•  ● The establishment of the Chair
On June 24th 2001 an agreement was signed by the Director-General of UNESCO and the Rector of the Haifa University, Israel, concerning the establishment of a UNESCO Chair in Bioethics at the International Center of Health, Law and Ethics, University of Haifa.
... [more]
  •  ● Director   Prof. Amnon Carmi
 

Bioethics Education: an UNESCO Chair’s Methodology

What to teach and how?

Amnon Carmi

Introduction

In 2001 an agreement was signed by the Director-General of UNESCO and the Rector of the Haifa University, concerning the establishment of a UNESCO Chair in Bioethics. Article 2 of the Agreement defined the purpose of the Chair: to coordinate and stimulate an International Network of institutes for Medical Ethics Training, associating higher education institutes in both the developed and developing countries, and to develop an up-to-date syllabus for medical ethics education which will satisfy the requirements of medical schools in the world.

During the first decade the Chair has established about 190 Units in five continents, and produced twelve guiding books on ethics education.

The following review will describe the novel educational method of the Chair, its professional background and its scientific foundation, as well as the administrative mechanism that enabled the successful development of the Chair.

 

Part one: History

A. The Bioethics Core Curriculum

On 19 October 2005 the 33rd Session of the General Conference of UNESCO adopted the Universal Declaration on Bioethics and Human rights. The Declaration embodies a set of bioethical principles that provides a common global platform by which bioethics can be introduced and taught to university students.

The UNESCO Division of Ethics of Science and Technology, the Sector for Social and Human Sciences, has produced the Syllabus for Ethics Education Program: The Bioethics Core Curriculum (BCC). The BCC was developed with the assistance of the Advisory Expert Committee (AEC) for the teaching of ethics, comprising of the following members: R. Apressyan, D. Balasubramaniam, A. Carmi, L. de Castro, D. Evans, D. Garcia, N. Guessous-Idrissi, H. ten Have and J. Williams. The BCC sets out to introduce the bioethical principles of the Universal Declaration that are shared by scientific experts, policy-makers and health professionals from all over the world. The BCC presents a core: it defines what should be regarded as the minimum in terms of teaching hours and contents for appropriate bioethics teaching.

The BCC is meant to provide the teachers a way of getting students to reflect upon the ethical dimensions and human rights considerations of medicine, health-care and science. In other words, the BCC answers the question: What should be taught? However, as will be argued below, the BCC does not and cannot answer the question: How should bioethics be taught? The present review will try to offer an answer to this dilemma.

B. The first Haifa Research

Initial  research into the importance and quality of education in ethics at medical colleges and faculties of medicine all over the world was conducted by the International Center for Health, Law and Ethics at the University of Haifa in 1996, when 110 medical institutions completed and returned the Center`s questionnaire. The following review refers to that research and reflects the factual findings at that period of time.

Statistically and primarily the subject of ethics was taught at 105 ( 95 %) of these institutions. Although, on the face of it, this situation is almost ideal, in actual fact it lends support to our major premise, namely that something must have been fundamentally wrong with the methods by which the subject was taught in a considerable number of the medical schools, owing to the fact that since many physicians fail to practice ethically in spite of their study of, or concerning, ethics, the methods by which they have been trained were questionable.

Secondly, it appears that although 88 % of the medical institutions make their courses in ethics compulsory, this imposition does not guarantee that students` conduct will always be guided by ethical values.

The questionnaire laid great stress on the identities of the teachers of ethics at the medical schools. It reveals that in 32 % of the institutions the teachers of ethics are medical practitioners, while only one school employs a teacher with legal qualifications.

In 18 % the teachers are philosophers or ethicists; 6 % employ both a doctor and a lawyer; 15% a doctor, a philosopher and an ethicist; 3 % a lawyer, a philosopher and an ethicist;14 % a doctor, a philosopher, an ethicist and a lawyer; at 4 % of the institutions instruction is given by a minister of religion.

