morality and combat stress factors in medicine in general.

Euthanasia(or euthanasia) (Greek . ευ- "good" + θάνατος "death") - the practice of terminating (or shortening) the life of a person suffering from an incurable disease, experiencing unbearable suffering, granting a request without medical indications in a painless or minimally painful form in order to end suffering.

Types of euthanasia.

In theory, there are two types of euthanasia: passive euthanasia (deliberate cessation of the patient's maintenance therapy by physicians) and active euthanasia (administration of drugs to the dying person or other actions that entail quick and painless death). Active euthanasia is often referred to as suicide with a doctor's help (giving the patient, at his request, drugs that shorten the life).

In addition, it is necessary to distinguish between voluntary and involuntary euthanasia. Voluntary euthanasia is carried out at the request of the patient or with his prior consent (for example, in the United States it is common practice to express his will in advance and in a legally reliable form in the event of an irreversible coma). Involuntary euthanasia is carried out without the consent of the patient, usually in an unconscious state.

The term "euthanasia" was first used by Francis Bacon in the 16th century to define "easy death".

The history of euthanasia.

Before the outbreak of World War II, the idea of euthanasia was widespread in a number of European countries. At that time, euthanasia and eugenics were quite popular in the medical circles of European countries, but the actions of the Nazis, such as the program of killing the T-4, discredited these ideas for a long time. Among famous people We note Freud, who, due to an incurable form of cancer of the palate, with the help of Dr. Schur, committed euthanasia in his London home on September 23, 1939, having previously survived 19 operations to remove tumors under local anesthesia (general anesthesia was not used in such operations at that time ).

Medical deontology includes:

Medical Confidentiality Issues

Measures of responsibility for the life and health of patients

Relationship problems in the medical community

Relationship problems with patients and their relatives

The Ethics and Legal Committee of the American Medical Association has guidelines for intimate relationships between physician and patient:

intimate contacts between the doctor and the patient that occur during the treatment period are immoral;

an intimate relationship with a former patient may in certain situations be recognized as unethical;

the question of the intimate relationship between doctor and patient should be included in the curriculum of all health professionals;

physicians are required to report medical ethics violations by their colleagues.

Medical secrecy- medical, legal, socio-ethical concept, which is a prohibition of a medical worker to provide third parties with information about the patient's health status, diagnosis, examination results, the very fact of seeking medical help and information about personal life obtained during examination and treatment. The prohibition also applies to all persons to whom this information became known in the cases provided for by law.

Medical secrecy refers to the basic principles of the Hippocratic Oath:

... Whatever during treatment - as well as without treatment - I see or hear about human life from something that should never be divulged, I will keep silent, considering such things a secret ...

Fundamentals of legislation Russian Federation on the protection of the health of citizens of July 22, 1993 N 5487-1 in article 61 define the concept of "medical confidentiality". It also defines the circumstances under which it is allowed to transfer information constituting a medical secret to other citizens, including officials, with the consent of the citizen or his legal representative, as well as without such consent.

There is also legal deontology, which is a science that studies questions of morality and ethics in the field of jurisprudence (it is believed that the norms of law coincide with the norms of morality not 100%, but only about 80%)

In connection with the development of medicine in its various fields, new ethical problems have arisen. For example, in transplantation, when transplanting a kidney from a living donor, doctors deliberately (in the name of a humane goal) violate the Hippocratic commandment "first of all, do not harm." Heart transplant surgery requires the resolution of a number of difficult ethical issues concerning both the recipient and the donor (his relatives). In transplantation, physicians are often faced with a doubled surgical risk. In these conditions, the concept of "ethical risk" is becoming increasingly important.

The nursing staff conducts to lay down. institutions, especially hospitals, take significantly longer than doctors. The role of a nurse in creating an optimistic environment around the patient, faith in a favorable outcome of the disease can hardly be overestimated. A modern medical worker must have a broad outlook, be a versatile educated and thinking specialist, to-ry is called upon to compensate with his attentive and cordial attitude to the patient the costs of modern "technicalization" of medicine.

Ethical concerns of nurses

How does a nurse's approach to ethical issues differ in daily work from the doctor's approach? Nursing Ethics mainly focused on activities that provide professional patient care.

