Mmr Humanism and Ethics

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MYANMAR ACADEMY OF MEDICAL SCIENCE

The First Myanmar Academy of Medical Science Oration12 August 2001

HUMANISM AND ETHICS IN MEDICAL

PRACTICE, HEALTH SERVICES, MEDICAL

EDUCATION AND MEDICAL RESEARCH

Professor U Mya Tu, M.B.,B.S. (Rgn), Ph.D. (Edin)

Formerly Professor of Physiology, Faculty of Medicine, University of Rangoon,

Retired Director-General, Department of Medical Research, Yangon, and

Retired Director, Health Systems Infrastructure, World Health Organization, South-

East Asia Regional Office, New Delhi, India

Myanmar Academy of Medical Science

27, Pyidaungsu Yeik Tha Road,

Dagon Township, Yangon, Myanmar


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The First M.A.M.S Oration

The Myanmar Academy of Medical Science was founded with the objectives,

inter alia, to contribute knowledge and expertise of medical scientists in building a

peaceful modern developed nation, and to undertake the progressive improvement ofhealth care of the people. The duties of the Academy of Medical Science include

holding meetings for paper presentations and lecturing and demonstrating in

dissemination of medical education (Medical Science).

The Academy therefore had undertaken various scientific works and activities

to attain these objectives. During the past two years, the Academy has organized four

Symposia on various subjects, a workshop on developing research culture, scientific

meetings, and supported a number of Quick and Simple Research projects andcommissioned writing books.

The first MAMS Oration is being organized as a major scientific activity

aiming at promoting interest and disseminate knowledge. Webster's Encyclopedic

Unabridged Dictionary of the English Language defines Oration as a formal speech,

especially one delivered on a special occasion. According to the Shorter Oxford

English Dictionary, an Oration is a formal speech, or discourse, especially one

delivered in connexion with some particular occasion. Oration is a structured speechdelivered on a formal occasion presented by an orator, who, by invitation is a

distinguished personality.

The title of this present oration is " Humanism, and Ethics in Medical Practice,

Health Services, Medical Education and Medical Research". The subject is a very

topical one. Humanism and Medical Ethics are fundamental and at the core of all

endeavours of the medical profession, be it medical practice, medical education,

health care services or medical research. All members of the medical profession are or

should be governed by these principles.

The orator for the First MAMS Oration is Professor U Mya Tu, a medical

graduate from Yangon and the first Myanmar to obtain Ph.D in Physiology, the

founder Director General of Medical Research Institute and finally retired from WHO

service as Director of Health System Infrastructure in SEARO New Delhi.


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Diabetes, Obesity and Cardiovascular Diseases, International Union of Nutritional

Sciences.

In 1977, Professor U Mya Tu joined the WHO, South East Asia Regional Office

as Regional Adviser in Health Manpower Development on deputation from the

Government. He was then appointed successively as Chief of Health Manpower

Development and as Director of Health System Infrastructure till his retirement from

WHO in 1987. His contributions during his ten years with WHO include, promoting the

reorientation of medical education in the countries of the WHO South-East Asia Region,

initiating and promoting the development of the Health Literature and library Services

(HELLIS) Network in the SEA Region, and the conceptualisation of the comprehensive

health system based on primary health care, and the development of the Primary Health

Care Model.

Professor U Mya Tu's research interests and publications have been wide in the

fields of electrophysiology of the heart, physical fitness and sports physiology,

population genetics, medical education, primary health care and the HELLIS Library

Network. He is also the author of a number of books, which include the WHO 40th

Anniversary Volume entitled "Health Development in South-East Asia", in 1988, and its

Update in 1992, and also the 50th

Anniversary Souvenir volume for the World Health

Organization, Regional Office for South-East Asia entitled "Fifty Years of WHO in

South East Asia-Highlights: 1948-1998"

Professor U Mya Tu has been the recipient of several international honours and

academic awards during his career.

Professor U Mya Tu's hobbies include music. He plays the piano for relaxation.

He is also a keen golfer and he led the Department of Medical Research Team to victory

for three successive years in 1973, 1974 and 1975 in the Inter-Professional/ Trade Golf

Tournament at the Burma Golf Club.