We assume that on principle the teacher should be a physician, because medical students` tendency to experience a sort of professional empathy with a senior member of their own future profession should induce them to absorb his ethical directives with greater ease. We would not of course disqualify them from meeting with experts in philosophy, law and religion during the course of their study in order to acquaint themselves with other experts` views on ethics. However, the fact that approximately 77 % of the persons involved in one way or another in the teaching of ethics are doctors, although encouraging, adds to the enormity of the dilemma. Why has the teaching of ethics not attained its objectives?

The research tried to explore an additional issue of no less relevance with regard to the number of hours that have been allotted to the teaching of ethics. It was found that 9% of the institutions devoted up to ten hours to tuition of ethics; at 29 % there were ten to twenty hours; 33 % teach between twenty and fifty hours; 7 % between fifty and a hundred hours; while at 8 % of the institutions there were over a hundred hours of instruction. 

One should logically deduce that the horns of the dilemma are located not so much in the quantity as in the quality of the tuition.

A final question concerned the location of ethical education in the whole syllabus of medical studies, namely in what year or years should ethics be taught? The research disclosed that 54 % of the institutions place ethics in one year of study and they vary in their choice of years. At 10 % the subject is taught during two years; at 9 % it is placed within three years; at 10 % it stretches over four; at  5 % over five; and at 3 % over all the six years of study.

It would appear that the more time is spent on the teaching of ethics, and the longer it stretches over the students` whole course in medicine, the better the results should be. However, even if such a recommendation is universally accepted, it will not be strong enough to challenge and eliminate the problem of ineffectual teaching methods which were crying out for modernization and radical reform.

C. The second Haifa research

An additional research was conducted in 2001. The International Center for Health, Law and Ethics asked 1500 deans of medical schools to complete another questionnaire and return it to the Center. As only sixty deans returned the questionnaire, the survey can by no means present a worldwide picture, although it embraces the Americas in the west, Tasmania in the east, Sweden in the north and South Africa. Respondents consisted of medical schools in underdeveloped as well as developed countries.

The sixty respondents may be divided into four groups. The first comprises 48 medical schools at which courses in ethics are compulsory. At three institutions courses are optional. Three integrate ethics into their medical and surgical lectures. The fourth group is nondescript. An interesting condition in Scotland`s Aberdeen required all students before they transfer to the medical course to sign a detailed declaration promising that they will follow the ethics code during their practice as physicians.

Thirteen institutions entitle their courses Medical Ethics, 3 favor Bioethics as a title, 3 prefer Medical Ethics and Health Law. Others are called Seminars on Bioethics, Medical Ethics and the Law, Lectures in Ethics, Medical Ethics and Deontology, Clinical Skills, Ethics and Aesthetics, Professional Ethics, Ethics and Morals, Biomedical Ethics, and Philosophy of Medicine.

The hours devoted to specific lectures on ethical subjects vary so significantly that at this time it may be assumed that there are widely different opinions on what a course in ethics should comprise.

Nine institutions devote less than ten hours to the subject, eight run courses for between ten and nineteen hours, four schools devote between twenty and twenty-nine hours to ethics, five between thirty and thirty-nine hours, two between forty and forty-nine hours. Two institutions teach the subject for fifty hours, two for between sixty and sixty-nine hours. Two other schools state that there are 108 and 240 hours of ethics in their programs, which does not seem to leave much time for medicine and surgery. From the other twenty-four respondents we received such statements as, one lecture weekly, one fortnightly, three weeks and four weeks of projects, two semesters or no answers at all.

The years during which courses are given are also wide in their variety.

At four institutions the subject is studied during the first year only; at two during the second year; at ten during the third year; and at two during the fourth year of study. Three schools teach ethics during the first three years of the medical course; one during the third, fourth and fifth years; another during the third and fourth, one during the first and second, another during the second, third and fourth; another during the second and third; another during the third and fifth; and another during the first, third and fifth years of study. One institute allocates the subject to its second and ninth semesters and another to what it describes as different years. Twenty- four schools did not answer the question clearly.