In the XIX century. it was believed that the nurse should be fully subordinate to the doctor, since her duties were seen as derived from the orders of the doctor. Traditionally, the doctor was given a special place in the process of providing assistance to the patient; he could treat his subordinates with authoritarianism. This meant that the nurse had to support the goals that the doctor was trying to achieve in treating patients. Nursing support from a doctor was seen as important factor in maintaining and strengthening the patient's faith in the doctor. Therefore, there was a list of ethical qualities of nurses that they were required to possess in both their professional and personal life, namely: patience, trust, personal integrity, faith, courage, honesty, wisdom and dedication.

This social and professional discrimination of sisters continued until the first half of the 20th century. After World War II, health care focused on prevention, which has traditionally become part of nursing responsibilities.

Over the past 20 years in nursing the level of training has grown significantly. Methods for studying research in nursing have emerged. All of this contributed to the creation of a foundation of nursing knowledge, nursing theories and nursing models.

A brief review of the international literature on issues related to the sociological role and position of nurses reveals the following:

The responsibilities of doctors and nurses are very different: the doctor usually occupies a position that ensures him high status, and the role of nurses in the provision of health care becomes an important intermediate link;

Nurses are often faced with a huge number of orders, rules and orders from the administration; communication channels for proposals, complaints to higher hierarchical levels are limited; this situation suppresses initiative and generates feelings of inferiority and discontent;

The nurses support the scientific work of physicians through complementary responsibilities;

A nurse should restrain emotions, not point out to patients about doubts, insecurities, mistakes that she observes in her work;

Medical care is an important social ideal of the general welfare of the state, where it is in the context of social values; on the other hand, genuine physical care is usually undervalued and rewarded, which creates an unpleasant experience of nursing.

Little attention is paid to the ethical issues of nurses. As a consequence, nurses try to delegate care responsibilities to nurses.

The conclusion is that the sisters are trapped in a confrontation between perspectives and hopes.

Apollo was considered the doctor of the gods.

Asclepius (Aesculapius), son of Apollo - the god of medical art.

Hygieia - the daughter of Asclepius - the goddess of health (hence our hygiene); she was portrayed as a blooming girl with a bowl from which a snake drank.

Panakeya - all-healing, another daughter of Asclepius; hence the word panacea, i.e. a cure for all the diseases that medieval alchemists were looking for.

Ethics(Greek ethika, from ethos custom, disposition, character) is a philosophical discipline that studies morality.

Medical ethics should be seen as a specific manifestation of general ethics.

Medical ethics - This is a teaching about the role of moral principles in the activities of medical workers, about their highly humane attitude towards a person as a necessary condition for successful treatment. The subject of medical ethics research is the psychoemotional side of the activities of a doctor, nurse, laboratory assistant, and junior medical personnel. In addition, the range of issues of medical ethics includes those on the successful solution of which the life and health of not only living, but also future generations depend.

Medical ethics is unique to it. She considers:

Ø attitude towards a person with impaired health;

Ø studies the features of the development and dependence of moral behavior medical worker on the conditions of his practical activity;

Ø determines the norms of behavior of a medical worker in everyday life, his culture, physical and moral cleanliness.

Professional ethics - these are the principles of behavior in the process professional activity person.

Deontology(from the Greek word deon - ought and logos - doctrine; literal translation - teaching about what should be) - that part of ethics, the subject of which is the doctrine of a person's duty to another person and society as a whole.

Medical deontology Is a complex ethical standards, the principles that the health worker is guided by, a set of relevant professional, moral, ethical and legal principles and rules that make up the concept of “duty of a health worker”. (teaching about the proper behavior of medical workers, contributing to the creation of the most favorable environment for the patient's recovery)

The main tasks of medical deontology:

Ø study of the principles of behavior of medical personnel aimed at maximizing the effectiveness of treatment;

Ø elimination of adverse factors in medical practice;

Ø study of the system of relationships that are established between the medical staff and the patient;

Ø elimination of the harmful consequences of defective medical work.

The aspects of medical deontology are:

Ø the relationship of medical workers with patients;

Ø the relationship of medical workers with the patient's relatives;

Ø the relationship of medical workers with each other.

The main goals of the professional activity of medical workers are: caring for patients, alleviating their suffering, restoring and strengthening their health, preventing diseases. To achieve these goals while fulfilling their functional responsibilities the nurse must know and observe the following basic ethical principles such as humanity and compassion.

