Medical ethics in Slovakia
My paper is devided in two different (but in reality) related aspects. In the first part 1 would like to analyse some aspects of medical and ethical educations from our point of view and, in the second, Slovak experiences in establishing ethics in medicine and health care and legal support for medical ethics.
The universal nature and meaning of medicine itself proves that medicine is inherently ethical. In every cultural context medicine is needed, recognized and valued by all. ( ucha, J., 1997) That medical education which aims at making its students and physicians good doctors is not an individualistic task, ( me and my students, my colleagues, etc.), it takes place within a context of medical practise, a medical community, that although concrete in particular place and time, is also of universal significance.
The moral integrity of health professionals should be saved by permanent ethical education and training and by developing and strenghthening their up to date professional competence.
What is a good medicine ? What makes for a "good" doctor? But the essential underlying question is: "who has the competence to judge what is good or bad; whether the doctor is good or not ?" To claim this competence is audacious. The physician plays many roles, not only one. And to be good as a diagnostic, a therapist, a head of department, a confessor or husband and father, is not a state, rather,' it is a process. A physician maintains, increases his goodness by improvement: he must maintain and defend it, or he may regress and loose lt. To be a good means to endeavour to become good and to continue that goodness.
Albert Schweitzer (who became a physician in order to become the better theologian), pointed out the ethics of respect to life, to the ethics and to science. In this sense, science and life, in medical praxes, go together and their relation is like the relationship between a good coalition and a good opposition. The process to become a good doctor is an education of self-awadreness.
The relation between professional and private life can not be one of independence in relationship to each other. The one who is fighting for rights, liberty and justice, must not be a despot in his own family, cannot mislead his nearests and has to be fair also in his own family. In reforming the surrounding world we may not neglect ourselves. It is the testimony to the values, in the name of which we are acting. (~olt6s, L., 1997)
Frustration, deprivation and mistakes are on all sides in a professional life. Physicians should be sensitive to their mistakes. The mistakes seduce. Every man who contemplates his mistakes knows how success is manipulated by his own mistakes. To face, no confront our own mistakes and the limitations of mistakes of the others is very difficult. The myth of seducer and temptater is one of the central myths of humanity. Certainty is not by chance. To be aware of mistakes is not only the rule of the sceintific analysis but also an ethical imperative. To be good is a lifelong process. (bolts, L., 1995)
"How to learn" rather than "what" you to learn, is the critical issue. It is a fact that of the three basic questions in the teaching process, (i.e., the Why, What and How), the latter is often neglected.(Kou ilea, M., 1997)
Briefly, the "How" is the rationale, a set of organizational and operational principles and strategies undelying those processes which facilitate acquisition.
The basic premise is that the learning process must be selective and integrating rather than discrete. Our aim is meaningful learning: learning by understanding that is both selective and organizing. Efficient dealing with the information burden is one of the most urgent challenges in the world of both business and science. The renowned news agency, Reuters, has recently organized a conference in London addressing the questions :
A monster has been created which makes us feel inferior, incompetent, lost, and afected by " Information Fatigue Syndrome" causing physical illness and mental anguish. Paradoxicaly, one symptom is an addictive drive to seek even futher information being obsessed by a fear of missing something important. The result is paralyses of analysis, characterised by distorted judgment, wrong decisions, flawed conclusions and even serious blunders. This carries ethical implications to our approach to our present and future problems.
And now allow me to proceed to the second point of my lecture.
Bioethics in Slovakia was born after the so-called "Velvet revolution" in November 1989.(Šoltés, L., 1998) The fall of the totalitarian ideology and despotism of Marxism -Leninism over society, the sciences and culture, opened the door for a new freedom with exciting possibilities for progress and development. In the fields of medicine and health care this was marked by a remarkable interest in the old combined with novel ethical problems, rising from new problems emerging within the health care system reforms and by enormous progress in science, technology together with new opportunities within the diagnosis, curing and caring of patients.
The roots of interest in medical / ethical problems, as well as the first enthusiasts that started to be engaged in the field of Bioethics in Slovakia, arose from circles of intellectual and spiritual resistance to the totalitarian regime. It arose from within all the groups of society ( in e.g., medical ethics there were physicians, psychologists, sociologists, theologists, philosophers, etc.)
An important step in this direction was the creation of the Central Ethics Committee. In this respect, considerably important has been the publishing in 1991 by Ministry of Health : Guidelines for Work, The Establishment of Ethics Committees in Health Care Facilities, and Biomedical Research Institutions. These guidelines became a basis for the establishment of work ethical Committees and were among the first documents of this kind published in the Central and East Europian countries.
Without legal support of the Ministry of' Health the initiative for establishing and operation of ethical committees would not be possible.