About half of the deans were able to state that their lecturers had paper qualifications in Bioethics, but many regretted the fact that their limited budgets did not permit them to employ certificated experts in Ethics. Some teachers of the subject are defined as pediatricians, obstetricians, dermatologists, neurologists, and, of course, lawyers. Deans are almost unanimous in their wish to have doctors or more doctors qualified to instruct in ethics.

In brief conclusion, there is abundant evidence to prove that lots of medical schools will sincerely welcome guidance in the teaching of ethics. They will send physicians to courses; they will welcome modernized methods of instruction in the subject; they will adopt a new syllabus either in its entirety or insofar as it suits their environment. As for the hundreds of silent institutions it may not be too much to expect that many of them will realize that a 21st century ethical approach by physicians to their colleagues as well as to their patients will strengthen the efficiency of the medical profession.

D. The need for a novel method

In recent decades medical education curricula have undergone many modifications for a variety of reasons. In spite of these changes, ethics education has not received adequate attention in medical schools throughout the world. There is an emerging need for introducing medical ethics teaching as a consequence of several social and scientific processes:

Health-care consumers emphasize nowadays not only the need for health but the need for quality of life. Health-care providers are detached from traditional concepts of idealistic medicine, adopting a contractual consumers’ paradigm. Patients expect empathy, reliability and devotion, along with professionalism, effectiveness and quality.

Medical technology has created new dilemmas (e.g. procreation, euthanasia, intensive care, medical genetics and biotechnology). While at the same time causing previous ethical resolutions to become obsolete (e.g. definition of death, family composition).

Specialization and sub-specialization in medicine were encouraged technicality at the expense of patient-physician relationship and communication skills, thus creating a growing gap between physicians and their patients, and between medicine and society at large. Growing social concern, suspicion and demand for closer inspection on medical activities is filling this gap. The demand is materialized in the form of ample litigation, increased health-related legislation and formulation of international declarations, conventions and charters, creating new ethical and legal frameworks and new obligations for the practicing physician. Resource allocation in face of growing monetary constraints creates a substantial effect on the everyday practice of medicine. The need to adhere to ethical norms in scientific research and experimentation (human cloning, pharmacology) remains a constant challenge.

A medical ethics curriculum ought to reflect the changing faces of medicine and should govern the following arenas, each having multiple sub-categories, with varying ramifications:

The relationship between health-care providers and their patients; the choice of medical intervention for the individual patient; the choice of public health interventions; the evaluation of effects of health-care interventions; the collaboration between teams engaged in health care activities; the choice of goals and methods of medical research.

These studies that were conducted at the International Center for Health, Law and Ethic indicated, inter alia, three crucial findings.

First, many of the doctors who taught ethics in medical schools around the world have never studied ethics and bioethics, certainly not in an exhaustive systematic way. Second, most of the doctors who taught ethics have never acquainted with the art of teaching. Third, most physicians were accustomed to teach and talk about ethics ex-cathedra.  One may also learn from different studies conducted in various centers around the world that many students feel a lack of interest, rejection and even disgust when compelled to listen to speeches or preaching.

In light of these findings, and due to the need of allocating a different manner of delivering the message of ethics to students, an international committee undertook the mission to form a new method for teaching ethics in medical schools in the world. The following members took part in this project: A. Carmi (chair), M. Cotler (USA), S. Fluss (UK), G. Kutukdjian (France), A. Okasha (Egypt), and N. Sartorius (Switzerland).

The aim of the project was to form a new, modern curriculum of medical ethics to be taught at medical schools all over the world. The need for a modernized curriculum derives not only from the fact that many of the existent curricula are antiquated and completely out of tune with the intricacies of recent scientific developments, but also from the safeguards which we require in the form of educational innovations which will inseminate ethical values into our students, in spite of this materialistic age in which we live.