Aspects of medical ethics:

Ø informing the patient about his rights;

Ø informing the patient about the state of his health;

Ø humane attitude towards the patient;

Ø respect for the human dignity of the patient;

Ø prevention of moral and physical harm to the patient (do no harm);

Ø Respect for the patient's right to undergo medical intervention or to refuse it;

Ø respect for patient autonomy;

Ø respect for the patient's right to quality and timely medical care;

Ø manifestation of respect for the dying patient (distributive justice);

Ø keeping professional secrets;

Ø maintaining a high level of their professional competence;

Ø protecting the patient from incompetent medical intervention;

Ø maintaining respect for one's profession;

Ø respectful attitude towards colleagues;

Ø participation in health education of the population.

Medical ethics(Lat. ethica, from the Greek. ethice - the study of morality, morality), or medical deontology (Greek. deon - duty; the term "deontology" has been widely used in the domestic literature of recent years), - a set of ethical norms and principles of behavior of medical workers when performing their professional duties.

By modern ideas, medical ethics includes the following aspects:

Scientific - a section of medical science that studies the ethical and moral aspects of the activities of medical workers;

Practical - the field of medical practice, the tasks of which are the formation and application of ethical norms and rules in professional medical practice.

Any medical worker should have such qualities as compassion, kindness, sensitivity and responsiveness, caring and attentive attitude towards the patient. Ibn Sina also demanded special approach to the patient: “You should know that everyone individual person possesses a special nature inherent in him personally. It is rare, or even impossible, for someone to have the same nature as him. " The word is of great importance, which implies not only the culture of speech, but also a sense of tact, the ability to raise the patient's mood, not to injure him with a careless statement.

The behavior of the doctor, both from the point of view of his internal aspirations and from the point of view of his external actions, should be motivated by the interests and welfare of the patient. “Whatever house I enter, I will enter there for the benefit of the sick person, being far from everything intentional, unrighteous and harmful,” wrote Hippocrates. Practical attitude of a doctor to a person, initially focused on care, help, support, is undoubtedly the main feature of professional medical ethics. Hippocrates rightly noted the direct relationship between philanthropy and the effectiveness of a doctor's professional activity. Philanthropy is not only a fundamental criterion for choosing a profession, but also directly affects the success of medical practice, largely determining the measure of medical art. "Where there is love for people - wrote Hippocrates, - there is love for your art"

Of particular importance in medical profession acquire such universal norms of communication as the ability to respect and listen carefully to the interlocutor, demonstrate interest in the content of the conversation and the patient's opinion, correct and accessible speech structure. The neat appearance of the medical staff is also important: a clean robe and cap, neat removable shoes, well-groomed hands with short-cut nails. Even in ancient medicine, the doctor told his disciples-followers: "Now give up your passions, anger, greed, madness, vanity, pride, envy, rudeness, buffoonery, falsity, laziness and any vicious behavior."

PRIMUMNONNOCERE (lat.) - DO NOT HARM FIRST OF ALL - this statement is the main ethical principle in medicine.

The moral responsibility of a healthcare professional includes adherence to all principles of medical ethics. Improper diagnosis, treatment, behavior of a doctor, representatives of nursing and nursing staff can lead to physical and mental suffering for patients. Such actions of a medical worker as disclosing medical secrets, denying medical assistance, violating privacy, etc. are unacceptable.

Caring for the patient involves, among other things, also adherence to certain rules for communicating with him. It is important to give the patient maximum attention, calm him down, explain the need to comply with the regimen, regularly take medications, and convince him of the possibility of recovery or improvement of his condition. Great care must be taken when talking with patients, especially those suffering from cancer, who are not usually told the true diagnosis. And at present, the statement of the great doctor of antiquity, the father of medicine Hippocrates, remains significant: "Surround the patient with love and reasonable consolation, but, most importantly, leave him in the dark about what threatens him." In some countries, the patient is still informed about the severity of the disease, including the possible death (lat.letalis - fatal), based on socio-economic considerations. So, in the United States, a patient even has the right to initiate a lawsuit against a doctor who hid the diagnosis of a cancer from him.

Iatrogenic diseases

Violation of the deontological principles of communication with the patient can lead to the development of so-called iatrogenic diseases (Greek-atros- doctor, -gepes- generated, arising). An iatrogenic disease (iatrogenic) is a pathological condition of a patient caused by careless statements or actions of a doctor or other medical worker, which create in a person an idea of the presence of a disease or of the particular severity of his disease. Inadequate, injuring and harmful verbal contacts to the patient can lead to various psychogenic iatrogenies.