Since his retirement in 1987, Professor U Mya Tu has served as a consultant to

the WHO both at Headquarters in Geneva, and at the Regional Officer for South East

Asia in New Delhi. He is at present working on the "Who's Who in Health in Medicine in

Myanmar" Project together with his wife Dr. Khin Thet Hta.


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HUMANISM AND ETHICS IN MEDICAL PRACTICE, HEALTH SERVICES,

MEDICAL EDUCATION AND MEDICAL RESEARCH

(The First Myanmar Academy of Medical Science Oration)

By

Professor Mya Tu

Mr. Chairman, the Honourable Deputy Minister of Health, Professor Mya Oo,

His Excellency the Honourable Minister of Health, Major-General Ket Sein,The Honourable President of the Myanmar Academy of Medical Science,

Professor U Ko Ko,Distinguished Members of the Myanmar Academy of Medical Science,

Honoured Ladies and Gentlemen,

It is indeed a great honour and privilege to be asked to deliver the first oration ofthe Myanmar Academy of Medical Science before this august assembly of Academicians.

I have chosen as the subject of my Oration Humanism and Ethics in Medical

Practice, Health Services, Medical Education and Medical Research because in this

present age and climate of materialism, reductionism and economic rationalism, themedical profession is in danger of losing sight of its social roots and its high ideals of

altruism and service to humanity.

First, I would like to define what I mean by the terms Humanism and "Ethics".

The meaning of ethics is well understood. Stedman's Medical Dictionary defines medical

ethics as the principles of correct professional conduct with regard to the rights of thephysician himself, his patients, and his fellow practitioners.

The term "humanism" needs a bit more explanation. Originally the term referredto a philosophical and cultural movement during the 15

thcentury European Renaissance.

But later it came to mean an attitude that was concerned with human interests andstressing compassion and individual dignity. It is in this latter sense that I use the wordhumanism in my Oration.

What does humanism in medicine imply? It implies respect for the dignity of the

patient as an individual human being; it implies showing feeling of compassion and an

Formerly Professor of Physiology, Institute of Medicine 1, Yangon , Director-General, Department of

Medical Research, Ministry of Health, Yangon, and Director, Health Systems Infrastructure, World Health

Organization, South-East Asia Regional Office, New Delhi, India


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understanding of his/her fears and apprehensions; and it implies meaningful

communications with the patient to understand him/her as a whole person and not just as

a disease. Humanism in medicine is more than medical ethics. It is more than refrainingfrom doing physical and mental harm to the patient through professional misconduct. It is

more than just abiding by the Hippocratic Oath. Humanism is a positive action, just as

compassion is not only a feeling of concern for the suffering of others, but also promptingaction to give help or to promote its alleviation. It is indeed surprising that a definition of

'compassion' is not included in two major Medical Dictionaries Dorland's and

Stedman's. Yet compassion is as important as scientific knowledge and skills in a

humanistic physician.

What is the present situation with regard to the degree of humanism and ethics

imbued in the medical profession today at the beginning of this 21st

century?

In the 1999 Year Book commemorating the Silver Jubilee Reunion of the Class of

1974-75 Medical Graduates of the Institute of Medicine 1, Yangon, there were a number

of Commemorative Messages from retired teachers. Two struck me as resonating withthe theme of this Oration. One was by Professor Dr. Daw Khin Si, who wrote: "Human Relationship is important....Patient understanding is the secret of all human

relationship....".

Dr. Maung Maung Taik was more explicit. This is what he wrote:"... I must however add, with malice towards none that the present ethical standard of

our noble profession is much to be desired. We, as doctors, should safeguard ourselves

from human frailty: the lure of lucre. There is much need to uphold the ideals of ournoble profession today and to avoid practices that tarnish its name. We need to abide by

the sacred tenets enshrined in the Oath. Let us go out of our way to be more

compassionate to the suffering of the poor and the needy. Let us be doctors of mercy andcharity: rather than the doctors of money and affluence...."

What is it that has made these two respected teachers to voice their apprehensions

of the state of our profession?

When we take stock, we will realize how far we have strayed from the ideal. This

phenomenon is a world wide one and unfortunately it has also spread to our country. Not

only has medical practice and the care of patients deviated from the original social ideal,the concept of humanism is almost alien in medical education and medical research

endeavours. True, medical ethics is part of the curriculum in a number of medical schools,

but it has been alleged that medical faculties insert the teaching of medical ethics in thecurriculum to salve their consciences. As will be described a little later, much more than

inclusion of the subject of medical ethics in the curriculum is required for medical

graduates to imbibe humanism and ethical behaviour as their second nature.


