The evolution of traditional medical ethics. Medical ethics Hippocratic Oath about the basic values and moral standards of the relationship between doctor and patient

For more than 25 centuries in European culture, various moral and ethical principles, rules, and recommendations have been formed and replaced each other, accompanying the centuries-old existence of medicine. Is it possible in this diversity to identify approaches that are of enduring importance for a modern doctor? If we designate the whole variety of medical moral experience with the concept of “biomedical ethics,” we will find that today it exists in four forms or models: the Hippocratic model, the Paracelsian model, the deontological model and in the form of bioethics, which in turn is represented by two forms - liberal and conservative. The historical features and logical foundations of each model determined the formation and development of those moral principles that today constitute the value-normative content of modern biomedical ethics.

1. Principle do no harm(Hippocratic model)

Historically, the first form of medical ethics were the moral principles of healing of Hippocrates (460-377 BC), set out by him in the “Oath”, as well as in the books “On the Law”, “On Doctors”, etc. Hippocrates is called the “father medicine.” This characteristic is not accidental. It records the birth of professional medical ethics.

In ancient cultures - Babylonian, Egyptian, Judean, Persian, Indian, Greek - a person’s ability to heal testified to his “divine” chosenness and determined an elite, usually priestly, position in society.

For example, the first Babylonian doctors were priests, and the main means of treatment were rituals and magic. The first Egyptian healer, Imhotep (2830 BC), was a priest who was later deified, and the temple in his honor at Memphis was both a hospital and a medical school. Medical practice was the exclusive right of the magicians of Persia and the Brahmans of Ancient India. Researchers suggest that Hippocrates' father was one of the priests of Asclepius, the god of medicine in ancient Greek civilization.

The formation of Greek secular medicine was associated not only with the influence of rational knowledge and the accumulation of healing experience, but also with the principles of democratic life of the city-states of Ancient Greece. The sanctified and undiscussed rights of healing priests were gradually but inevitably replaced by moral professional guarantees and obligations of healers to patients. Thus, the moral duties of a doctor were first formulated in the Hippocratic Oath: “consider the one who taught me the art of medicine on an equal basis with my parents, share my wealth with him and, if necessary, help him with his needs; consider his offspring as their brothers, and this art, if they want to study it, teach them free of charge and without any contract; communicate instructions, oral lessons and everything else in the teaching to your sons, the sons of your teacher and students bound by an obligation and oath according to the law of medicine, but no other. I will direct the treatment of the sick to their benefit in accordance with my strength and my understanding, refraining from causing any harm or injustice. I will not give anyone the deadly means they ask from me and I will not show the way for such a plan; in the same way, I will not give any woman an abortion pessary. I will conduct my life and my art purely and immaculately. In no case will I perform sections on those suffering from stone disease, leaving this to the people involved in this matter. Whatever house I enter, I will enter there for the benefit of the sick, being far from everything intentional, unrighteous and harmful, especially from love affairs with women and men, free and slaves.

Whatever during treatment - and also without treatment - I see or hear about human life that should never be disclosed, I will keep silent about it, considering such things a secret.”

The practical attitude of a doctor towards a sick and healthy person, initially focused on care, help, support, is certainly the main feature of professional medical ethics. What later, in Christian morality, will become the ideal norm of a person’s relationship with another - “love your neighbor as yourself”, “love your enemies” (Matthew 5:44) - in professional medical ethics is a real criterion for choosing a profession , and to determine the measure of medical art.

The norms and principles of physician behavior, defined by Hippocrates, are not just a reflection of specific relationships in a specific historical era. They are filled with content determined by the goals and objectives of healing, regardless of the place and time of their implementation. Because of this, although changing somewhat, they do not lose their meaning today, acquiring in one or another ethical document, be it the “Declaration”, “Oath”, etc., their own style, a special form of expression.

An example of a document created in the “Hippocratic model” mode is the “Oath of the Russian Doctor”, adopted by the 4th Conference of the Association of Russian Doctors in November 1994:

“By voluntarily entering the medical community, I solemnly swear and make a written commitment to devote myself to the service of the lives of others, seeking by all professional means to prolong and improve them; the health of my patient will always be my highest reward.

I swear to constantly improve my medical knowledge and medical skill, to devote all my knowledge and strength to the protection of human health, and under no circumstances will I not only use it myself, but will not allow anyone to use it to the detriment of the norms of humanity.

I vow that I will never allow considerations of a personal, religious, national, racial, ethnic, political, economic, social or other non-medical nature to come between me and my patient.

I swear to immediately provide emergency medical care to anyone who needs it, to treat my patients carefully, carefully, respectfully and impartially, to keep the secrets of people who have trusted me even after their death, to seek advice from colleagues, if the interests of healing require it, and never to do not refuse them either advice or disinterested help, cherish and develop the noble traditions of the medical community, and throughout my life maintain gratitude and respect for those who taught me the art of medicine.

I undertake in all my actions to be guided by the code of ethics of the Russian doctor, the ethical requirements of my association, as well as international standards of professional ethics, excluding the provision on the admissibility of passive euthanasia, which is not recognized by the Association of Russian Doctors. I take this oath freely and sincerely. I will perform my medical duty conscientiously and with dignity.”

That part of medical ethics, which considers the problem of the relationship between doctor and patient from the point of view of social guarantees and professional obligations of the medical community, can be called the “Hippocratic model”. The set of recommendations that the medical community accepts, realizing its special involvement in public life, are the principles set by the ethics of Hippocrates. We are talking about obligations to teachers, colleagues and students, about guarantees of non-harm, provision of assistance, respect, justice, a negative attitude towards euthanasia, abortion, refusal of intimate relationships with patients, concern for the benefit of the patient, and medical confidentiality.

Among the listed principles, the principle of “do no harm” is fundamental to the Hippocratic model. The “Oath” says: “I will direct the treatment of the sick to their benefit in accordance with my strength and my understanding, refraining from causing any harm and injustice.” In the cultural and historical context of Hippocratic ethics, the principle of “do no harm” focuses on the civil creed of the medical class, that initial professional guarantee, which can be considered as a condition and basis for its recognition by society as a whole and by every person who trusts a doctor with no less than his life.

2. Principle do good(Paracelsus model)

The second historical form of medical ethics was the understanding of the relationship between doctor and patient, which developed in the Middle Ages. Paracelsus (1493-1341) was able to express it especially clearly. K.G. Jung wrote about Paracelsus: “In Paracelsus we see the founder not only in the field of creating chemical medicines, but also in the field of empirical mental treatment.”

The “Paracelsus model” is a form of medical ethics, within the framework of which the moral relationship with the patient is understood as a component of the doctor’s therapeutic behavior strategy. If in the Hippocratic model of medical ethics social trust of the patient’s personality is won, then the “Paracelsus model” is a consideration of the emotional and mental characteristics of the individual, recognition of the depth of his mental and spiritual contacts with the doctor and the inclusion of these contacts in the healing process.

Within the boundaries of the “Paracelsus model”, paternalism as a type of relationship between doctor and patient is fully developed. Medical culture uses the Latin concept of pater - “father”, which Christianity extends not only to the priest, but also to God. The meaning of the word “father” in paternalism states that the “model” of connections between a doctor and a patient is not only blood-related relationships, which are characterized by positive psycho-emotional attachments and socio-moral responsibility, but also the “healing”, “divinity” of the “contact” between doctor and patient.

This “healing” and “divinity” is determined, given by the good deeds of the doctor, the direction of his will towards the good of the patient. It is not surprising that the main moral principle that is formed within the boundaries of this model is the principle of “do good,” goodness, or “do love,” beneficence, mercy. Healing is the organized implementation of good. Goodness is essentially of divine origin. “Every good gift... comes down from above, from the Father of lights” (James 1:17). Maximus the Confessor wrote: “Every virtue is without beginning, and time does not precede it, since from eternity it has as its Parent the only God.” Paracelsus taught: “The power of a doctor is in his heart, his work must be guided by God and illuminated by natural light and experience; the most important basis of medicine is love.”