However, even more than 300 years ago, the "English Hippocrates" Thomas Sydenham (1624-1689) emphasized the danger for the patient not only of the actions of a medical worker, traumatizing the patient's psyche, but also of other possible factors - the undesirable consequences of medical manipulations. Therefore, at present, any diseases are considered iatrogenic, the occurrence of which is associated with certain actions of medical workers. So, in addition to the psychogenic iatrogeny (iatropsychogenia) described above, there are:

Jatropharmacogeny: a consequence of drug exposure to the patient - for example, side effects of drugs;

Manipulative iatrogenies: adverse effects on the patient during his examination - for example, complications during coronary angiography;

Combined iatrogenies: a consequence of the influence of several factors;

The so-called mute iatrogenies are a consequence of the inaction of a medical worker.

Medical secrecy

The deontological issues of patient care include the need to preserve medical confidentiality. Medical workers have no right to disclose information about a patient of a deeply personal, intimate nature. However, this requirement does not apply to situations that pose a danger to other people: sexually transmitted diseases, infectious, infection with the human immunodeficiency virus (HIV), poisoning, etc.

In these cases, health workers are obliged to immediately inform the relevant organizations about the information received. In order to carry out sanitary and epidemiological measures in the outbreak when an infectious disease, food poisoning or pediculosis is detected, a nurse within 12 hours from the moment of diagnosis is obliged to inform the sanitary and epidemiological station by phone and at the same time send there a completed emergency notification form (form No. 058 / y ).

Errors and medical delinquencies

The observance of moral and ethical standards by a medical professional provides not only for the fulfillment of their duties, but also for the responsibility for evasion or unprofessional performance of their duties.
"The Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health" (1993) regulates the legal liability of a medical worker for causing harm to the health of citizens.

Art. 66 - "Grounds for compensation for harm caused to the health of citizens."

Art. 67 - "Reimbursement of the costs of providing medical care to citizens who have suffered from illegal actions."

Art. 68 - "Responsibility of medical and pharmaceutical workers for violation of citizens' rights in the field of health protection."

Art. 69 - "The right of citizens to appeal against actions government agencies and officials infringing on the rights and freedoms of citizens in the field of health protection ”.

Orthodoxy and medical ethics

Orthodoxy, being historically and logically the first Christian doctrine, has formed the tradition of the ontological understanding of morality, i.e. deep involvement of morality in a single and integral "order of the world."

That is why moral values in Orthodox Christianity and the first of them - love for God and neighbor - are not only a desirable norm of behavior. This is the principle of being, the law of the "order of the world", without which the "connection of times" and meanings disintegrates, one of the links of which is the meaning of human life. The meaning of human life in Christian ethics is directly related to serving one's neighbor.

In this regard, healing in essence is one of the unique human professions, the meaning and purpose of which coincides as much as possible with "doing good", with the Christian values of mercy, philanthropy and saving life. It is no coincidence that the first model social institution health care as an active manifestation of mercy and philanthropy was implemented in Christian monasteries. "Such is the power of mercy: it is immortal, incorruptible and can never perish" (John Chrysostom).

A science that studies questions of morality and ethics. Medical ethics consists of a set of standards for the professional activities of medical workers. It occupies a special place in medical practice, because the life and health of every person depends on its observance.

Since ancient times, doctors' activities have been based on the desire to help people and alleviate their suffering. Almost two thousand years before our era, the first set of rules for healers was adopted in ancient Babylon.

Medical ethics is related to deontology. This term denotes the doctrine of the proper conduct of physicians. The concept of "deontology" was introduced in the nineteenth century by the Englishman I. Bentham.

Ethics and deontology in medicine are not the same, although they are deeply connected. Deontology contains a set of rules for medical professionals on how to properly communicate with a patient. The theoretical basis for these rules is medical ethics.

Deontology, like ethics, studies morality. But this science examines how a doctor interacts with patients and their loved ones, his colleagues and with the whole society as a whole.

Eras succeed each other, but the basic ethical principles for medicine have remained:

The doctor acts for the good of people, not harm;
The patient or his relatives should not be inflicted unnecessary suffering by action or inaction;
The physician should use all the means at his disposal and all modern knowledge to help the patient;
The doctor keeps secret the information about the patient's health and life, which he learned during the treatment.

Modern deontology and medical ethics

Throughout the various periods of human history, the medical code has remained largely unchanged. For a long time, doctors have been hostages of religious and secular prohibitions.