The goal of the project was to ameliorate the current tuition of ethics in medical schools and to intervene in several plains: To solicit conceptual changes in medical faculties, to form modern curriculum for education of ethics, to train the potential teachers for the instruction of ethics, and to create modern educational tools and materials.

The purpose of the initiators was to form an updated and modern curriculum, reflecting the need for the integration of ethics in everyday practice, for augmenting interest and respect for values involved in health care delivery, and for raising awareness for competing interests. The project was expected to introduce students to various non-medical facets of medicine: sociology, economics, psychology and public administration. The idea was to create training programs for teachers and instructors of ethics in medical schools, and to develop novel, modern and sophisticated educational tools and materials in order to facilitate attractive teaching.

The new method that was compiled by that team consisted of a few basic components.
First of all, waiver or abandonment of long speeches as teaching tools for ethics education. Second, the initiation of and call for active involvement of the students in the discussion and decision-making process. Third, the use of real medical cases while dealing with ethical dilemmas.  Fourth, the collection of such cases from different countries and variety of cultures in order to formulate a universal method of teaching to fit any site.
Fifth, the construction of a uniform structure of the syllabus: Starting with a short review of the case, that is followed by a leading question such as: “What or how should the doctor react in this case?” In the next stage the syllabus presents the students with a few alternative ethical options. Finally, after the classroom’s discussion, the teacher may provide the students with a condensed ethical definition or explanation.

The method in question was forwarded to another ad-hoc international scientific committee that included over one hundred and fifty experts from more than fifty countries. That ad-hoc committee elaborated the method and delivered it to the UNESCO Division of Ethics of Sciences and Technology that examined
the method and adopted it. The Director- General of UNESCO decided to realize the message of this method and established in 2001 a special Chair at the International Center for Health, Law and Ethics of the University of Haifa. The DG declared that one of the essential factors favoring development in the fields of competence of UNESCO is the exchange of experience and knowledge between universities and other higher education institutions. The new Chair was authorized to develop an up-to-date syllabus for medical ethics education which will satisfy the requirements of medical schools in the world.

 

Part two: The new method

A. The Cases’ system

The Chair undertook the mission of producing a series of guiding books for teachers and students thereby using the new method that was compiled by its experts. These books possess heuristic and pedagogical characteristics, thus translating complicated ethical dilemmas and conveying their messages in an easy and clear manner. The editors of this series of books have collected and chosen vignettes as the tool to teach ethical concepts. While as a teaching tool the use of cases may have its detractors, they are commonly used to convey in a few paragraphs the central elements of a case and to demonstrate in practice the application of concepts. The cases are collected from many countries worldwide and reflect a universal perception. The problems that the vignettes depict are similar everywhere, and doctors have to grapple with them no matter where they practice. The cases in this series of books cover large segments of issues and topics that most often bedevil the medical practice, and on occasions become a matter of public debate about the appropriateness of medical interventions.

Contributors were asked to mask much as possible any identifying elements in each case, in order to protect the patients’ rights of confidentiality and privacy. Some cases describe behaviors that are blatantly unethical and even border in legal wrongdoing. They have been kept as an indication that, at times, the dividing line between unethical behavior and criminal lawbreaking is blurred, and that unethical behavior may carry legal consequences when that line trespassed. Following the presentation of each case a binary approach has been used to indicate the possibilities of at least two opposite answers to the problem. Of course, students are invited to develop their own favored ethical choices for the resolutions of these case studies. While this approach may be considered too simplistic, the idea is to provide students with alternatives in thinking ethically, without encumbering them with deep ethical concepts for which texts and other books have been specifically written. The cases are drawn from real-life experiences. They are based on simple fact situations, so that the students can address their ethics elements, rather than evade ethical engagements by resort to technical means or development of additional facts. The use of case studies for medical ethics teaching stimulates ethical debates by calling for a combination of concrete problem solving and abstract principled reasoning. Through case studies, students will learn, firstly, to develop sensitivity for ethical problems and to describe an ethical conflict; secondly, to identify and analyze the underlying ethical principles and values which are relevant to the case, and, thirdly, to stimulate ethical decision-making in the practice of health-care. The aim is to produce a tool and a platform for active participation of students in the decision-making process.   Students should learn how to develop a position on an ethical problem and how to justify it. Combined efforts of teaching, educating and training by the use of such a methodology may plant and root in the minds of the students ethical values that should guide every physician providing health-care.  The danger of using vignettes would be to become too specific and to concentrate too closely to the issues of the case while forgetting the major socio-political and other relevant implications underlying the cases. These books should be considered as just a “primer” in ethics with no pretenses to be a scholarly text. A few books offer wide discussions rather than short explanation with regard to the relevant ethical dilemmas. While doing so, the editors do not profess to solve all the ethical issues, but rather to inspire the students to think about all of them more closely and more carefully.