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Humanism and ethics in medical practice

Caring for the sick at its most fundamental level is rooted in the human spirit andhumanism. Take for example the young mother caring for her young sick infant or child;

or her kith and kin rallying round her offering advice, helping wherever needed; or an

older woman friend in the community who have experience in looking after the sickresponding to the call of the young mother for help. All of them have no pecuniary

motive save compassion for the sick child.

At a different level are the priests, priest-doctors, and witch doctors who sincetime immemorial have taken to treating sick people because of the belief of ancient

people that disease is a manifestation of evil influence exercised by a god or supernatural

being or another human being. Their motive for curing sick people may not wholly bealtruistic for certainly they benefited from the offertories, in addition to the power and

authority it gave them over the community.

When it comes to the medical profession, we are made to believe that its socialorigins are rooted in its attitude of humanism, a compassion for our suffering fellow

people, and a desire of being of service to them. Present day medical practitioners and

specialists have a one-to-one doctor-patient relationship. It is a unique relationship, and avery private one, involving a complete submission, dependence, and trust of the patient to

the authority, knowledge and skills of the doctor. And with that authority comes the

social obligation to treat with compassion those who trust us and are dependent upon us.

In spite of this relationship and the authority the doctor has over the patient, the

prestige and status of the medical profession in society was not always as high as we haveseen it in the 20th century. For example, in ancient India, the status of physicians, was

not high, except for the King's physician who was highly honoured especially during

times of war and had his tent next to the King's with a flag of his own. According toManu, the first law-giver in India, the physician was considered to be always impure and

was never invited to sacrifices offered to the gods. A Brahman was not supposed to eat

the food given by a physician because it was considered vile (Rao & Radhalaxmi, 1960).

In the Roman Empire, physicians were slaves, freedmen and foreigners, and medicinewas considered a lowly occupation. In 18

thcentury England, surgeons and apothecaries

were considered as tradesmen, and physicians were at the margins of the gentry class.

Even as late as the 19th

century, doctors in France were extremely poor and lacked status(Starr, 1949).

However, with the growth and advances in medical science and the ability ofdoctors to radically influence the course of disease, beginning in the latter part of the 19 th

century, medicine gradually changed from a trade to a profession and the power and

prestige of the medical profession have correspondingly increased reaching an all time

high in the 20th

century.


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When medicine gained the status of a profession from that of being a trade, it

acquired all the characteristics of a profession, namely autonomy, controlling the entry

into the profession, maintaining the standards of competency through training whichincluded theory, as compared to just skills training for tradesmen. The medical profession

thus organized the structural institutions of professions, such as associations, publications

and medical schools that they controlled, and had as its aim the altruistic or humanisticservice to society. It also constituted bodies to develop and apply a code of professional

conduct and ethics.

Ethics has been a fundamental part of medicine since early times and dealt withthe obligations and responsibilities of the physician. The principal concern of the doctor

for the welfare of his patient and the clear admonition to do no harm were embodied in

the Hippocratic Oath. It should be noted however that all the statements of ethics wereprofessionally oriented. There were none concerning the humanistic aspects.

Practitioners of medicine have been governed by codes of conduct since recorded

history. The earliest known code is that of Hammurabi, the Babylonian King who livedabout 2000 B.C. It prescribed rewards for successful treatment and punishments for

failure. In the code of medical ethics of ancient Egypt also, punishments were meted out

for malpractice that were even more severe than those of the Babylonian Code ofHammurabi, even to the extent of forfeiting the physician's own life. These codes were

imposed on the medical practitioners by kings and rulers. Hence their harsh nature.

The next well-known Code is that of the physician Hippocrates (460 355 B.C.) ,

exemplified in the Oath which is familiar to all medical graduates. In this code of ethics,

the graduate is reminded of the dignity and responsibility of his calling, and among otherthings, urged to seek above all the benefit of the patient, and taking no mean advantage of

the position of the medical adviser. In hisAphorisms he mentions the idea of focusing full

attention on the patient, rather than on theories of the disease. No more are the extremepenalties for failing to cure. (Sigerist, 1961)

The pattern of medical practice in the early eighteenth century was the Solo Fee-

for-Service type of practice where the individual doctor renders medical services for afee, the fees being either money or some farm produce as still occurs in developing

countries in some very poor communities and villages. This was the age of the country or

'horse and buggy' doctor or the family doctor who knew the families in the villages orcommunity well, went on house rounds, and often acted as 'guide philosopher and trusted

friend', in addition to treating all the illnesses in the family.

