by Nazan Karaoglu, Francesco Carelli

Although we are in a time of progress and civilization, uncountable natural and man-made disasters are going on all over the world. We are unable to avoid terrorism, wars and violence and at times, like the recent Haiti disaster, feel that we are entrapped between national policies and medical ethics.

In 1978 the WHO in the Alma-Ata conference identified primary health-care as the key to achieving an acceptable level of health throughout the world. Besides the technical education of the family physician, political, ethical, and communicative competencies are very important for the multi-professional approach of a family physician. A successful humanitarian work depends on historical and ethical consciousness, knowledge of international humanitarian law and a culturally sensitive healthcare provision based on  social and communicative competencies.

Being a kind, considerate and honourable professional practitioner is defined as possibly the most important element of being a good doctor.1 Making the care of patients our first concern, protecting and promoting the health of patients and the public, treating patients as individuals, and respecting their dignity are the main responsibilities of family doctors.2 The 1978 conference of the WHO in Alma-Ata identified “primary health care as the key to achieving an acceptable level of health throughout the world”.3

Family physicians are in a unique and challenging position because they are often in the frontline of organizational and social change.4 In this position family physicians suffer various tensions as they attempt to balance their own values with the expectations of their patients, the values adopted by organizations for which they work, and responsibilities of their profession.5 Medical practice as an organized autonomic profession tries to update itself according to social and individual necessities.2 Besides in special situations like natural disasters and terrorism the responsibility and the ethical challenges of family physicians naturally increase.

The impact of war on the health of a population is undoubtedly a cause of health inequalities.6 The last decade has witnessed a large number of humanitarian emergencies of unprecedented proportions and variety.7 Long-term exposure to such humanitarian emergencies causes serious psychological consequences in the wide spectrum of post-traumatic reactions both in patients and care givers.8,9 Terrorism may have a severe impact on physicians’ practices too.10 Family doctors are likely to be the first point of care if a bioterrorism attack is suspected and they might need special training for this role.11

In a study in Lebanon the war and political tensions had a clear negative effect on interns in their attitude about life in general, their interactions with their patients, and their relationships with colleagues and staff.12 Besides, according to a study in Iraqi it is suggested that physicians participated in human rights abuses through falsification of medico-legal reports on violence and death certificates.13 Unfortunately this is the other side of the coin.

In complex emergencies, public health activities have been shown to promote peace, prevent violence, and reconcile enemies.7 As Wong noted “as advocates of social justice, the medical profession has a duty to inform the public and to convince warmongers that war is unjust, damages life and health, creates misery and suffering, damages the environment, and wastes resources – resources that should be used to improve the health and welfare of people and to preserve our global environment”.14

What should we do against the ethical challenges which we have in primary care? Apart from the technical education of the family doctor, education in political, ethical and communicative competencies are very important for the multi-professional approach of a family physician, as defined also in the European Definition of Family Medicine.15

Professionalism, humanism and medical ethics education have now resurfaced. Until recent years, these areas were generally neglected in education and in medical literature. Since we are healthcare professionals trained to help and care for others and following from the Codes and Oaths we have since Hippocrates and Maimonides, everything we did was by default ethical.16 Obviously this is a wrong deduction.

As it is apparent in its definition, professionalism is a way of behaving in accordance with certain normative values and at least in theory, physicians could act in such a way as to fulfill all the expectations of professionalism without actually believing the values which underpin them.17  Indeed daily expressions of professionalism mostly appear in physicians’ offices and in the communities they serve, not in the academic corridors.18

Humanism  is a way of being which comprises a set of deep-seated personal convictions and addresses the question of what it means to be human.17,18 While humanism appeals to universal values, professionalism is rooted in the local traditions and thus the content of professionalism is narrower than that of humanism because it is the professional group which defines what the content and issues for professionalism will be.19

As mentioned before, specialty-specific training in ethics is especially important for family physicians and medical ethics education gained in medical school does not answer the need.4

As a conclusion, a family doctor (every one of us) should have the spirit of peace, humanity and ethics at the end of residency education.

References

  1. Jacobson L, Hawthorne K, Wood F. The ‘Mensch’ factor in general practice: a role to demonstrate professionalism to students. Brit J Gen Pract 2006; 56:976-9.
  2. General Medical Council. Good Medical Practice. London: GMC. 2006.

3.World Health Organization. Primary health care report of the International Conference on Primary Health Care in Alma-Ata, USSR. Geneva: WHO. 1978.

  1. Manson H. The need for medical ethics education in family medicine training. Fam Med 2008; 40:658-64.
  2. Ellsbury KE, Carline JD, Wenrich MD. Competing professionalism values among community-based family physicians. Acad Med 2006; 81(10 Suppl):S25–S9.
  3. Torinek T, Katiæ M, Kern J. Morbidity of Native, Immigrant, and Returned Refugee  Populations in Family Medicine Practice in Croatia after 1991-1995 War. Croat Med J 2005; 46:990-5.
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  9. The European definitions of general practice/family medicine. The key features of the discipline of general practice. The role of the general practitioner and a description of the core competencies of the general practitioner/family physician. EURACT. 2005. Available at www.euract.org/index.php?folder_id=25
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