Medical Ethical Principles - Research Paper Example

Running Head: MEDICAL ETHICS Medical Ethics of the of the Several researches have proved Medical Ethics asan essential component of Medicine. Just like other professions, the profession of arms, also possess some codes of conduct in their profession. A number of principles of military medical ethics are understood as the Laws of War. The four self-evident ethical principles for military are modern medical ethics-autonomy, beneficence, non-malfeasance, and justice. The Defence Medical Ethics Committee made a law of asking researchers for a prior declaration of intention to circulate their work prior to granting final approval for biological research in the military area. The present usage of best-practice anti-malaria drugs, optimal forms of pilot training in high-G environments, and some forms of optimal fitness training for the soldiers are also examples of the end results of military medical research. Medical Ethics Introduction Ethics has always been an integral component of every walk of life. The profession of arms, like any profession, lays down codes of conduct for medical too that bind members of a ship, a regiment, or a squadron, or an entire service or nation. Many tenets of military medical ethics at the national or international level are understood as the Laws of War, most formally codified in the Geneva Conventions. (Pearn, 2005, 10) By contrast, at the individual level, issues of medical ethical import are a recent phenomenon. (Day, 2005, 349) Military dictates of discipline, control by line of command, and the subservience of any individual rights for the greater aim-all are themes that, at least in the historical context, have made medical ethics questions irrelevant. The core doctrines on which the discipline of medical ethics is built beneficence, non-maleficence, autonomy, and justice often represent the antithesis of what service members are required to do. (Gillon, 2004, 186) Historically, a parallel system of loyalty, respect, courtesy, and chivalry has evolved to form an alternative modus operandi that binds those who command to those who obey. According to Pearn (2006) since the Second World War, and specifically since the Nuremberg Trials of 1945 and 1946, the medical ethics responsibilities, indeed some medical ethics rights, of service members have been specified. The International Military Tribunal was established by the London Agreement of August 8, 1945. Representatives from the United States, the United Kingdom, and the Soviet Union (and with the provisional membership of France) formed the Tribunal. Subsequently, 19 other nations accepted the provisions of its terms of reference. The Nuremberg Trials, held over 10 months beginning on October 18, 1945, formalized international concepts of (a) crimes against peace, [b) crimes against humanity, and (c) war crimes. But beyond these three themes, the Nuremberg Trials and their pronouncements established certain ethical principles relating to the ethical duties of individuals. Codes of conduct had in fact been in place in pre-Nuremberg Germany, relating to ethical issues and human experimentation. The Nuremberg Trials established, however, some extension of the autonomy of individuals in uniform and defined issues of personal responsibility for the actions of those in control of captive subjects, albeit in a line-of command context. (Day , 2005, 351) The Nuremberg Trials clarified these issues, in the international judicial sense, for the first time. Specifically, the millennia-old traditions of the soldier or sailor as an ethical automaton were changed. Individual service members were not only allowed, but for the first time were required, to exercise autonomy and to observe justice in certain circumstances-a development that, in some armies or navies, even a decade before would have been seen as dereliction of duty in the face of commands or orders from superiors. These themes were to impose ethical imperatives on medical researchers. Especially in the context of research projects that involved uniformed researchers or subjects, they were to codify certain safeguards for the protection of both. Saas (2004) reveals that tlthough these imposts had their genesis primarily in the military domain, from the early 1960s an increasingly educated and informed civilian society began to question the historical paternalism, albeit altruistic benign paternalism, of health professionals. The medical profession responded to these secular changes in society, and by the last decade of the 20th century it had become proactive rather than reactive to such advocacy for best-practice medical ethics in research. The World Medical Associations Declaration of Geneva (1946) and its Declaration of Helsinki (1964) encompassed these changing attitudes in professional society-a society in which the rights and duties of health professionals were thus spelled out for the first time. Explicitly, those codes anticipated the possibility of such duties coming into ethical conflict with local or national laws. Day (2005) reveals that as a response to these national and international influences, health institutions in all developed countries began to establish institutional medical ethics committees to oversee human and animal experimentation conducted in the name of the parent institution. The first of these institutional ethics committees (IEC) was established by the Senior Specialist Staff Association of the Royal Childrens Hospital in Brisbane (in 1967), the forerunner of some 180 institutional ethics committees that operate today. These committees are always established voluntarily at the discretion of the parent institution. Although some funding bodies (such as the National Health and Medical Research Council) demand IEC approval before research funding is awarded, there is usually no regulatory or legal state or federal requirement for such ethical monitoring of research in the health domain. However, such has been the strength of the moral persuasion of societal trends in general, and of the proactive work of caring health professionals in particular, that virtually no institution involved in human welfare and health would neglect this issue and remain unadvised by a site-specific institutional ethics committee. Part of the imperative driving the institution of such IECs has also been the fear of litigation, with its potential of both individual claims and class actions. ‘The Defence Medical Ethics Committee (DMEC) was launched on orders of the Chief of the Defence Force Staff during 1988. (Sass, 2004, 115) He says that, this committee, chaired by the Surgeon General, gives advice on ethical issues to all members of the Defence Force and, through the committees regulatory powers, controls peacetime discretionary research that involves the Defence Force. In addition to its chair (the Surgeon General), the committee consists of one senior uniformed officer experienced in clinical medicine, five members of the general public representing the disciplines of law and theology, and with community representation by both a man and a woman. It reviews all aspects of biological and health research undertaken by or involving any member of the Defence Force. Medicinal Risks and Rights As suggested by Gillon (2004) there are four axiomatic moral principles of contemporary medical ethics-autonomy, beneficence, non-maleficence, and justice-- were developed (by the Americans Beauchamp and Childress3) in a civilian context. If these are rights, the question "to whom do they apply?" is