The development of major cities and hospitals during the 18 th and 19th centuries

saw the country doctor slowly disappear as more and more doctors settled in the urban

areas to practice medicine. Some authors have commented that the disappearance of the

country 'horse and buggy' or family doctor has contributed to the beginning of what hasbeen called 'dehumanized care' in the hospitals.


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Within the last few decades of the 20th

century, the pattern of medical practice

radically changed in industrialized countries with market-oriented economies. From the

solo individual practice type of organization, there are now more of group practices,where the medical services are provided by a group of three or more doctors under a

formal agreement for the joint use of facilities and equipment and allied health personnel,

the incomes being distributed according to a previously agreed upon plan.

During the 1970s and the early 1980s, business in the developed countries

particularly in the United States, saw a big market in the health care field, resulting in an

increasing commercialization of medical care, and the growth of the medical industrialcomplex. Large for-profit corporations were formed offering to government and business

purchasers on a pre-payment basis a variety of packages of services, including a range of

products from wellness programmes through organ transplantation to hospice services.With doctors forming into groupings, and the practice of medicine becoming big business

with health care corporations reaping revenues in billions of dollars, medicine is no

longer a cottage industry as the traditional fee-for service solo practice was termed. This

meant that it is the managers of these corporations the economists and the ChiefExecutive Officers, rather than doctors who are deciding more and more on the type of

health care practice and organization. With emphasis on cost-containment and efficiency,

these managers of the for-profit corporations are placing restrictions and applying pressure on the physicians or their staff to follow prescribed patient care protocols,

reduce admissions and patient length of stay in the hospital, and the number of diagnostic

tests, resulting in an overall loss of control over aspects of patient management by thedoctor.

The reverse situation applies when the doctor has financial interests in thecompany operating a private hospital and is encouraged to employ high-tech diagnostic

tests and procedures. In both cases, it is the patients who come worse off.

The result of this commercialization of medicine has been a sky-rocketing of the

cost of drugs and medical care consequent upon the application of highly sophisticated

medical equipment in diagnosis and treatment. While the rational and systematic use of

high technology procedures is definitely of benefit to the patients, indiscriminate use witha profit motive is to be deplored. It has been said that the more physicians come to

depend solely on technology, the more they lose their humanism, continuing the slide

towards 'dehumanized care'. This is compounded by the fear of being sued formalpractice, doctors paying a high insurance premium, which is of course passed on to

the patients, driving the cost of medical care still higher.

This situation in developed industrialized countries with market-oriented

economies is also being reflected in the developing countries. Fortunately litigation for

malpractice has not yet reached our shores.

These changes have coloured the behaviour and attitudes of the profession, with

increasing emphasis on the financial and technological aspects of treatment to the

detriment of the altruistic and humanitarian calling of the profession.


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In this context, the following words of that great humanitarian and physician of

the late 19th

and early 20th

centuries, Sir William Osler, came to mind:

"If I can ease one life its suffering and brush away one pain.If I can stop one heart from breaking ---

I will not have lived in vain."If I can help one ailing brother regain his strength again.

If I can calm one weeping mother ---

I will not have lived in vain".

"If I can ease one life its suffering and brush away one pain".

He did not say "I will wait for the admission forms to be filled and all the bureaucraticprocedures to be completed, and then I will try to ease the suffering and the pain of the

patient".

"If I can stop one heart from breaking "He realised the anguish and suffering that illness can cause, not only to the patient, but

also to the family members.

"If I can help one ailing brother regain his strength again".

He talks of a 'brother', not a patient or a case.

"If I can calm one weeping mother "

He did not say he would stop a mother from weeping by curing or healing all illnesses. A

physician's role does not end when the patient dies, but to provide a calming, reassuring,soothing influence even in tragedy.