B. The first book

The first book was  Informed Consent (Carmi, 2003). This book was edited according to the original concept of the founders of the new methodology. The book includes 30 cases. The stories of these cases were delivered to the Editor by senior clinical physicians from: India, Philippines, Turkey, Malawi, Germany, Canada, France, Russia, West-Indies, Poland, Bulgaria, Italy, Indonesia, USA, Holland, Israel, Japan, Ethiopia and Spain. The structure of the book consisted of thirty paragraphs. Each paragraph started with the story of a case, and the name and title of its presenter. The second part of the paragraph presented the students with a question concerning the potential behavior of the physician in this case. The question was followed by two or more alternative ethical solutions. The third part of the paragraph offered a very short ethical explanation concerning the specific ethical dilemma that was raised in the relevant story. Illustration: Case Report No. 2 (Informed Consent, p.5):  Mr. N., 46 years old, is the father of two children. The oncologist was keeping him under observation in connection with his adenoma of prostate for three years. In due course the tumor became malignant. Consequently Mr. N. was admitted to hospital for prostatectomy. Before the surgery he was informed about the state of his health and about forthcoming surgery. Informed consent was obtained. In the course of the surgery a seminoma was found. The surgeon decided on prostatovesiculectomy.  As a result, Mr. N. sued the surgeon because the treatment was harmful to him and his right of reproduction was affected.

C. The second book

The second book was published two years later: Teaching Ethics in Psychiatry: Case-Vignette (Carmi, Moussaoui, Arboleda- Florez, 2005 a). The book includes 38 cases. The stories of these cases were delivered to the Editors by senior clinical physicians from: Canada, Australia, Serbia, Montenegro, Israel, Czech Republic, Denmark, Italy, Morocco, Georgia, Germany, Switzerland, Poland, USA, Spain, Uruguay, South Africa.

The structure of the book consisted of thirty eight paragraphs. Each paragraph started with the story of a case, and the name of its presenter. The second part of the paragraph presented a question for the students with regard to the potential behavior of the physician in this case. The question was followed by a few alternative ethical solutions. The third part of the paragraph offered a detailed discussion of the ethical dilemma that was raised in the relevant story. Comment: The active involvement of two psychiatrists within the editorial team facilitated the compilation of a coherent professional consideration concerning the complex dilemmas.

Illustration:  A 25 year old man goes to see a psychiatrist for the first time. He is accompanied by his father, who says that his son has been acting strangely for the last three weeks. He is seen on his own by the psychiatrist, and the young man describes the aural hallucinations that he has been having for three weeks. His discourse reveals an intense, invasive mystical delusion, with no signs of being dangerous. The psychiatrist diagnoses an acute psychotic episode and fears that it marks the beginning of schizophrenia. He wants to start neuroleptic treatment as soon as possible and tells the patient so. He explains the benefit of swift treatment and the possible side effects of the medicine. The patient refuses the treatment, fearing that his intellectual capacities will be harmed. The psychiatrist then sees the patient again in the presence of his father, to explain the situation. At this point, the patient agrees to the treatment as he thinks that his father is the “emissary of God”, and he must obey him.

