Monitoring Ethics in Clinical Practice


[Text of speech given by Prof. Carlo Fonseka, President, Sri Lanka Medical Council at the inauguration of the Sri Lanka Bioethics Unit, National Institute of Mental Health]

Historically, the only sanction known to ethics in a given society has been the assent of the majority of the people comprising that society. Therefore, ethics inevitably leads to politics. Why so? Because in order to ascertain the majority view on a given matter a vote must be taken. To take a vote is to indulge in politics. That is probably why the great Greek philosopher Aristotle regarded ethics as a branch of politics, and not as a branch of metaphysics.

Perhaps a dramatic way to make the point that in the end ethics leads to politics is to remind you that in 1967 it was the politicians in the UK who changed the law on abortion. As a result, as Sir Douglas Black, a former president of the Royal College of Physicians of London and, at that time a member of the General Medical Council of UK, gravely noted, "abortion changed overnight from being a crime to being something entirely legal." On the basis of this (shocking!) change Sir Douglas Black, for one, concluded that "medical ethics are relative and not absolute." If something which is unethical in clinical practice today becomes ethical in clinical practice tomorrow, monitoring ethics in clinical practice becomes a very dicey business. Dicey or not, the business has to be transacted.

Medical Oath

It was in that backdrop that the Sri Lanka Medical Council (SLMC) published in July 2009, a comprehensive set of guidelines on ethical conduct for medical and dental practitioners registered with the SLMC. These guidelines were formulated by the ethics committee of the SLMC. In actual practice, at the time of being admitted as a member of the profession the prospective practitioner is obliged to take an Oath consisting of a set of declarations or promises, administered by an official of the SLMC, usually the registrar. The Oath takes the form of a set of eight ethical rules undertaken by the practitioners solemnly, freely and upon their honour. The essence of these eight ethical rules (reminiscent of the noble eightfold path! may be summarized as follows:

(i) I will pledge my life to the service of humanity

(ii) I will give primary consideration to the health of the patient and I will not use my profession for exploitation and abuse of the patient

(iii) I will practice my profession with conscience, dignity, integrity and honesty.

(iv) I will respect the secrets which are confided in me even after the patient has died.

(v) I will give to my teachers the respect and gratitude which is their due.

(vi) I will maintain the noble traditions of the medical profession.

(vii) I will not permit considerations of religion, nationality, race, party politics, caste or social standing to interfere with my duty as a doctor.

(viii) I will maintain the utmost respect for human life from its beginning.

Ideal and Reality

Everybody will agree that these are excellent ethical rules by which doctors should live and move and have their professional being. However, when people see that our practice is far short of the ideal and ask for an explanation, my knee-jerk answer has been to quote the great ethical philosopher Baruch Spinoza to the effect that, "all excellent things are as difficult as they are rare." Only a little thought is necessary to realize that these ethical rules have but one ultimate aim and that is to try and ensure that doctors will always practice their profession competently and compassionately. Doctors perform their duties in three separate but related and overlapping areas. The first is serving humanity. The second is teaching the younger generation aspiring to become doctors. The third is to search for new knowledge by conducting scientific research. In the present state of the science and art of medicine, technical things have become incredibly complex. The pioneers in the National Institute of Mental Health who are in the forefront of establishing the Bioethics Unit in Sri Lanka are two senior psychiatrists Dr. Harischandra Gambheera and Dr. Jayan Mendis. When working in the necessarily relative and therefore maddening subject of bioethics, the risk they run of losing their sanity cannot be ruled out. My remit in this seminar is to focus on the service component of our profession, namely, the role of the SLMC in monitoring the ethics of clinical practice. I fear that I too am losing my senses in discharging my duties.

Unethical Behaviour

Unethical behaviour in clinical practice is called PROFESSIONAL MISCONDUCT. Way back in 1894, Lord Justice Lopes famously defined professional misconduct as follows: "If a medical man" – remember in those chivalrous days, ‘man’ always embraced ‘woman’ – pursuit of his profession has done something in regard to which it will be reasonably regarded as disgraceful and dishonourable by his professional brethren of good repute and competency, then, it is open to the Medical Council, if that be shown, to say that he has been guilty of infamous conduct in a professional respect." Suffice it to say in this brief presentation that professional misconduct, if and only if it is officially brought to the notice of the SLMC, is scrutinized under five major headings.

* Neglect or disregard by doctors of their professional responsibilities. (medical neglect)

* Abuse of professional privileges or skills.

* Derogatory (or degrading) professional conduct.

* Advertising and canvassing.

* Commenting maliciously on professional colleagues.

In investigating allegations of serious professional misconduct, the SLMC goes through a quasi-judicial procedure. If a doctor is found guilty of serious professional misconduct, Section 33 of the Medical Ordinance enacted in 1927 empowers the SLMC to erase the name of the guilty doctor from the medical register. This means that such a doctor cannot legally practice medicine. Thus Section 33 makes the SLMC a very powerful body. Currently I happen to preside over the SLMC. The astute psychiatrist Dr. Gambheera is well aware of my power. That must be why he thought it prudent to accord to the President of the SLMC – now an old man near his end – the honour and privilege of addressing this epoch-making inauguration. For this honour I thank him very sincerely.

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