In the March 2000 issue of the Myanmar Medical Journal the editorialdwelt on the same subject of medical ethics. You might remember that the title of the

editorial was "Of Patch Adams and Goose Eggs". (Nyunt Wai, 2000) The thrust of the

editorial was on financial aspects, on altruism, the observance of professional ethics, andon practicing what 'Patch' Adams called "a little bit of excessive happiness ". Dr. Hunter

D. "Patch" Adams to give his full name, is an American doctor, a social revolutionary

who believes that care of the sick should not be a business transaction; that the doctor-patient relationship has deteriorated from the time when doctors gave time to listen and

communicate with patients, to the aloofness of doctors nowadays, because of undue

dependence on technology. A video version of the film on Patch Adams is available andis worth watching for a number of telling commentaries Patch Adams makes. Forinstance, he criticizes the Medical Superintendent telling him: "You don't even look atpeople when you're talking to them.... You don't connect to people". And again when he

argues his defence before the Medical Board: "Death is not the enemy, gentlemen. It is

indifference. You treat a disease, you win or lose. You treat a patient, you will win,

whatever the outcome".


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Some of you who have seen the satirical popular British TV series "Yes Minister",

might remember that in one episode, it is the bureaucracy that is against the patient.

When the Minister asked why the new hospital was still not admitting patients but hademployed the full complement of non-medical administrative and other staff, the Health

Secretary replied: "They have great experience at the Department of Health and Social

Services in getting hospitals going. The first step is to sort out the smooth running of theplace. Having patients would be of no help at all they'd just get in the way".

Even during the medieval period, physicians and surgeons recognized the

importance of treating the patient in addition to the disease. It has been reported that oneHenri de Mandeville (1260-1320) suggested a method 'to solace (the patient) by playing

on a ten-stringed psaltery". He even suggested some dubious means such as writing false

letters telling him of the death of his enemies, or if he is a canon of the church he shouldbe told that the bishop is dead and that he is elected. I am not suggesting that present day

doctors should follow explicitly the advice of Henri de Mandeville and start to learn how

to play a musical instrument to entertain patients or to employ such unethical methods as

he advocated. However it goes to show that even in those days, doctors tried what theycalled "sustaining the spirits of the patient" in addition to treating the disease.

In passing, it should be noted that it is not only the practicing clinicians whoforgot the humanitarian roots of their profession in their drive for technological

excellence. In the field of public health also, where the dictum is "the greatest good for

the greatest number", there are instances where the individual patients suffered. Considerthe treatment of lepers in ancient and until relatively recent times when they were treated

as social outcasts. Some years back I occasion to visit the Molokoi Island, once a leper

colony in the Hawaii Islands and associated with the name of Father Damein. I was toldof how lepers were rounded up in the main Hawaii Islands and taken by ship to Molokoi

Island where they were told to jump from the ship and swim ashore, or those who were

hesitant, were pushed into the bay. Consider also the imposition of quarantine for plagueand cholera in the early days. Where was humanism then?

Humanism and ethics in the health services

Since ancient times, kings and rulers have taken the responsibility of looking after

the health of its people. There are records that in ancient India, the Kings established

places where the sick and disabled were cared for. The ancient Ayurvedic literaturementions specifications of different types of hospitals like obstetrics and surgical

hospitals. Asoka's Rock Edict II (4th

century B.C.) described curative arrangements and

hospitals or dispensaries for men and animals. (Rao & Radhalaxmi, 1960)

In the Roman Empire, medical services for the poor and for their legions were

organized. Public physicians were appointed to attend the poor and to supervise medical

practice within their area. The first hospital in Rome was built on the island of St.Bartholomew in 293 B.C. Later various writers mentioned the existence of private

hospitals and nursing homes (Guthrie, 1958).


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During the Dark Ages in Europe, when intellectualism and experimentation were

discouraged, it was in the monasteries that the light of medicine was maintained. Many

monasteries had herbal gardens and hospices. During this period, medicine in the Arabcountries flourished. There were magnificent hospitals in Damascus, Cordova and Cairo,

which catered to all aspects of patient care, including the humanistic aspects: such as the

spiritual side (where speakers recited the Koran day and night without ceasing); theaesthetic aspects (such as playing soft music at night to lull the sleepless); and aspects

for lifting the spirits (such as having storytellers to amuse the patients). The rehabilitative

aspects were not overlooked. Each patient, on departure was given a sum of money,

sufficient to tide him over convalescence, until he should be fit to resume work (Guthrie,1958). It was a very humanitarian approach to patient care indeed!