Question: Should the psychiatrist treat the patient within these premises?

  1. YES, because the patient did express consent.
  2. YES, because the patient has a good chance of recovery.
  3. YES, because if the patient does not take antipsychotics, he might worsen clinically and even become dangerous for himself or for others.
  4.  NO, because consent was not given freely. The young man said that he was obliged to submit to his father’s wishes.

Comments:

Informed consent is defined as the willing and uncoerced acceptance of a medical intervention by a patient after adequate disclosure by the physician of the diagnostic assessment, the prognosis, the nature of the intervention, the risks and benefits, as well as of alternatives with their risks and benefits. The doctrine of informed consent can be seen as a special form of communication between a physician and patient. The therapist-patient relationship must be based on mutual trust and respect to allow the patient to make free and informed decisions. For a patient’s consent to be considered informed, it must adequately address three essential elements: Voluntariness, information and competency. For a psychiatrist, one of the recurrent questions in daily practice is: “is it ethical to use a delusional content in the best interest of a patient?” In this case report, the psychiatrist did not comment on the change of decision made by the patient because of the presence of his father; he accepted the change without interfering, since this represented in the opinion of the psychiatrist the best possible decision by the patient. The psychiatrist chose a consequentialist approach.

D. The next books

 The third book was published one year later: Reproductive Health: Case studies with ethical commentary (Dickens et al, 2006). The book includes 31 cases. The editors followed the trend of the second book and enlarged the debate concerning the factual description of each case.

The fourth book was published two years later: Psychiatric ethics and the rights of persons with mental disabilities in institutions and the community.  Perlin et al (2008). This book too includes many real cases, but is built in a different structure. The book includes two main parts that are divided into several chapters. Every chapter includes several cases. Unlike the other books, this one offers the students lot of bibliographical references for every chapter. Most of the cases in this book were dealt by various courts. The editors provided the students with summary of the judicial decisions. Every chapter starts with the summary of a case. The summary is followed by a short review: What happened in the court case? A long ethical explanation accompanies that legal report.

The next book dealt with organ transplantation: Teaching ethics in organ transplantation and tissue donation: Cases and movies. (Schicktanz et al, 2010).  The editors collected 30 cases from different regional, cultural and religious backgrounds. The cases cover a  multitude of topics. For further discussion, each case ends with possible solutions to the problem. Unlike in the other books, the editors offer the ethical explanation in the introduction of the book. This does not cover all sorts of ethical problems related to organ transplantation but will provide basic information to start with in class-room discussions. For an in-depth reading the editors have compiled a list of open-access sources and basic books at the end of the introduction.

The Chair has produced another book on Moral Games for Teaching Bioethics. (Macer, 2008). The book offers 43 games, online resources and references.

In addition, the Chair published a book on Class Communication. (Keidar, 2005). The book offers the use of emotional intelligence and non-verbal communication in ethics educational at medical schools.

Two additional books were published by the UNESCO Social and Human Sciences Sector in 2011:  Casebook on Human Dignity and Human Rights. (Carmi et al, 2011a), and  Casebook on Benefit and Harm. (Carmi et al, 2011b).  Each book includes about 30 cases. Every case refers to a certain ethical dilemma. Every case is followed by ethical and medico-legal comments. Whereas the editors of the previous books collected and got most of the cases from clinical physicians who provided them voluntarily, the editors of these two books collected the cases from judicial literature. The editors made global research and examined a lot of Supreme Courts’ decisions from various continents, societies and cultures, all of them dealing with relevant medico-ethical dilemmas.

The advantages of this newer method are obvious. First of all, court decisions are not copyrighted. Therefore, there was no need to hide, change or camouflage the identities of the persons or the circumstances. Secondly, the factual descriptions were more thoroughly inspected by the lower courts until the cases reached the higher judicial instances.