one that is inescapable for all who work in the domain of military medicine. (Gillon, 2004, 186) The principles of autonomy and of non-maleficence have a particular combined practical expression in an understanding of risks. (Dodson, 2003, 208) He further says that, in peacetime, the experimental risk must approach zero, at least with respect to mortal risk. Even with best-practice medical research, the risk may not be one of zero mortality. The concept of risk implies both objective mathematical assessment and the subjective interpretation of risk, and there is a clear duty of care for researchers using captive subjects, such as uniformed personnel, to communicate and explain the nature of the risks inherent in a proposed research project. Such risks, in the military context, may not be only the risks of death or disability but may include the risks of a compromise or modification to ones military career if results are found (perhaps serendipitously) that would compromise further military service in peace or on operations. Medical research always carries a small risk of injury or disability. There are no published studies on how service members perceive such risk; however, data from the parents of children who are potentially involved in research projects indicate that such risks must generally be perceived to be less than one in many hundreds of a chance of injury or hurt. Day (2005) reveals that a military IEC has a responsibility to all research subjects who volunteer for its projects, irrespective of nationality. Many military-sponsored anti-malaria drug trials, for example, include soldiers of developing nations as subjects. (Day, 2005, 351) These individuals usually have the most to gain from the results of such research; but in the sense that such individuals are "doubly captive," special protection by means of extra communication of risks and special monitoring of the process of volunteering is always required. These ethical overtones in the context of military research are not unique to this latter domain, and the potential exploitation of indigenous peoples in particular needs special sensitivity, courtesy, and the sharing of the fruits of such research, just as it does in the military domain. As given in Day’s research (2005) the legal rights of service members are distinct from those of civilians and are nation specific. In the United States, the Feres doctrine, based on a 1950 case (Feres v. United States16, does not permit a service member to sue for the potential recovery of damages for injuries which arise out of or are in the course of activity incident to service). Medical Ethics in Audit of Publication According to Sass (2004) The Defence Medical Ethics Committee has been a pioneer in asking researchers for an a priori declaration of intent to publish their work before granting final approval for biological research in the military domain. He further argues that there are rare exceptions to this, such as when questions of national security or military secrecy are applicable. The publication of research is an audit not only of the research itself but of the institutional ethics committee and the institution as a whole that allows such research. Such an ethical audit is valid only if all such research is potentially submitted to peer-reviewed journals for publication. The selective submission of research reports, dependent post hoc on the outcome of research, not only makes any ethical audit impossible but biases published research. A post hoc decision to submit research for publication, dependent on the decision of researchers, also means that any evidence based audit or meta-analysis of the subject in question is compromised. Following the lead of ADMEC, a number of other ethics committees have also introduced this codicil as a form of openness and self-audit. The underlying principle is that institutional ethics committees, and in this context military ethics committees, represent not only the institution but the broader society of which it is a part. ‘The audit of publication, itself an ethical imperative, acts as a second-line advocacy for adherence to the principles and conventions enumerated in the spirit of both the Geneva Conventions and the principles of medical research enunciated by the World Medical Association. (Sass, 2004, 117) Within such a self regulating system, any potential research on the offensive use of biological warfare agents would be disallowed. In this context, the IEC monitoring in-country military research is an extension of and a muscular expression of those principles that banned human experimentation and gave rise to the Nuremberg Trials (with prosecutions continuing today) and the Geneva Conventions themselves. Medical Ethics in Uniform Accordiing to Gillon (2004) the majority of biological research programs that are submitted to military ethics committees in peacetime require some modification to conform to best-practice ethics. Many of these changes are relatively trivial in nature. However, many civilian researchers (including those affiliated with drug companies and universities) see uniformed personnel, working within a discipline infrastructure, as desirable research subjects for case fording. In this context, the style of military ethics committees tends to be more, rather than less, conservative in what they deem to be allowable research. (Gillon, 2004, 189) For example, of the last 175 research protocols submitted to ADMEC (13.1%) were not given ethical clearance and were disallowed. (Dodson, 2003, 205) Ethics committees of the upcoming years will probably have extra legal or regulatory requirements placed on them for ongoing monitoring of research. This occurs today in institutional ethics committees following best-practice standards. Although it is resource intensive to do so, many ethics committees now monitor biological research that has been initially approved by means of ongoing, in-program ethical surveillance. Biological research in the military domain, as in civilian life, is necessary for the advance of knowledge. The current use of best-practice anti-malaria drugs, optimal forms of pilot training in high-G environments, and some forms of optimal fitness training8 are examples of the end results of military medical research. Conclusion Thus various studies proved that, Medical Ethical Principles, as they apply to the profession of arms, are rarely stated explicitly. Whether one is a uniformed doctor, nurse, dentist, or medic, all codes of professional medical ethics are developed from certain underlying assumptions about the nature of the profession of arms and the nature of medicine. Unlike civilian health workers, service members are enmeshed in a tripartite relationship in which to the basic doctor-patient or researcher-subject relationship is added the defense force of which both are members. An underlying medical ethical principle of serving members of the profession of arms is that of the nice human being who happens to be a service member. References Day. RO, Chalmers DRC, Williams KM, Campbell TJ (2005) ‘The death of a healthy volunteer in a human research project’ Med J Aust pg. 349-51. Dodson. M, Williamson Pc (2003) ‘Indigenous peoples and the morality of the Human Genome Diversity Project’. J Med Ethics, 200-210. Gillon. R, (2004) ‘Medical ethics’ Br Med J, pg 184-8. Pearn. JH (2006) ‘The Geneva conventions and military service’ J R Aust Army Med Corps, 9-13. Sass. H-M: Reichsrundschreiben (2004) ‘German regulations concerning new therapy and human experimentation’ pg 100-120. Read More