In Europe, particularly England, heath services for the population as we know itand sponsored by the State, is a relatively late phenomenon, although from medieval

times the State has taken emergency measures and ad hoc legislation to deal with

epidemic diseases. In the early 19th

century, as a result of the industrial revolution, there

were growing health and social problems while there was no legislation to deal with theseproblems and no central or local authority specifically concerned with the health of the

population. It took a cholera epidemic in 1831 for England to form an emergency Board

of Health which later became the General Board of Health. A Ministry of Health was notformed till 1919. Nowadays all countries regard the preservation of the nation's health as

one of their moral duties and have formed Ministries of Health or similar Agencies.

Hospitals have sprung up but mainly concentrated in large cities and urban areas.

During the first part of the 20th

century, the health care system in industrial

countries developed around hospitals. After World War II, developing countries ongaining independence followed the health care delivery system of the industrialized

countries, and built huge hospitals or as Dr. Halfdan Mahler the former Director General

of WHO called them, "disease palaces". By the late 1950s and 1960s societal pressureon the medical profession for change in the manner of medical and health care became

more pronounced. The spectacular advances in medical care using highly sophisticated

technology was acknowledged. But it was costly and was available only to those few

who had access to and could afford it. The plight of the vast multitude of the poor as wellas the rural population went unserved or underserved. Doctors whose training was

hospital-based, using sophisticated technology, and instructed by academic research-

oriented professors were ill-equipped to deal with the health problems in the communityand with the new developments in health care. These trends were disturbing to society.

At this time, a new philosophy of health development based on equity and social justice

was evolving in WHO which ultimately resulted in the Primary Health Care and theHealth for All movements. (World Health Organisation, 1981)

The voices of two eminent people eloquently expressed the situation of the health

care system in the 1980s. The situation is not much better today. Jimmy Carter, the ex-

President of the United States, said: "...Although American medical skills is among the

best in the world, we have an abominable system in this country for the delivery of health


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care with gross inequities towards the poor particularly the working poor and

profiteering by many hospitals and some medical doctors who prey on the vulnerabilityof the ill"

Dr. Halfdan Mahler, the ex-Director-General of WHO describes the global view:

" ...The general picture in the world today is of an incredibly expensive health industrycatering not to the promotion of health, but to the unlimited application of disease

technology. This perversion of health work is self-perpetuating. There is a vast professional establishment concentrating on the problems of the few. The whole

"unhealth" system finds its most grandiose expression in buildings, in "disease palaces'

with their ever growing staff needs and sophistication."

As stated previously, in relatively recent times under market economy, medicinehas become big business even in developing countries. Large corporations have moved

into what has been called the medical industrial complex. And when medicine is run as a

business for profit, there is a rise in the cost of medical care, thereby further denying

medical care to the poor. The relationship and attention given to the poor patients also donot match that given to the more well-to-do. It is true that the State subsidized hospitals

are there to cater to the needs of poor patients, but the reality is there are costs involved in

attending any hospital and it has been known that many poor patients have foregonetreatment in hospital rather than have the family face financial ruin.

Humanism and ethics in medical education

What is it then that makes a doctor technically proficient and also develop an

humanistic attitude, to cultivate 'bedside manners'? Is it part of the training and educationof medical students and the role model of the Professors and other teachers? So let us

now turn our attention to humanism and ethics in medical education.

Both in the western world and in the eastern traditional cultures, the training of

future medical practitioners originated with the apprenticeship system. In the west, up

until the eighteenth century, the majority of practitioners received their training through

this system. This was a highly decentralized system of training in which the apprenticeand the master were bound in a personal relationship. In India, this traditional method of

teaching through a close personal relationship between the pupil and the teacher of

Ayurvedic medicine dates back to a few thousand years B.C. The pupil stayed in thehouse of the teacher and in fact became a member of the household also doing household

chores, the teacher being actually regarded as a father. (Bhatia 1977) In ancient Greece,

the apprentice paid the master a fee, and spends a number of years with him, assistinghim, and learning and observing, until the day came when he was a master himself.

(Sigerist 1941).