In the Middle Ages, the nature and level of development of medical knowledge was in harmonious connection with Christian anthropology, in particular with the formulation and solution of the problem of the relationship between soul and body. Pathological processes in the human body manifested themselves and were recorded in experience and medical knowledge only at the level of pain. The medieval understanding of illness itself is primarily a state of experiencing pain. But pain, just like joy, gratitude is a human feeling. “And feeling,” taught Augustine the Blessed (354-430), “is that by which the soul is aware of what the body is experiencing.” The feeling of pain, for example, from a knife wound is experienced by the soul; “pain is not contained in a knife wound, since purely mechanical damage does not contain pain.” The soul is the active and governing principle for the body.

Ten centuries later, the Christian philosopher John of Joden would formulate this principle of Christian anthropology as follows: “I believe and am firmly convinced that the substance of the soul is endowed with natural faculties, whose activity is independent of any bodily organs... Such faculties belong to a higher level than physicality, and far exceed its capabilities.” Undoubtedly, under the influence of Christian anthropology, Paracelsus considered the physical body of man “only as a house in which the true man dwells, the builder of this house; therefore, when examining and studying this house, we must not forget the main builder and true owner - the spiritual man and his soul.”

It is believed, and not without good reason, that the Christian understanding of the soul contributed to the development of suggestive therapy (suggestion therapy), which was actively used by the outstanding physician of the 16th century Gerolamo Cardano, considering it as a necessary and effective component of any therapeutic intervention. Cardano understood the role of the trust factor and argued that the success of treatment is largely determined by the patient’s faith in the doctor: “He who believes more is cured better.”

At the end of the 19th century, S. Freud desacralized paternalism, stating the libidinous nature of the relationship between doctor and patient. His concepts of “transfer” and “countertransference” are a means of theoretical understanding of the complex interpersonal relationship between doctor and patient in psychotherapeutic practice. On the one hand, Freud states the “healing” nature of the doctor’s personal involvement in the healing process. On the other hand, it speaks of the need for its maximum depersonalization (on the part of the doctor), in particular, as a means of psycho-emotional protection for the doctor, who, as a rule, works simultaneously with several patients.

The condition and means of achieving depersonalization is the ethical behavior of the doctor. Z. Freud believed that every psychotherapist, and the work of a doctor of any specialty includes a psychotherapeutic component, “must be impeccable, especially in moral terms.” Obviously, we are talking not only about “impeccability” as a theoretically verified strategy of therapeutic behavior, based both on the peculiarities of the nature of therapeutic activity and on the essential principles of human life, but also about “impeccability” as an almost mechanical accuracy of compliance of the doctor’s behavior with certain ethical standards requirements.

3. Principle observance of duty(deontological model)

Moral integrity - in the sense of compliance of a doctor's behavior with certain ethical standards - is an essential part of medical ethics. This is its deontological level, or “deontological model”.

Term deontology(from the Greek deontos - due) was introduced into Soviet medical science in the 40s of the 20th century by Professor N.N. Petrov. N.N. Petrov used this term to designate a real-life area of medical practice - medical ethics - which was “abolished” in Russia after the 1917 coup for its connection with religious culture. But there is no escape from this connection. The origins of ideas about the “should” are in the religious and moral consciousness, which is characterized by constant comparison, compliance with the “should” and the assessment of actions not only by results, but also by thoughts.

The deontological model of medical ethics is a set of “proper” rules corresponding to a particular area of medical practice. An example of this model is surgical deontology, N.N. Petrov in his work “Issues of surgical deontology” identified the following rules:

“surgery is for the sick, not the sick for surgery”;

“perform and advise the patient to perform only such an operation that you would agree to under the current circumstances for yourself or for the person closest to you”;

“for peace of mind of patients, visits to the surgeon are necessary on the eve of the operation and several times on the very day of the operation, both before and after it”;

“the ideal of major surgery is to work with a truly complete elimination of not only all physical pain, but also all mental anxiety of the patient”;

“Informing the patient,” which should include a mention of the risk, the possibility of infection, and collateral damage.

It is symptomatic that from the point of view of N.N. Petrov, “informing” should include not so much “adequate information” as a suggestion “about the insignificance of the risk in comparison with the likely benefits of the operation.”

Another example of a deontological model is the rules regarding intimate relationships between physician and patient developed by the Committee on Ethical and Legal Affairs of the American Medical Association. They are:

Intimate contacts between doctor and patient that occur during treatment are immoral;

An intimate relationship with a former patient may be considered unethical in certain situations;

The issue of intimate doctor-patient relationships should be included in the training of all health care professionals.

Doctors must absolutely report violations of medical ethics by their colleagues.”

The principle of “observance of duty” is fundamental to the deontological model. “Complying with duty” means fulfilling certain requirements. An improper act is one that contradicts the requirements presented to the doctor by the medical community, society and his own will and mind. When the rules of conduct are open and precisely formulated for each medical specialty, the principle of “compliance with duty” does not recognize excuses for evading its fulfillment, including arguments from “pleasant and unpleasant,” “useful and useless,” etc. The idea of duty is the determining, necessary and sufficient basis for the doctor’s actions. If a person is able to act according to the unconditional requirement of “duty,” then such a person corresponds to his chosen profession; if not, then he must leave this professional community.

Sets of “precisely formulated rules of conduct” have been developed for almost every medical specialty. Numerous Soviet publications on medical deontology from the 60s to the 80s present a list and description of these rules for almost all medical fields.

4. Principle respect for human rights and dignity(bioethics)

In contrast to medical ethics at the level of the deontological model, for example, in obstetrics and gynecology, where we are talking about “caution in statements in front of patients,” “about gaining trust,” “about the smooth, calm, reasonable behavior of a doctor, combined with caring and attentive attitude towards the patient”, in bioethics the conflict of rights becomes the main one, in this case, “the right of the fetus to life” and “the woman’s right to an abortion”. Another example of such problems is the attitude towards euthanasia. Here, the patient’s legal consciousness, rising to the awareness of the “right to a dignified death,” comes into conflict with the doctor’s personal right to fulfill not only the professional rule “do no harm,” but also the commandment “thou shalt not kill.”

In modern medicine, we are no longer talking only about “helping the sick,” but also about the possibilities of controlling the processes of pathology, conception and dying, with very problematic “physical” and “metaphysical” (moral) consequences of this for the human population as a whole.

Medicine, working today at the molecular level, is increasingly becoming “predictive”. French immunologist and geneticist J. Dosset believes that predictive medicine “will help make a person’s life long, happy and disease-free.” But only one “but,” from the point of view of J. Dosset, stands in the way of this bright prospect. This is “a person or group of persons driven by a thirst for power and often infected with totalitarian ideology.”

Predictive medicine can also be defined as subjectless, impersonal, i.e. capable of diagnosing without subjective indicators, complaints, etc. patient. And this is truly a real and unprecedented lever of control and power over both an individual human organism and the human population as a whole. These processes highlight why in the 60-70s of the 20th century such a form of medical ethics as bioethics was formulated, which begins to consider medicine in the context of human rights.

The main moral principle of bioethics is the principle of respect for human rights and dignity. Under the influence of this principle, the solution to the “main issue” of medical ethics is changing - the issue of the relationship between the doctor and the patient. As is known, paternalism worked in the regime of undeniable priority or “primacy” of the doctor’s authority. Today, the issue of patient participation in medical decision-making is acute. This far from being a “secondary” participation is taking shape in a number of new models of the relationship between doctor and patient. Among them are informational, deliberative, interpretive, each of which is a unique form of protecting human rights and dignity.