Illustration:

 Dr. D was an obstetrics/gynecology resident pursuing a joint residency at the State University Medical Center and the regional Hospital. During an invasive surgical procedure, Dr. D was accidentally cut by the attending physician. The record does not indicate whether there was any actual blood contact between Dr. D and the patient. It appears there was no blood exposure, although no one can be certain. The following day, Dr. D voluntarily submitted to blood testing for the HIV virus. The results confirmed that Dr. D was HIV-positive. After being informed of the test results, Dr. D willingly withdrew from participating in further surgical procedures, informed the appropriate officials of his condition, and requested a voluntary leave of absence. Upon investigation, the Medical Center identified 279 patients who had been involved to some degree with Dr. D during the course of their medical treatment. Likewise, the Hospital identified 168 patients who had been in contact with Dr. D since the time of his joint residency. Unfortunately, hospital records do not necessarily indicate each time a physician is cut, nor do they specify the distinct role of each physician in a surgical procedure. Thus, every patient with a reasonable chance of exposure to Dr. D was included in the statistics outlined above. Both the Medical Center and the Hospital filed petitions alleging a “compelling” need to disclose information regarding Dr. D’s condition to those patients potentially affected by contact with him. In addition, the hospitals believed there was a compelling need to disclose Dr. D’s name to the other treating physicians in the department, so that those physicians could contact their patients in the event they had been assisted by Dr. D in any invasive procedures.  In response, Dr. D asserted his right to privacy, arguing that no compelling need was tantamount to a justification to disclose his HIV-related information.

Should the hospitals disclose Dr. D’s disease?

Here are a few, but not all, possible answers. Discuss them, as well as other possible answers. Identify ethical issues and decide which answer applies to you most, giving your reasons.

  1. YES. Medical institutes have a duty to insure the health of their patients to the best of their ability. Therefore, it is the hospital’s responsibility to inform possibly affected individuals of their potential exposure to HIV and to offer them treatment, testing and counseling. In addition, disclosure of Dr. D’s identity is necessary to prevent the spread of AIDS.
  2. NO. The hospitals have no right to disclose Dr. D’s name to the other treating physicians in the department. Dr. D’s right to privacy is not different from that of any other person. Therefore, disclosing Dr. D’s name is a severe violation of his right to privacy.
  3. YES. Undoubtedly, an individual’s health problems are a private matter to be dealt with subject to informed consent. However, Dr. D’s medical problem is not his alone. It became a matter of public concern the moment he picked up a surgical instrument and joined a team involved in invasive procedures. Therefore, the hospitals must disclose Dr. D’s disease.
  4. NO. Disclosing Dr. D’s disease will send the public a message that they are at risk of contracting AIDS if treated by an HIV-infected physician. Hence, hospitals in the future will risk liability if they fail to follow through with similar unsubstantiated patient notification. Expensive medical care will become even more costly due to needless repeated HIV testing and the high cost of doctors indemnity insurance. Furthermore, physicians and other health care workers will be discouraged from treating those infected with HIV.
  5. NO. This extensive notification will discourage physicians and other health care workers from treating HIV infected patients.

NOTES ABOUT THE CASE STUDY

COURT DECISION

The case came before the Court of the country. The court weighed the competing needs of public disclosure and the doctor’s right to privacy. The Court ruled that the hospitals had met the test and ordered that Dr. D’s identity and his HIV-related information may be conditionally revealed. The trial court’s order:

 “…Petitioners are hereby authorized to disclose the identity of Dr. D, M.D. as follows and only as thus authorized:

  1. By providing the name of Dr. D to the physicians in the Obstetrics and Gynecology Departments including the physicians in the residency program.
  2. By providing the name of Dr. D to a physician authorized in writing by a patient for whom Dr. D participated in a surgical procedure or obstetrical care.
  3. By describing Dr. D in letters to patients and in media releases as ‘a physician in our joint Obstetrics and Gynecology residency program’ and by setting forth the relevant period of such service.