The basic principles of ethics for health workers were formulated by Hippocrates two and a half thousand years ago. The "Hippocratic Oath" still proclaims that the purpose of medicine is precisely the treatment of the patient. Its main principle is known to all: "Do no harm." V modern world this medical code is not legal document, but its violation can become the basis for judicial responsibility.

Currently, based on medical ethics, the doctor is obliged to observe the following rules in relation to the patient:

Communicate the rights of the patient;
To report on the state of his health;
Respect the patient's human dignity and treat him humanely;
Do not cause moral or physical harm;
Take good care of a dying person;
Keep medical confidentiality;
Do not allow ignorant interference with the patient's health;
Maintain a high level of knowledge in their profession;
Be respectful to colleagues;
Maintain respect for medicine.

Doctor and patient

Medical ethics says that a doctor should be a highly educated specialist, and deontology helps to see a person in a sick person and respect his rights. After all, he gives his own, special oath, the "Hippocratic Oath". The profession of a doctor combines humanism, civic duty, professional knowledge and high morality.

When interacting with wards, it is important appearance doctors, as well as their manners. Bright hairstyles or jewelry, or a flashy wardrobe can be uncomfortable for people undergoing treatment or colleagues. The doctor must remain calm even if the patient or his relatives behave inappropriately - these are the requirements of ethics.

If the doctor feels antipathy towards the patient, he should not express it either in words or in gestures. This should in no way affect the treatment, all personal hostility remains outside the hospital.

Compassion for a sick person is based on scientific knowledge, and not on simple universal humanism. A modern physician must inform the patient about the severity of his illness.

Traditional rules of interaction between doctor and patient may change over time under the influence of new ethical principles, but their essence, that "do no harm", is always preserved.

Nurse and patient

The nursing profession originated from a woman's desire to help a sick or wounded person. It is based on the principle of caring for each patient, regardless of his social status, nationality or religion. This principle in work should be put above all.

A nurse is called upon to care for patients, relieve or prevent suffering, and help rehabilitate health. According to the code of ethics for nurses, they should respect the rights of everyone to physical and mental health, observe the principles of humanity, do their job well and observe moral principles in relations with patients and colleagues.

Respect the patient's human dignity - necessary condition work in this profession. According to ethics, a nurse has no right to show arrogance, neglect or rudeness to patients, and also should not impose her point of view on them on any issue. She must inform the patient about his rights, health status, diagnosis and treatment method.

It is permissible to inflict pain on a patient only in one case - if it is carried out in his interests. Threats to human life are unacceptable. Disclosure confidential information about the patient is prohibited.

Doctor and Nurse

Teamwork is an important condition correct work medical institution. Its team is united by common hard work, which is based on responsibility for human life and health. Therefore, the correct climate within the walls of the hospital is governed by medical ethics.

Medical work assumes that medical ethics underlies the correct attitude not only to patients, but also to each other, regardless of the position. It's not just that doctors wear white coats - this emphasizes not only the purity, but also the high meaning of their profession. Neglect or liberties of communication in the medical community reduces the patient's confidence in all health workers.

Doctors should be respectful of middle and junior medical staff... The nurse is currently - chief assistant a doctor, without whom complete treatment is impossible. Nurses are obliged to observe the rules of etiquette in relation to doctors and to everyone around them at work. Nurses should use all their knowledge to help doctors in their work.

Medical professionals, all without exception, should not speak negatively about their colleagues, especially in the presence of patients or their loved ones.

Myths about medical ethics

Though modern technologies I penetrate deeper and deeper into medicine, it still combines science and art. This duality, as well as a direct connection with human health and life, creates the basis for various myths.

In medicine, there are topics that excite the minds, cause heated discussions and are sometimes misinterpreted (organ transplant). The kidneys, heart, lungs and other organs are transplanted from people who have already died. An uninitiated person in this, if he sees the process of organ removal, will perceive everything in such a way that required material extracted from a still living person.

Or euthanasia. Doctors either stop prolonging the patient's life, or apply special measures for painless death. In some civilized people this procedure is voluntary, in most countries of the world it is prohibited. This topic causes a lot of controversy. And disputes breed rumors. The myths about "killer doctors" disturb people.

But there is also AIDS and other dangerous diseases. Most people are not well informed about this, and the medical community is unable to agree on what rules to follow. Until health care issues and consolidates a final verdict on these "slippery" topics, the mass consciousness will continue to fuel false rumors.

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