The conflict of “rights”, “principles”, “values”, and in essence - human lives and the destinies of culture - is the reality of a modern pluralistic society. A specific form of resolving possible contradictions in the field of biomedicine are bioethical public organizations (ethics committees). Professor B.G. Yudin believes that “bioethics should be understood not only as a field of knowledge, but also as an emerging social institution of modern society.” This institute includes ethical committees at hospitals, ethical commissions at research institutions, specialized bioethical organizations that, along with doctors, unite priests, lawyers, biomedical ethicists and other citizens. Their task is to resolve issues related to the development of recommendations for specific problematic situations in medical and biological activities, be it its theoretical or practical side.

The introduction of ethical committees as an independent structure into the Russian healthcare system is also provided for in the “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens” (1993). In Section III “Organization of the protection of the health of citizens in the Russian Federation”, Article 16 states: “Committees (commissions) on issues of ethics in the field of protection of the health of citizens may be created under state authorities and management, at enterprises, institutions, organizations of the state or municipal health care system and for the purpose of protecting human rights and specific population groups in this area.”

A historical and logical analysis of the development of healing ethics leads to the following conclusion. The modern form of medical ethics is biomedical ethics, which now works in the mode of all four historical models - the model of Hippocrates and Paracelsus, the deontological model and bioethics. Biomedical knowledge and practice today, as in previous eras, are inextricably linked with ethical knowledge, which in the space of European and Russian culture is inseparable from Christian traditions. To neglect or distort, consciously or unconsciously, the connection between medicine, ethics and religion means inevitably distorting the essence and purpose of each of these vital ways of human existence. Elder Nektary of Optina taught: “If you live and study in such a way that your scientific character does not spoil morality, and your morality does not spoil scientific character, then your life will be a complete success.” Gilson E. Reason and Revelation in the Middle Ages. - “Theology in the culture of the Middle Ages.” Kyiv. 1992, p. 31. “About God, man and the world: from the revelations of the holy fathers, elders, teachers, mentors and spiritual writers of the Orthodox Church.” M. 1995, p. 19.

A. A. Stabredova

Medical ethics of Hippocrates and modern medicine

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

In Ancient Greece, a doctor who paid special attention to the ethical standards of healing was Hippocrates, a famous healer who came from the island of Kos. It was Hippocrates who, in his treatises, reflected the inextricable connection between medicine and ethics. The name of Hippocrates is associated with the idea of high moral character and ethical behavior of a doctor. The ethical views, requirements and prohibitions of Hippocrates are set out in the books of the “Hippocratic Corpus”: “Oath”, “Law”, “On the Doctor”, “On Decent Behavior”, “Instructions”.

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

These principles are:

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

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

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

4. Obligation to refrain from intimate relationships with patients.

5. The principle of medical confidentiality and confidentiality.

6. Commitments to teachers.

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

8. Commitments to professional and moral self-improvement and decent behavior.

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

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

In Hippocrates, an important role is played by the principle of careful informing the patient, allowing him to be misinformed. The treatise “On Decent Behavior” states that the doctor has the right to hide all the details of the course of the disease so as not to worsen the patient’s situation: “Everything ... must be done calmly and skillfully, hiding much from the patient in his orders ... and without telling the patient what will happen or came, because many sick people for this very reason... were brought to an extreme state” (“On Decent Behavior,” XVI). However, in modern medical ethics, unlike the ethics of Hippocrates, the patient has the right to have complete information about the diagnosis, the purpose of the proposed treatment, its possible consequences, and the prognosis in case of refusal of treatment.

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

Particular emphasis should be placed on the principle of obligation to renounce intimate relationships with patients. The “Oath” says: “Whatever house I enter, I will enter there... being distant... from love affairs with women and men, free and slaves” (“Oath”). These days it is also considered inappropriate to have intimate relationships with patients. Thus, this principle in modern medical ethics is fully consistent with the teachings of Hippocrates.

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

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

Also important is the principle of obligation to impart knowledge to students and consult with colleagues. The “oath” reads: “I swear... instructions, oral lessons and everything else in the teaching to communicate to my sons, the sons of my teacher and students” (“Oath”). The treatise “Instructions” says: “There is nothing shameful if a doctor, who has difficulty in some way with a patient... asks to invite other doctors with whom he could jointly clarify the patient’s situation” (“Instructions”, VIII). The Code of Medical Ethics of the Republic of Belarus states: “When professional difficulties arise, a doctor is obliged to immediately seek help from competent specialists.”

The last of the principles we have highlighted is the obligation of professional and moral self-improvement and decent behavior. The “Oath” says: “I will conduct my life and my art purely and immaculately” (“Oath”). The Code of Medical Ethics of the Republic of Belarus states: “The main condition for successful medical practice is the professional competence of the doctor and his high moral qualities. A doctor is obliged to improve his qualifications throughout his professional activity.”

Thus, in modern medicine, some of the principles of Hippocratic medical ethics have remained virtually unchanged, others have undergone some changes, and others are controversial both among doctors and in society. They are united by the fact that they did not cease to exist with the end of the era of Hippocrates, but continue to one degree or another maintain their relevance and develop along with the evolution of society.

Literature

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

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

3. Shamov, AND. A. Bioethics: textbook. manual on ethical and legal documents and regulations / I. A. Shamov, S. A. Abusuev. - Makhachkala: Publishing House of the DSMA, 2001. - 446 p.

About the author(September 2015): Stabradava Alyaksandra Anatolyeva - 2nd year student of the special course “Classical Philology” of the Faculty of Philology of the Belarusian State University (Minsk).

Output: Philalagic studies = Studia philologica: zb. navuk. art. / pad ed. G.I. Shauchenka, K. A. Tananushki; editorial office: A. V. Garnik [and others]. - Vol. 8. - Minsk, 2015. - pp. 75–78.

- 81.50 Kb

Introduction

The history of medical ethics available to us in written monuments goes back more than three thousand years. For European medicine, the ethics of the ancient Greek physician Hippocrates (460 - 370 BC), especially his famous medical “Oath,” remains relevant to this day. After in the 16th century. The first printed works of Hippocrates (“Hippocratic Corpus”) were published in Europe; the growth of his authority among European doctors can be figuratively called the “second coming” of Hippocrates. Already at this time, doctors receiving their doctorate of medicine at the Paris Faculty of Medicine were required to give a “Faculty Promise” in front of a bust of Hippocrates.

The purpose of this study is to explore the basic ideas underlying Hippocratic ethics, historically the first European form of medical ethics.

In this regard, it seems necessary to consider the following questions:

Consider the Hippocratic oath and analyze its provisions on the basic values and immoral norms of the relationship between doctor and patient;

Show how the ideas of Hippocrates were developed in Europe in the works of Paracelsus and Percival;

Show the role of Hippocratic ideas in modern medicine.

1. The Hippocratic Oath about the basic values and moral standards of the relationship between doctor and patient

Around 400 BC. e. Hippocrates, an ancient Greek physician who is called the father of medicine, compiled the text of a medical oath, expressing the fundamental moral and ethical principles of a doctor’s behavior.

Hippocrates believed that the medical oath has special significance. As one of the founders of medicine, Hippocrates asked doctors to swear:

“I swear by Apollo the physician, Asclepius, Hygieia and Panacea and all the gods and goddesses, taking them as witnesses, to honestly fulfill, according to my strength and my understanding, the following oath and written obligation: to honor the one who taught me on an equal basis with my parents, to share with him my wealth and, if necessary, help him in his needs; consider his offspring as their brothers, and this art, if they want to study it, teach them free of charge and without any contract; communicate instructions, oral lessons and everything else in the teaching to his sons, the sons of his teacher and students bound by an obligation and oath according to the medical law, but to no one else. I will direct the treatment of the sick to their benefit in accordance with my strength and my understanding, refraining from causing any harm or injustice. I will not give anyone who asks me a deadly drug and will not show the way for such a plan; Likewise, I will not give any woman an abortion pessary. I will conduct my life and my art purely and immaculately. In no case will I perform sections on those suffering from stone disease, leaving this to the people involved in this matter. Whatever house I enter, I will enter there for the benefit of the sick, being far from everything intentional, unrighteous and harmful, especially from love affairs with women and men, free and slaves.