Each physician to whom the name of Dr. D is provided under 1. and 2. above shall be reminded that the Act prohibits further disclosure of such information.”

The Superior Court affirmed the trial court’s order allowing the hospitals to inform patients of Dr. D’s HIV status, stating that the hospitals were allowed to release otherwise confidential information about the appellant due to the compelling need to inform and treat patients potentially exposed to HIV.

DISCUSSION: PRIVACY

Human dignity is probably one of the most important principles of bioethics. Although there is no clear definition for this principle, it is not just a saying, but rather reflective of the need to promote respect for the intrinsic value of every individual human being. To achieve this goal, international bio-law defines dignity as an overarching principle accompanied by other effective and practical rights, such as privacy.

The right to privacy is an integral part of the inherent right of every human being to dignity. It represents the right of every individual to determine when and how much personal information will be exposed to the public. Every human being has a right to privacy and thus, patients, as well as practitioners, are entitled to it.  

  This right actually enables individuals to maintain their autonomy and to live as they want. Some countries ground this right in their laws, as stated in Article 9 of the Universal Declaration of Bioethics and Human Rights:

 “The privacy of the persons concerned and the confidentiality of their personal information should be respected. To the greatest extent possible, such information should not be used or disclosed for purposes other than those for which it was collected or consented to, consistent with international law, in particular international human rights law.”

Nevertheless, the right to privacy sometimes conflicts with other rights, such as the right of others to know the truth about their health. In such situations, we must find a balance between the different rights and interests.

The right to confidentiality is not an absolute right. Sometimes, third parties face risks that require the withdrawal of this right. We must consider the gravity and imminence of the threat. Where the threat is serious and imminent, then even coerced disclosure would be appropriate. It should be emphasized that, in some countries, such disclosure is set out by the law. In addition, the public’s right to know about incidents that may affect them is also part of their right to dignity.

One of the most common practices for balancing the two rights is revealing only the relevant information while avoiding disclosure of names etc.  

 

For additional books, see the following list of references.

References

Carmi A (2003) Informed Consent. Yozmot, Haifa

Carmi A, Moussaoui D, Arboleda-Florez J (2005 a). Teaching Ethics in Psychiatry: Case-Vignettes. Yozmot, Haifa

Carmi A, Apressyan R, Guessous-Idrissi N (eds) (2011a). Casebook on Human Dignity and Human Rights. UNESCO, Paris

Carmi A, De Castro L, Evans D, (eds) (2011b). Casebook on Benefit and Harm. UNESCO, Paris

Carmi A, et al (eds) (2016). Casebook on Bioethics for Judges. Israel National Commission for UNESCO

Chelouche T, Brahmer G,  Benedict S (2013). Casebook on Bioethics and the Holocaust. Israel National Commission for UNESCO

Dickens b, Cook R,  Kishmodi E (2006).  Reproductive Health, Case Studies with Ethical Commentary. Yozmot, Haifa

Haque O S,  De Freitas J, Bursztajn H, Cosgrove L, Gopal A, Paul R, Shuv-Ami I, Wolfman S (2013). The Ethics of Pharmaceutical Industry Influence in Medicine . Israel National Commission for UNESCO

Keidar D (2005).  Classroom Communication, Use of Emotional Intelligence and Non-Verbal Communication in Ethics Education at Medical Schools. Yozmot, Haifa

Macer D (2008) Moral Games for Teaching Bioethics. Yozmot, Haifa

Perlin M, Bursztajn H, Gledhill K, Szeli E (2008). Psychiatric Ethics and the Rights of Persons with Mental Disabilities in Institutions and the Community.  Yozmot, Haifa

Schicktanz S, Wiesemann C, Wohlke S (2010). Teaching Ethics in Organ Transplantation and Tissue Donation, Cases and Movies.  Universitatsverlag,  Gottingen

 

 
 

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