Family Medicine

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World Book of Family Medicine – European Edition 2015 Nazan Karaoglu, MD drnkaraoglu@gmail.com 94 – War – Terrorism – Ethical Challenges and Family Physician Education Nazan Karaoglu, MD, Associate Professor, Head of Medical Education and Informatics Department, Necmettin Erbakan University Meram Medical School, Konya, Turkey Co-author Francesco Carelli, MD In spite of the fact that we are living in a modern, civilized world, every living creature- human beings, animals and plants-get a slice of natural or man-made disasters. Of course it is not possible to predict and shape the future but it seems that in most of the events as the main player in these disasters, man has had a chance to prevent them. The history of our world holds the clues as to what could have been prevented and what could not. Please take a history book from your country and have a look. Human beings like to break The Golden Rule stating that one should treat others as one would like others to treat oneself, defying all religions which decree "Do to no one what you yourself dislike” Koran (1). Let’s go to our specific profession “medicine” and more specifically “family medicine”. Throughout the history of man, physicians have featured in these disasters, sometimes as medicine man, shaman or as doctor. This means that the conflicts encountered by physicians throughout humanity are not new. Since ancient times, depending on universal humanistic rules and the history of medicine - written or verbal - physicians have had ethical rules underpinning their lives in addition to their practice. Unfortunately, the wealth of experience does not mean great expertise and still “our daily routines confront us with situations that neither we nor Hippocrates could have anticipated” (2). The basis for medical ethics education was established. In general, the aims of this education are; awareness of values and ethical conflicts, knowledge of basic ethical principles, professional obligations and law and practical skills in clinical reasoning and decision making through the use of ethical principles (3,4). Although physicians know what to do in most situations, in most of the cases the dilemmas they face are complex and they are required to face them alone and manage according to their own standards within ethical boundaries (2). Specifically, ethical challenges are more frequent in family practice and more complex and this complexity stems from the nature of the work within primary care (3). The Characteristics of Family Medicine Which May Create Ethical Dilemmas Are: 1. The emphasis on the patient as a psychosocial being, presenting in the context of culture, family, and community. 2. The existence of social and cultural diversity in the patient population. 3. The involvement in decision-making processes of multiple stakeholders, more than one of whom may be the physician’s patient. 4. The interaction of the physician with vulnerable patient populations such as minors and the mentally disabled. 5. The physician’s responsibility to manage the full spectrum of health conditions. 6. The responsibility to provide personal care to a patient over a prolonged period of time. 288
World Book of Family Medicine – European Edition 2015 7. The inclusion of patients of all ages in the patient population. 8. The pressure of conflicting duties on the family physician due to health care system organization and change (3) “Doctors are often among the first to witness evidence of torture, massacres or of other forms of cruel and degrading treatment” (5). Physicians accompany military forces during war to serve the army and they participate in military clashes which are contrary to our medical codes (2). Unfortunately, there are findings that some physicians participated in human rights abuses including falsification of medical-legal reports of alleged torture, physical mutilation as a form of punishment and falsification of death certificates among those surveyed (6). Physicians are not only torn between humanity, personal feelings, national policies, and medical ethics during times of war and terrorism, but also in daily practice, even in safe places with no apparent acts of violence they encounter challenges (2,7). It is claimed that modern life in times of peace as well as war and global terrorism, raises issues physicians have not encountered before (2). Uniquely, family physicians are often in the front line of organizational and social change and must be able to adapt to the increasing complexity of medical care options, expectations of patients and society, increasing cultural diversity of patients, and the health system organization (3). Despite the strong evidence-based need for ethics education, recognized globally by professional organizations in family medicine, there were indications that ethics teaching was not being provided in residency programs (8). It is well recognized that ethics teaching must: be integrated throughout medical training, building on the ethics education received in medical school and continuing into residency, aim to “custom-fit” the learner’s needs at different stages of medical training, as new roles and responsibilities provide new ethical challenges, and address the particular ethical issues that occur in the resident’s chosen specialty (8). In conclusion; although we are living in a time of progress and civilization, numerous natural and man-made disasters are taking place all over the world. Vague opinions are put forth by the medical societies and ethical boards, but there is no clear statement concerning these issues (2). Take Home Messages Before being a doctor, a physician is a human being, who should never forget The Golden Rule. “Medicine” as a profession rooted in ancient times, carries huge experience regarding humanity, but still faces challenges that are not predictable in every patient-physician encounter. Some physicians such as those working for the army are in conflict with the ethical codes of medicine but family physicians who are primarily confronting organizational and social changes face greater challenges. Family medicine carries a specific complexity regarding ethical issues because of the particular nature of primary care. Regardless of times of peace or war, modern life raises specific ethical issues that result in a need for a planned professional ethics education in family medicine. Original Abstract http://www.woncaeurope.org/content/p-215-war-terrorism-ethical-challenges-and-family-physician-education References 1. http://en.wikipedia.org/wiki/Golden_Rule (accessed in 30 October 2014) 2. Kivity S, Malke Borow M, Shoenfeld Y. Hippocrates Oath is challenged. Isr Med Assoc J. 2009; 11(10): 581-4. 3. Manson H. The need for medical ethics education in family medicine training. Fam Med 2008; 40(9): 658-64. 4. Ogle K, Sullivan W, Yeo M. Teaching ethics in family medicine. Introducing a faculty handbook. Canadian Family Physician 2013; 59: 1126-7. 5. Tobin J. The challenges and ethical dilemmas of a military medical officer serving with a peacekeeping operation in regard to the medical care of the local population. J Med Ethics 2005; 31: 571–4. 6. Reis C, Ahmed AT, Amowitz LL, Kushner AL, Elahi M, Iacopino V. Physician participation in human rights abuses in Southern Iraq. JAMA 2004; 291:1480-6. 7. Rosner F. Ethical dilemmas for physicians in time of war. Isr Med Assoc J 2010; 12(3): 133-5 8. Manson H, Satin D, Nelson V, Vadiveloo T. Ethics Education in Family Medicine Training in the United States: a National 289
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