So that during treatment - and also without treatment - I neither see nor hear about human life that should never be disclosed, I will remain silent about it, considering such things a secret. May I, who inviolably fulfill my oath, be given happiness in life and in art and glory among all people for eternity; to the one who transgresses and swears a false oath, let the opposite be done to this” 1 .

The god Apollo mentioned here is the patron saint of doctors in ancient Greece and Rome (and the god of music, poetry, divination and the founding of cities). Asclepius, the son of Apollo, was considered a special god - the patron saint of doctors. Hygieia (Hygiene) - goddess of health, Panacea (Panacea) - goddess-healer of all diseases - daughters of Asclepius.

The philosophy reflected in this document is more likely to correspond to the ideas of the Pythagoreans of the 4th century BC. BC, who preached the sanctity of life and were known as opponents of surgical intervention 2.

The basis of the Hippocratic Oath is the idea of respect for the sick, the patient, the mandatory requirement that any treatment does not cause him harm.

Medical ethics requires a specialist not only to not cause harm, but also to perform good deeds. “Whatever house I enter, I will enter there for the benefit of the sick,” says the Hippocratic Oath.

A curious aspect of the oath is the prohibition of intimate relations between the doctor and the patient.

The most famous commandment of Hippocrates' ethics is his prohibition on disclosing medical confidentiality. The medical community thus appears to us as a very closed social organization, which could be designated as an order or clan.

Finally, it should be noted that society in ancient Greece highly valued and encouraged the dedication and selflessness of doctors. In ancient Greek mythology, the patron of medicine, Asclepius, was philanthropic. The work of a doctor was highly paid in Ancient Greece (better, for example, than the work of architects). But Hippocrates advises his student, when it comes to fees, to take a differentiated approach to different patients: “And I advise that you do not behave too inhumanely, but that you pay attention to the abundance of funds (the patient) and their moderation, and sometimes treat would be for nothing, considering grateful memory higher than momentary glory. If the opportunity arises to provide assistance to a stranger or a poor person, then it should be especially delivered to such people” 3 .

Hippocrates saw the deviation in the moral behavior of a doctor from the everyday practice of human relations primarily in the fact that it should not be focused on the personal individual good of the doctor and the search for ways to achieve this good (be it material, sensual, etc.).

The doctor’s behavior, both from the point of view of his internal aspirations and from the point of view of his external actions, must be motivated by the interests and welfare of the patient. “Whatever house I enter, I will enter there for the benefit of the sick, being far from everything intentional, unjust and harmful,” wrote Hippocrates.

He 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,” said Hippocrates, “there is love for one’s art.”

2. Development of the ideas of Hippocrates in European medicine of the 16th-18th centuries.

2.1. Paracelsus’ model of medical ethics

The second historical form of medical ethics after Hippocrates was the understanding of the relationship between doctor and patient, which developed in the Middle Ages. Paracelsus (1493-1541) was able to express it especially clearly. C. Jung wrote about Paracelsus: “In Paracelsus we see not only the founder in the field of creating chemical medicines, but also in the field of empirical mental treatment” 4.

The Paracelsian model is a form of medical ethics in which the moral attitude towards the patient is understood as one of the most important components of the doctor’s therapeutic behavior strategy. If in the Hippocratic model of medical ethics, first of all, social trust of the patient’s personality is won, then in the Paracelsian model the emphasis is on taking into account the emotional and mental characteristics of the individual, recognizing the importance of mental contact with the doctor and the inclusion of such contact in the treatment process.

Within the boundaries of Paracelsus' model, paternalism (from the Latin pater - father) is fully developed as a type of relationship between doctor and patient. The real meaning of the paternalistic approach is that the connection between the doctor and the patient reproduces not only the best examples of consanguineous relationships, which are characterized by positive psycho-emotional attachments and socio-moral responsibility, but also a certain “divine healing” of the contact between the doctor and the patient 5.

This “divine healing” is determined and given by the good deeds of the doctor, the direction of his will towards the good of the patient. It is not surprising that the main moral principle that is formed within the boundaries of this model is the principle of do good, goodness, or create love, beneficence, mercy.

Paracelsus taught: “The power of a doctor is in his heart, his work must be guided by God and illuminated by natural light and experience; the most important basis of medicine is love.”

2.2.Features of Percival’s medical ethics

In 1803, the English physician T. Percival published the book “Medical Ethics, or a Set of Established Rules for the Professional Conduct of Physicians and Surgeons” (surgeons in those days were not classified as doctors) 6 . If you get acquainted with these rules, you can see that they can be used for official instructions to doctors and nurses of the 20th century:

“Hospital doctors and surgeons must provide care to the sick in such a way that they are given the impression of the importance of their service; that the peace, health and life of those entrusted to their care depend on their skill, attention and devotion. They must also learn that their demeanor should combine tenderness with firmness, condescension with authority, so as to awaken in the minds of their patients feelings of gratitude, respect and confidence.The feelings and emotions of patients in critical circumstances should be known and taken into account no less than the symptoms of their illness. an incorrect assessment can intensify a real evil (disease) or create an imaginary one, no discussions about the essence of the disease are allowed in the presence of patients, either with a doctor (surgeon), or with hospital students or other physicians invited to the hospital. In large wards of a hospital, patients should speak about their complaints in such a tone of voice that it cannot be heard by others. Secrecy, when special circumstances require it, must be strictly observed. And women should be treated with the most scrupulous delicacy. It is cruel to neglect or laugh at their feelings... No precautions in the admission of patients suffering from incurable diseases, or contagious in nature, or tending to be aggravated in an unclean atmosphere, can eliminate the evil that cramped rooms and false economy bring. The delineation of diseases for which they are admitted to the hospital, the state of the air, nutrition, cleanliness, medications - all this should be carefully checked at certain periods of time" 7 .

If in Hippocratic ethics the doctor must put the needs of the patient above his own personal interests, serve the patient day and night with all his heart and soul; do not allow yourself to commit crimes, drunkenness and adultery; keep professional secrets secret. Then in Percival’s ethics we see a slightly different attitude towards patients. Percival's doctor acts as a philanthropist, bringing benefit to them and receiving appropriate gratitude from them. In his opinion, a doctor should behave with patients “delicately, balancedly, condescendingly and authoritatively.”

Percival was the first to recognize the physician's obligations not only to his patients, but also to society.

3. The role of Hippocrates’ ethical ideas in modern medicine

The principles of modern medical ethics for the most part remain adequate to the ethics of Hippocrates: non-harm, mercy, justice, but with recognition of patient autonomy.

In Hippocratic ethics, the “doctor-patient” relationship was built on the basis of “strong” and “weak”, laying down a model of a paternalistic approach in medicine. The dilemma of paternalistic and non-paternalistic is now “cross-cutting” in the ethics of modern medicine. The paternalistic model is based on the asymmetric nature of the moral relationship between the doctor and the patient - the doctor assumes all (or almost all) full responsibility for making clinical decisions. On the contrary, the non-paternalistic model of the relationship between the doctor and the patient is based on the priority of the patient’s moral autonomy, due to which the category of the patient’s rights becomes the key category of this approach 8 .

The main moral principle of modern medicine is the principle of respect for human rights and dignity. Under the influence of this principle, the solution to the main issue of medical ethics is changing - the issue of the relationship between the doctor and the patient. Today, the issue of patient participation in medical decision-making is acute. This - far from being secondary - participation is formalized in a number of new models of the relationship between doctor and patient. Among them are informational, deliberative, and interpretative. Each of them is a unique form of protecting human rights and dignity.