The next step was the foundation of the Chair of Medical Ethics at the Postgraduate Medical School, in September 1991. This started regular courses for physicians and nurses in medical and nursing ethics. The following the Chair of Medical Ethics was transformed into the Institute of Medical Ethics and Bioethics which is a joint institution of a medical faculty and a postgraduate medical school. The new institute added to the above mentioned regular courses for the physicians and nurses ( and other health care workers in ethics) teaching medical ethics as a compulsory discipline / 2 credits / for medical students in the first and fourth year of study. In eddition to regular lectures that cover the most impotant basic and special ethical problems of medicine, our system of teaching and learning is focused on the work in small grous of students in the form of regular seminars. The students are expected to write a short essay on a chosen medical ethical topic and then present it for discussion to the group. lt is not aimed to expose the students to the sole definitions and philosophical constructs but rather, should enhance their abilities in medical reasoning and effectivness ethical decision making.(Šoltés, L., 1997)
Now, in conclusion, a description of our activities concerning The Institute of Medical Ethics and Bioethics. I would stress that our Institute coordinates and harmonizes the teaching of medical ethics in the undergraduate and postgraduate level, with a view to lifelong process which started for the students and medical faculty and carries on during the professional life of physicians and nurses. I would very modestly state that our concept of medical ethics was noted and appreciated by many of our friends from several countries around the world.
And now I would like to inform you about our international activities during the last years.
In January 1992 we organized the Czecho-Slovakia-Hungary-Poland regional symposium on contemporary problems of medical Ethics in Central Europe. The symposium was supported and welcomed by the Council of Europe and was followed by an active collaboration and partipication of Slovak Bioethicists. In connection with the symposium the first International Postgraduate Course of medical Ethics was held.
In May 1992, another major international meeting with medico-ethical issues was held in Bratislava: "The World Pro-Life Congress", organized with collaboration and participation of several national and international institutions and organizations with about 2,300 participants from all 5 continents. At the end of the Congress we organized The International Symposium on Medical Ethics, with about 500 participants.
In July 1992, the second International Postgraduate Course of Bioethics was organized by our Institute.
In June 1993 the third International Postgraduate Course of Bioethics was held in Bratislava.
In November 1993 a Conference on the Teaching of Bioethics in Europe was organized by the Council of Europe with collaboration of our Institute.
In September 1994 our Institute took part with an official Slovak Goverment Delegation to the UN International Conference on Population and Development in Cairo.
In October 1995 an international conference, ..Patient and care" was organized with the International Association for Law, Ethics and Science Paris.
In August 1996 the Fourth International Course and Conference of Bioethics took place in Bratislava, entitled, "Health Care under Stress: Maintaining Integrity in Time of Scarcity."
In 1998 The International seminar with collaboration of the Council of Europe was organized on the topic: "Human Foetus, Ethical and Legal Aspects and Ethical Aspects of Research."
In April 1999 we shall organize an international symposium on the topic, "European Convention on Bioethics," because Slovakia was the first country in Europe which ratified this convention.
And now some comments about the present situation in Slovak legislation considering these problems.
The health legislation in Slovakia is initiated by the Constitution of the Slovak republic, (from the basic document for legal standards).
According the 15. Article of the Constitution: 1. Everybody has the right for life. Human life has value even before birth. 2. Nobody should be deprived of life. 3. Capital punishment is not acceptable.
The Slovak republic was the first country which ratified the treaty about bioethics, reclaimed by a team of experts of the Council of Europe and the same time refused cloning as a method absolutely unacceptable as applicable for human beings.
Finnaly, allow me please, to recall the conditions of the operative rules allowing to interruption in medical institution. It is about an old law from the period of totalinarianism No. 73/1986 conserning the artifical termination of pregnancy. According to paragraph 4, An artificial termination of pregnancy is possible if requested in writing, and if the pregnancy does not exceeded 12 weeks and if they not prevent disease reasons. According to paragraph 5, It is possible to terminate a pregnancy for disease reason with the consent or initiative of the expectant mother, in the case of disease in either the mother or the healthful development of the foetus, or in the case, of a defective development in the foetus.
According to paragraph 6, section 1, It is possible to interrupt the pregnancy of a woman, who has not completed the age of 16 years, with the consent of her legal guardian, or alternatively, of the person consigned with her custody. According to the same paragraph 6, section 2, If artificial termination of pregnancy occursaccording to paragraph 4 in the case of a woman in the age of 16 - 18 years, the medical institution is obligated to inform the person, consigned with the custody of expectant mother.
Referring to genetic grounds and its possible diagnostic accessibilities, the law was completed with a regulation. The regulation No. 74/1986 completes the above mentioned law No. 73 about the artificial termination of pregnancy: from genetic grounds it is possible to realize an artificial termination of pregnancy till 24 weeks of persistation.
Euthanasia is not acceptable. There are efforts to humanize the care for the dying in hospitals. A movement for building hospices and paliative care has begun with the entrance of charitable institutions.
Prof. Dr. med. Ladislav Šoltés