In Russia, the overwhelming majority of doctors still adhere to the traditional paternalistic model of relationships with patients, in particular, professing the belief in the ethical justification of the doctrine of the “holy (saving) lie” in the conditions of healing. When Sigmund Freud learned from his doctor that he had cancer, he whispered: “Who gave you the right to tell me about this?” The great fighter against all self-deception in the field of sex did not find the strength to face another biological truth - inevitable death. Is it possible to reveal a “terrible” diagnosis to a patient or family or should it be kept secret? Is it advisable to tell the patient a less traumatic diagnosis, and what should be the measure of truth? We often prefer not to know the details of the treatment ahead of us and the risks associated with it. According to surveys, the number of patients who are not interested in receiving information on these topics reaches 60% in Russia 9 .

However, even in America, where for most people knowing the truth about their condition is a self-evident right, doctors take cultural factors into account. A young doctor tells a 68-year-old Chinese patient that he has cancer. From the doctor’s point of view, he is doing everything right - realizing the patient’s right to truthful and accurate information about his condition. But the patient’s son is outraged: he believes that the doctor should have first talked with the patient’s family members, and then they themselves would have decided whether to tell their relative the truth and in what form. In Chinese culture, the ethical basis for decision-making is Confucianism and Buddhism, which emphasize the values of consent and submission to authority. This tradition is directly opposed to the Western model of independent personality, in which concealment of information is seen as a violation of fundamental individual rights 10 .

Description

Content

Introduction 3
1. The Hippocratic Oath about the basic values and moral standards of the relationship between doctor and patient 4
2. Development of the ideas of Hippocrates in European medicine of the 16th-18th centuries. 7
2.1. Paracelsus’ model of medical ethics 7
2.2.Features of Percival’s medical ethics 8
3. The role of Hippocrates’ ethical ideas in modern medicine 10
Conclusion 13
References 15

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

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

The physician must learn to remember medicines, how to prepare them and use them correctly, not to get lost at the patient’s bedside, to visit him often and carefully observe the deceptive signs of change. “All this must be done calmly and skillfully, hiding much in one’s orders from the patient, ordering with a cheerful and clear gaze what should be done, and turning the patient away from his wishes with persistence and severity” (“On Decent Behavior”). However, when treating a patient, it is necessary to remember the first commandment: “first of all, do no harm.” Later this thesis will appear in Latin literature: “Primum popse-ge.”

When worrying about the health of the patient, the healer should not begin by worrying about his fee (remuneration), since “paying attention to this is harmful for the patient.” Moreover, sometimes it is appropriate to treat “for free, considering a grateful memory higher than momentary glory. If the case If it becomes possible to provide help to a stranger or a poor person, then it should be delivered to such people in particular” (“Instructions”).

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

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

It is not known when the “Oath” was first composed. In oral form, it passed from one generation to another and in its main features was created before Hippocrates. In the 3rd century. BC e. The “Oath” was included in the “Hippocratic Collection”, after which in wide circles it began to be called by the name of Hippocrates.

Along with the medical “Oath”, in ancient Greece there was a legal “Oath”, oaths of witnesses and many others. All of them assumed the assistance of the gods, who sanctified the “Oath” and punished the perjurers (in the case of the medical “Oath” these are the gods Apollo, Asclepius, Hygieia and Panacea). Thus, the “Oath” given by the healer upon completion of training, on the one hand, protected patients, being a guarantee of high medical morality, and on the other hand, provided the healer with the complete trust of society. The laws of medical ethics in ancient Greece were strictly followed and were the unwritten laws of society, for, as they say in the “Instructions,” “where there is love for people, there is love for one’s art.”

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

Aware of the danger posed by nuclear weapons, fight tirelessly for peace and to prevent nuclear war.

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

"Medical Law and Ethics" N 1, 2004
FROM Hippocratic ETHICS TO BIOETICS
The European tradition of medical ethics has existed uninterrupted for about 2400 years. The set of books of Hippocrates (V-IV centuries BC) on medical deontology ("Oath", "Instructions", "On Art", "On the Doctor", etc.) contains ethical instructions that are mandatory for the doctor as a representative of the secular profession (which had already taken final shape in those days in Ancient Greece along with healer-priests). It is believed that the Hippocratic Oath, the core of his ethical system, goes back to the ascetic ethics of Pythagoras, who lived about 100 years before Hippocrates.
Hippocratic ethics is virtue ethics. Its most important commandments are: prohibition of causing harm to the patient; to euthanasia (and in general, to the transformation of medical art into a means of murder); for assisting suicide; for induced abortion; to senseless attempts from the point of view of medical science (medical art) to treat the dying; on an intimate relationship with the patient; medical secrecy; careful informing of the patient, allowing him to be misinformed; correct attitude towards colleagues, if necessary, consultation with colleagues; exposing false doctors and medical charlatans. If we use the language of modern medical ethics, the first four commandments of Hippocratic ethics can be defined as the principle of unconditional respect for the life of the patient (1, pp. 87-130).
From a philosophical point of view, Hippocratic ethics are a mosaic of moral precepts that were formed in various historical periods and were influenced by most of the main schools of ancient Greek philosophy. In the Hellenistic era, the doctor’s system of ethical values was supplemented and enriched on the basis of Stoic philosophy with the ideas of moral duty, sympathy for the patient, and even love and friendship in the relationship between doctor and patient.
Greek medicine and Greek philosophy mutually nourished each other. Socrates, Plato, and Aristotle made extensive use of medicine as a teaching tool, especially as a model for the moral use of knowledge. In medicine they found a source of analogies that brought together the health of the body (medicine) and the health of the soul (philosophy). The closeness between medicine and philosophy was so great that at one time doctors were forced to specifically assert their independence by emphasizing the empirical nature of medical art.
The first special works on medical ethics in modern times appeared in England at the end of the 18th century: J. Gregory “Lectures on the duties and qualifications of a doctor” (1772), T. Percival “Medical ethics” (1797). The appearance of these works should be considered in the context of the rapid socio-economic development of England, its leadership in the industrial revolution, and, as a result, an earlier transition from traditional to industrial society than in other European countries, and finally, the earliest of all bourgeois revolutions - " The Glorious Revolution" of 1688, which consolidated the socio-political system of the British constitutional monarchy. And all this was reflected in the development of social consciousness, in the achievements of the era of the English Enlightenment. Here is F. Bacon’s “New Organon” (1626) - a kind of manifesto of experimental scientific knowledge of nature, and I. Newton’s great work “Mathematical Principles of Natural Philosophy” (1687), and J. Locke’s treatises on religious tolerance and government (1690) , which laid the foundations for the theory of the rule of law, the philosophical and ethical doctrine of human rights (the right to life, liberty and private property), and, of course, the works of the founders of political economy from W. Petty’s “Treatise on Taxes” (1662) to “The Wealth of Nations” by A. .Smith (1776).
In the first special works on medical ethics mentioned above, we find the ethical and normative basis of professional medical activity of the era of early capitalism, when the social position of the doctor, which developed in the Middle Ages and was characterized by the doctor’s vassal dependence on the lord, radically changes: the doctor as the owner of special knowledge and special personal experience, art becomes a participant, a free subject of market relations in society. Under these conditions, the deontological code of Hippocrates is enriched, according to the spirit of its time. At the same time, the regulation of competitive relationships between doctors and the institutionalization of this regulation becomes a very important topic in medical ethics. As T. Percival wrote: “The doctors of any charitable institution are to some extent ... guardians of each other’s honor. Therefore, no doctor or surgeon should speak openly about incidents in the hospital, which could harm the reputation of one of his colleagues... You cannot behave selfishly, trying directly or indirectly to undermine the patient's trust in the doctor or surgeon. However... there are cases when energetic intervention is not only justified, but also necessary. When cunning ignorance abuses the patient's trust; when a dismissive attitude towards the patient leads to danger to his life, or haste leads to even greater danger..." (Quoted from 2: p. 34).
If we transfer (in a metaphorical sense) Haeckel’s biogenetic law from the field of biology to the field of culture, then the logic of the formation and development of medical ethics in Russia (a kind of “ontogenesis”) repeats the formation and development of medical ethics in European civilization in general (a kind of “phylogeny”) . Interesting pages in the history of medical ethics in domestic medicine open only at the beginning of the 19th century, when, let’s say, university medical education in our country “gets on its feet.” M.Ya.Mudrov (1776-1831), who was elected five times after 1812 as dean of the medical faculty of Moscow University, read to students the basics of therapy, pharmacology, dietetics, etc., translated the books of Hippocrates from ancient Greek (“Captured by the wisdom of Hippocrates... I decided to spend my nights with Hippocrates"; "This chapter would be worth reading on my knees"). The ethical instructions of M.Ya.Mudrov include not only the commandment about medical confidentiality (“Silence in reprehensible diseases... about heard and seen family disorders”), the prescription of a wise solution to the problem of informing doomed patients (“Promising healing in an incurable disease is a sign or an ignorant or dishonest doctor"), but also requirements regarding cleanliness, neatness of clothing, demeanor, and strictness in one’s speech (3, pp. 93-95).
Throughout the 19th century. Russia largely remained a feudal society, in which capitalist social relations gradually took shape and the features of an industrial society were formed. The famous doctor Haaz (German and Catholic) arrived in Russia in 1806 as the family doctor of Princess Repnina. According to the contract, he was obliged to treat her family and servants, but also had the right to engage in private practice in Moscow. He later becomes a legendary doctor when he enters public service - the chief physician of Moscow prisons (1829-1853). Usually, the historical role of Dr. Haas is quite rightly seen in unparalleled, selfless service to the medical profession, which was confirmed in the initiative-appeal to the Vatican in 1994 by Moscow Catholics about the official canonization of “Saint Doctor Fyodor Petrovich” by the Roman Catholic Church. We will emphasize here that Dr. Haas created a model of penitentiary medicine, which received international recognition only in the last decades of the 20th century: the professional duty of doctors working in prisons is only medical care for prisoners; Prisoners as patients should receive medical care without any discrimination.
During the 19th century. Russian medicine has reached European levels in many respects. We are talking not only about the rapid progress of medical science (N.I. Pirogov, I.P. Pavlov, I.I. Mechnikov, etc.), but also the corresponding level of ethical consciousness of domestic doctors, nurses, etc. The weekly newspaper “Doctor”, published for 20 years (1881-1901) under the editorship of Professor V.A. Manassein, and the famous book “Notes of a Doctor” by V.V. Veresaev (first edition in the magazine “World of God” in 1901) - evidence of such a level of discussion, for example, on the topic of biomedical (clinical) experiments on humans as objects, that both of these sources remain very interesting and important in the light of modern medical ethics (4, pp. 56-62).
During the Soviet period in the history of domestic healthcare, the development of professional medical ethics was deeply contradictory. On the one hand, the Soviet healthcare system, earlier than in many modern Western countries, realized the ideal of universal accessibility of professional, including many types of specialized, medical care to almost the entire population on the scale of such a huge country as the USSR. The real implementation of the right of citizens in the Soviet Union to qualified medical care undoubtedly contained enormous moral potential. In the personal dimension, the social nature of Soviet healthcare was continued by a fairly high consciousness of professional duty by Soviet doctors and nurses, which ultimately determined the moral climate in domestic medical institutions (at the same time, we do not forget about the “double standards” in medicine for everyone and for the elite , primarily for state nomenclature).
On the other hand, the socio-political nature of the totalitarian society in the Soviet Union (which leveled the role of the human personality), the logic of communist ideology in the Soviet version (personal interests should be completely subordinated to public interests), the state-bureaucratic organization of the entire medical business, which was managed primarily through command -administrative “levers” - all this became the reasons for a kind of ethical nihilism among Soviet doctors and paramedics. A striking manifestation of this nihilism was the position of the first People's Commissar of Health N.A. Semashko in the 20s, who repeatedly stated that we were firmly committed to abandoning medical confidentiality (5, p. 364). From our point of view, underestimation of confidentiality issues in the professional consciousness of domestic doctors still persists.
The most important milestone for the fate of medical ethics in the 20th century. became the Second World War. Nazi medicine (forced sterilization for eugenic purposes of hundreds of thousands of Germans; forced euthanasia of tens of thousands of patients in German psychiatric hospitals; criminal medical experiments - mainly on concentration camp prisoners, i.e., overwhelmingly non-Germans) became a falsification of the medical profession unprecedented in history . It is precisely the contempt for the entire ethical system of Hippocrates (and above all for the principle of unconditional respect for the life of the patient), which Nazi doctors quite consciously demonstrated, that explains the unrelenting attention to Nazi medicine of the entire world medical community during the second half of the 20th century. Nowadays, when discussing moral problems of health care, world medicine takes almost all of this experience of Nazi doctors as a kind of “absolute ethical zero.”
The attitude towards the problems of medical ethics in the post-war USSR remained deeply contradictory. On the one hand, Soviet medicine occupied leading positions in many areas of medical science (for example, in experimental transplantology, resuscitation thanks to the work of V.P. Demikhov, V.A. Negovsky, etc.), i.e. domestic medical specialists inevitably faced new moral and ethical problems generated by the development of modern medical technologies. On the other hand, the inertia of ethical nihilism, laid down back in the 20s of the 20th century, was aggravated by the international isolation of the domestic scientific, medical and medical community, which sometimes led to an elementary ignorance of Soviet doctors and medical scientists about new ethical ideas, ethical approaches to modern medicine, which began to grow like an avalanche from the turn of the 60-70s.
This is confirmed by the fact that the community of Soviet doctors did not, as in many other countries, have a national association of doctors that could join the World Medical Association (WMA). Of course, history does not have a subjunctive mood, so we do not even discuss the issue of procedural difficulties in the entry of Soviet doctors into the Military Medical Academy, since the latter constantly emphasizes its political neutrality and ideological indifference.
But it was the Military Medical Academy that did most of the constructive work - the creation of a modern regulatory ethical framework for medicine in the second half of the 20th century. In 1948, the WMA adopted the text of the modern international physician's oath - the "Declaration of Geneva"; in 1949 - “International Code of Medical Ethics”; in 1964 - a set of ethical rules for conducting biomedical research on humans - the “Declaration of Helsinki”; in 1981 - the minimum international ethical standard for patients' rights - the "Lisbon Declaration" and dozens of similar international ethical documents. Suffice it to add that the first translation into Russian of these documents appeared only in 1995 (6).
The rule-making activity of the WMA has become especially productive in the last 30 years - with the emergence and rapid development of a new science - bioethics. The word “bioethics” has become widespread thanks to the works of the American specialist W.-R. Potter, in particular, the exceptionally successful title of his book “Bioethics - a bridge to the future” (7). Most authors identify the concept of “bioethics” with the concept of “modern medical ethics” or “clinical ethics”. While maintaining a connection with the traditional ethics of Hippocrates (in particular, with its humanistic spirit), bioethics critically evaluates some specific provisions of his ethical system.
The principle of respect for life still retains the significance of the philosophical and ethical principle of the entire system of moral values in medicine, however, its specific interpretation, when it comes to dying patients, seems to be split - many supporters of active euthanasia have appeared in society, but even more supporters of passive euthanasia , requiring morally difficult decisions about not treating some of the dying with certain means or methods. Other provisions of Hippocratic ethics, around which there are heated discussions in the mainstream of bioethics, are the boundaries of medical paternalism (ignoring by doctors and medical staff of the patient’s autonomy); the moral permissibility of abortion, etc. A characteristic feature of these discussions is the active involvement of professional philosophers in this process.
It is obvious that bioethics is a civilizational phenomenon, as the philosopher (and doctor by basic education) P.D. Tishchenko previously wrote about, characterizing the last third of human history as an “ecological turn of humanity” and a “bioethical turn of humanity” (8). It is worth remembering that earlier physician-philosophers, be it Alcmaeon or Empedocles in Dr. Greece, J. Locke or W. James in modern times practically did not touch upon issues of professional medical ethics. K. Jaspers devoted two essays in an informal style to the relationship between doctor and patient, but did not publish a single work in which a scientific analysis of medical ethics was carried out.
Social prerequisites for the emergence of bioethics in the last third of the 20th century. are taking shape with the formation of post-industrial society in Western countries and the corresponding evolution of the healthcare sector - the increasing role of “consumer stereotypes” in the public consciousness, the growth of ethnic self-awareness, the spread of feminism, growing respect for individual rights, the development of civil society institutions (with a relative decrease in the role of government bodies) . During these same years, rapidly developing new medical technologies caused the complexity and increase in the number of ethical problems in medicine. In the conditions of depersonalization of medical services, traditional ethical values in medicine began to be questioned, and the need for alternative systems of medical ethics arose, which were in demand both in the practical work of doctors and in the process of teaching students.
On the one hand, bioethics performs the functions of traditional medical ethics, since it prescribes ethical standards for the attitude of doctors and nurses to the patient (dying patient, donor, recipient, etc.), on the other hand, bioethics becomes the channel of in-depth philosophical research. The fact is that the new sociocultural prerequisites for the functioning of the health care system, which were discussed above ("consumer stereotypes" of public consciousness, increased respect for individual rights, etc.), with a simultaneous crisis of the "canonical" ethics of Hippocrates, turned into a temptation to replace ethics exclusively legal regulation of medical affairs or the choice of decisions based only on economic feasibility, or, finally, the replacement of generally valid professional ethics with the arbitrariness of the moral positions of individual doctors and specialists. Serious philosophical research in the field of bioethics has been a response to these challenges and dangers. In the form of bioethics, medical ethics, preserving the humanistic spirit of Hippocratic ethics, was revived at a new qualitative level.
In the more than thirty-year history of bioethics, several stages can be distinguished. The first stage can be called the “stage of principledism”, associated, first of all, with the fundamental book of American specialists T. Beachamp and J. Childress, “Principles of Biomedical Ethics”, which was repeatedly reprinted (9). Philosophers brought into medicine the tradition of a strict analysis of complex moral dilemmas, taking into account the pluralism and social heterogeneity (primarily in religious and ethnic terms) of modern society.
Beachamp and Childress identify four fundamental principles at the foundation of modern biomedical ethics - non-maleficence; beneficence (“Your duty is to strive only for the good of the patient, to act only in his highest interests!”); respect for individual autonomy; justice. Methodologically, Beachamp and Childress proceeded from the theory of moral principles developed by the American philosopher Ross, prima face (literally, this Latin expression means “in the first place”). When analyzing the complex ethical dilemmas of medical practice, each of these four principles does not have unconditional, absolute moral force, but in a given situation we can primarily rely on one of them (prima face). For example, when solving the dilemma of informing seriously, especially terminally ill patients, a doctor deals with the contradiction of the principles of “non-harm” and “respect for personal autonomy.” If a doctor consciously takes the path of limiting truthful information (i.e. limiting autonomy), then he must have sufficient grounds for such tactics, such a choice. He must substantiate with reason that in this particular situation he is forced, prima face, to rely on the principle of non-harm (10, pp. 16-17).
Beachamp and Childress were aware that it was extremely difficult to build a single, consistent theory of medical ethics, and therefore such a theory was based on four particular principles, the need to follow which is axiomatic. This tetrad of principles was immediately adopted to resolve ethical dilemmas in clinical practice by both bioethicist theorists and practitioners. By the way, the first domestic guidelines on bioethics, to a certain extent, also followed this tradition (11; 12).
The attractiveness of “new ethical thinking” for clinicians was determined by the fact that the degree of uncertainty and subjectivity in debates on moral issues in medicine was reduced. Clinicians saw in modern medical ethics (bioethics) an approach somewhat similar to the approach to solving the actual medical problems of diagnosing and treating diseases - in both cases a specific solution algorithm was developed. It was also important that prima face moral theory in a bioethical context made it possible to avoid direct confrontation on issues such as abortion and euthanasia.
Two of the four principles, according to Beauchamp and Childress, “do no harm” and “beneficence,” are quite consistent with the Hippocratic ethical system. It is no coincidence that both of these principles have been known since time immemorial to many generations of doctors thanks to the catchphrases “Primum non nocere!” (First of all - do no harm!) and "Salus aegroti - suprema lex!" (The good of the patient is the highest law!). But the other two principles of “respect for autonomy” and “justice” turned out to be completely new, not fitting into the ethical system of Hippocrates.
The principle of respect for patient autonomy came into direct conflict with the paternalism of Hippocratic ethics. The Hippocratic Oath says: “I will direct the treatment of the sick to their benefit, in accordance with my strength and my understanding...” (1, p. 87). That is, the patient here is completely excluded from the decision-making process concerning his health, life, and perhaps death. Recognizing the role of the principle of respect for patient autonomy was difficult, as it was associated with a violation of two other principles rooted in the very archetype of medical consciousness - non-harm and beneficence. The principle of respect for autonomy was eventually recognized by the medical community, but the main role here was played not by philosophical arguments, but by general cultural trends in health care and society as a whole in the West, due to which clinical practice began to be based on the informed consent of patients. As is known, for the first time in the modern sense, the concept of “informed consent” (implying the completeness of informing patients, especially regarding the risk of the proposed medical intervention) was actively discussed in the American media back in 1957 - in the “Martin Salgo v. Stanford University” case. It was about a patient who became disabled as a result of a complication after an invasive medical intervention, and during the judicial investigation of this case, the prosecution focused specifically on the patient’s lack of information about the possibility, the degree of probability of such a complication (by the way, the patient won this case).
The autonomy of the patient has become entrenched in medical practice because the lifestyle in modern post-industrial countries has become more individualistic, and self-reliance and independence have become the life credo of the individual.
Without a doubt, the principle of respect for autonomy and the resulting criticism of medical authoritarianism and paternalism have become the main factor in the evolution of the value system of modern medical ethics (bioethics). When the first domestic educational university program in bioethics was created in 1998 (approved by the Ministry of Health of the Russian Federation in 1999), the idea was discussed among the “developers” of the Program to begin presenting the principles of bioethics precisely with the principle of respect for autonomy. At the same time, there are clinicians (especially in modern domestic healthcare) who express doubt that patient autonomy should really be considered as a fundamental principle of medical ethics. Criticism of the principle of patient autonomy usually boils down to the following: this principle can destroy the mechanism for making optimal decisions, contribute to the alienation of the doctor from the patient, and even become a factor in causing harm to the patient.
The principle of justice was completely new to Hippocrates’ system of ethical values. Although for Plato and Aristotle the problem of justice is one of the central ones in their moral and political philosophy, this did not have a noticeable influence on the ethics of Hippocrates; the welfare of the individual patient is at the center of Hippocratic ethics. Here in the book “Instructions” Hippocrates advises the student: “We should not worry about establishing remuneration, since we believe that paying attention to this is harmful for the patient, especially in case of an acute illness: the speed of the disease, which does not give an opportunity for delay, forces a good doctor look not for profit, but rather for gaining fame... And I advise that you do not behave too inhumanely, but that you pay attention to the abundance of funds (the patient has) and their moderation, and sometimes treat for nothing..." (1, pp. 120-121). Of course, in such an ethical position of a doctor there is also an element of social justice, however, here too the principle “The duty of a doctor is to strive only for the good of the patient!” dominates.
Historically, the idea of social justice began to play an increasingly prominent role in medicine with the development of social medicine and the solution of public health problems in the 19th century. In the last decades of the 20th century. As medicine has become increasingly saturated with modern technologies, the availability of which to all patients in need is often limited, the issue of social justice in healthcare has increasingly come to the fore.
Sometimes the birth of modern bioethics is directly linked to an event that occurred in 1968 in Seattle: at that time there was only one artificial kidney machine and about ten patients with chronic renal failure who could have been saved by using renal hemodialysis. Doctors at a clinic in Seattle were faced with a difficult choice - which of these patients should be connected to an “artificial kidney” first, but at the same time, other patients were almost certainly doomed to death. A specially created public commission compiled a dossier on each of the patients (gender, age, social status, etc.), after which it was convinced that it was impossible to develop an algorithm for a fair solution to this ethical dilemma in such a formal way and, perhaps, a random sample (for example, by lot) ) will be the most fair.
In subsequent years of the development of bioethics, a whole range of philosophical theories of social justice appeared, the authors of which consider them the most appropriate for solving dilemmas of distributive justice in modern healthcare.
Firstly, this is the theory of justice of the American philosopher Rawls. The greatest social justice is achieved in a society that follows the following principles: the principle of providing each member of society with the most equal freedoms for all; the principle of equality (subject to equal levels of ability) for employment and public positions; the principle of differentiation, according to which society (if it respects the two previous principles) strives to maximize the availability of social benefits to the poor.
Secondly, this is also a very popular radical liberal theory of the American philosopher Nozick. Continuing in the tradition of the father of modern liberalism, John Locke (who first proclaimed the sacredness of private property), Nozick believes that government public health systems are generally unjust because they benefit mainly the government bureaucracy.
Thirdly, this is the concept of social justice of the German philosophers Apel and Habermas, who believe that an acceptable balance of equality and inequality for society will be the result of the participation of all members of civil society in public discussion (for example, on the issue of health), for which society should be created necessary communicative prerequisites (13, pp. 58-68).
In theoretical terms, the main drawback of Beauchamp and Childress's tetrad of bioethical principles was that these principles do not have any hierarchical core. Bioethics as applied ethics is in practice situational ethics, and the main difficulty of moral choice in a particular clinical situation is associated with the conflict of the above principles with each other (autonomy and justice, justice and beneficence, etc.).
The second stage in the history of bioethics can be called the stage of anti-principalism.
The dominant position at this stage is this: at a minimum, the tetrad of bioethical principles requires a deeper justification with the help of some traditional great ethical teaching. The principles of bioethics must be “placed” in the context of a general philosophical theory of morality. And yet, the main criticism of principledism in bioethics came not from philosophical, but from professional medical circles: the principles are too abstract, too rationalistic, far from the psychological environment in which real moral choices are made, they ignore a person’s character, gender, and upbringing received. . In other words, the very circumstance that contributed to the recognition of the tetrad of principles of bioethics by doctors (algorithmization of moral choice by analogy with the “algorithmization” of a doctor’s diagnostic thinking) now acted as a negative factor: principledism in bioethics means a kind of mechanistic method of making moral decisions.
In modern medicine, one of the alternative systems of medical ethics claims to be the so-called ethics of “sympathy”. Adherents of this theory argue that in specific situations that require ethical decisions, female doctors are more likely to show empathy than male doctors. Women are interested primarily in maintaining good relationships, rather than in self-affirmation, and are more inclined to establish cooperation than confrontation. Of course, there can be no objection to the fact that such virtues as empathy and compassion are important for a doctor, and especially a nurse, but this very concept of sympathy is extremely subjective, i.e. again requires conceptually sound rationalization, identifying sufficient grounds for one or another optimal solution. And yet, this direction of criticism of principledism in bioethics requires us not to discount such an additional factor as moral psychology.
Another alternative to the dominance of principledism in bioethics has been the revival of interest in the theory of “precedents,” which is attractive to clinicians because of its specificity. According to this theory, it is necessary to find typical cases (incidents) regarding which there is a consensus of professionals and society (or at least more or less complete agreement) in the application of ethical principles. In less clear cases, the method of analogies should be used, while developing rules of limitation. Criticism of this direction of bioethics primarily points to pluralism in modern society, emphasizing that casuistry is a product primarily of medieval culture, where there was agreement regarding dominant values. The theory of precedents is especially characteristic of Catholic moral theology, but in modern society there is no consensus on many moral issues, even among followers of the Roman Catholic Church.
The development of a new foundation for medical ethics is extremely complicated by the crisis state of modern philosophy and ethics with the spread of nihilism and skepticism in them. The philosophy of postmodernism relativizes the interpretation of truth in general, which calls into question the possibility of a rational approach to issues of ethics and morality.
Moreover, as modern bioethics spreads to countries outside the Western world, there is increasing talk of “cultural hegemony” in matters of morality. According to this concept of “cultural hegemony,” medical ethics, which dates back to Hippocrates and transformed into bioethics, is a product exclusively of Western civilization. The core idea of bioethics about patient autonomy is especially criticized. As soon as Western medical ethics comes into contact with other cultural traditions, all controversial issues immediately become aggravated.
Having noted the difficulties (philosophical, cultural) on the path to the development of bioethics, it should be further said that it is in modern medical ethics that an interesting dialogue of various religious doctrines, cultural traditions, socio-political programs and philosophical concepts takes place. In view of the universality of the phenomena of health and illness, the general similarity of the strategic and tactical tasks of medicine throughout the world, the possibility of reliable substantiation of the principles, norms and standards of behavior of medical specialists is not at all an insoluble problem.
The most promising direction for the further development of bioethics is “clinical ethics”. Clinical ethics focuses on the clinical realities of moral choice, taking into account the roles of all participants in this process (doctors, patients, and nurses, etc.). Based on empirical research, clinical ethics poses specific questions: “Is the imminent death of this particular patient inevitable?”; “How does public approval of euthanasia affect the psychology of doctors, nurses and patients?”; “What is the fate of ethics and morality if the decision of doctors to prescribe this or that treatment to a patient is dictated primarily by financial considerations?”; “Is patient autonomy always in his best interests?” etc.
In the development of clinical ethics, doctors and nurses seem to be doomed to dialogue with philosophers. Medical ethics is too important for doctors, patients and society as a whole, and it should not depend entirely on, on the one hand, philosophical “fashion”, and on the other, on the superficial judgments of clinicians in matters of ethics.
LITERATURE
1. Hippocrates. Selected books. - M.: SVAROG, 1994.
2. Yarovinsky M.Ya. Relationships among health care workers: Lecture notes. - Health care. - N 8. - P. 33-36.
3. Wise M.Ya. A word about a way to teach and learn practical medicine or active medical art at the bedside of patients. - M.: Medicine, 1968. - P. 79-94.
4. Ivanyushkin A.Ya., Khetagurova A.K. History and ethics of nursing. - M.: GOU VUNMTs, 2003, - pp. 56-62.
5. Ivanyushkin A.Ya. Medical secrecy. - Small medical encyclopedia. - M.: Sov. Encycl., 1991. - T. 1. - P. 363-364.
6. Medical associations, medical ethics and general medical problems: Sat. official materials. - Association of Doctors of Russia / Ed. V.N. Uranova. - M.: PAIMS, 1995.
7. Potter Van R. Bioethics: Bridge to the Future. Englwood Cliffs, NJ: Prentice-Hall, Inc., 1971.
8. Tishchenko P.D. Biopower in the era of biotechnology. M.: IF RAS, 2001.
9. Beauchamp T.L., Childress J.F. Principles of Biomedical Ethics. Fourth Edition. Oxford Univ. Press. N.Y. - Oxford, 1994.
10. Yudin B.G. Principles of bioethics. - Bioethics: principles, rules, problems. - M.: Editorial URSS, 1998. - P. 5-22.
11. Introduction to bioethics / Ed. B.G. Yudina. - M.: Progress-Tradition, 1998.
12. Bartko A.N., Michalovska-Karlova E.P. Biomedical ethics. Theory, principles, problems. Part 2. - M.: Publishing house MMSI, 1999.
13. Tishchenko P.D. Issues of equity in modern healthcare. - Bioethics: principles, rules, problems. - M.: Editorial URSS, 1998. - P. 53-72.
Professor of the department
philosophy of the Russian Academy of Medical Sciences
A.Ya.IVANYUSHKIN