Though an uneconomical method of production of physicians, nevertheless, thereis much to be said for this traditional apprenticeship system. With such a close

association and relationship with the teacher for several years, the student not only learns

from the teacher, but also imbibes his philosophy, his moral behaviour, his attitudes,values and methods from his daily life and his work and the way he deals with his

patients in fact his 'bedside manner'. This is very similar to the present day one-to-one


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relationship between a Ph.D. student and his Professor supervisor, where the student

working on a research problem together with his/her supervisor, imbibes the Professor's

approach, his methods, his way of thinking and the way he attempts to solve problems.

The next change in the system of training physicians occurred under the Roman

Empire. Because of the great need for physicians and surgeons for their armies, the Statetook responsibility for the training of physicians and surgeons by appointing teachers.

(Sigerist 1941).During the ensuring centuries, a number of countries followed suit. In the

Islamic countries, the education of physicians was already well established by the eighth

century A.D. The Islamic rulers founded hospitals with schools for teaching medicineattached to them. Well-to-do citizens also set up private hospitals employing reputed

physicians who had the dual responsibility of treating patients in the hospital as well as to

teach the medical students.

The famous medical schools in Europe in the ninth to the thirteenth century A.D.

- Salerno, Montpellier, Bologna and Padua - put medical education on a sound basis and

medical degrees were granted after a definite course of study and examinations. Thefaculty of the medical schools during this period not only trained physicians but also

controlled their actions, thus gradually assuming the same functions as the craftsmens

guilds of the period. During the Renaissance, medical faculties gradually lost their powerto control the practice, which in many countries were taken over by the State, and State

Medical Boards were formed. (Sigerist 1941).In England, the General Council of Medical

Education and Registration more commonly known as the General Medical Council,was established by the Medical Act of 1858 specifically to regulate the profession on

behalf of the State, to oversee medical education, to control the professional conduct and

ethical behaviour of the profession, and to maintain a register of qualified practitioners.Since the Council membership was primarily of doctors, this in effect gave the profession

the task of regulating itself.

In Europe, with the development of more hospitals in the nineteenth century, the

traditional apprenticeship system gradually gave way to a more centralized system of

medical education, firstly in the hospital medical schools and later in the universities.

As more and more students were being trained in hospitals, the plight of the

hospital patients seems to have been overlooked. Clinical teaching of a large number of

students had its effect on patients. As early as Roman times, under the apprentice system,one Latin poet by the name of Martial, who lived in the 1

stcentury AD complained:

"I'm ill. I send for Symmachus; he's here,A hundred students following in the rear;

All paw my chest, with hands as cold as snow:

I had no fever; I have it now."

Sounds very much like a contemporary scene in a teaching hospital!


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The nineteenth century saw dramatic scientific advances which was to have

profound effect both on medical practice and on medical education. Medical practice in

the early nineteenth century had been more or less of an empirical nature. But withmedical advances and discoveries, vaccination against smallpox, the establishment of the

bacterial origin of many diseases, and the introduction of anti-rabies vaccine and of

diphtheria antitoxin, and with some preparations such as digitalis, cinchona bark,morphine and aspirin, physicians now had some effective preparations at their disposal.

They could therefore afford to give up the time-honoured heroic but ineffectual measures

such as blood-letting, purging and blistering. All these developments strengthened the

armamentarium of the medical profession and contrasted sharply with the therapeuticimpotence of the practitioners prevailing during the early part of the nineteenth century.

The result was an increased faith of the public in the application of science for the

alleviation of human suffering, at the same time enhancing the prestige and status of theprofession.

The effect of these developments on medical education was also far-reaching. The

teaching of the basic sciences that had hitherto been neglected or haphazard was nowregarded as the foundation of medicine. The training of medical students became more

systematized during the twentieth century particularly after the 1910 Flexner Reportwhich analysed the state of medical schools in the USA and gave recommendations to

place them on a sound scientific footing. The teaching of the basic preclinical sciences

accompanied by dissection and experiments in the laboratory in the first few years of themedical course became the standard model. The Flexner Report had far reaching effects

beyond the borders of the USA. And to this day the basic structure of the organization of

medical education in many countries is largely based on the three segments of premedical, preclinical and clinical areas. With this increased emphasis on basic science teaching,

medical education became closely wedded to academic medicine and research.(Starr

1949). Nowhere was this more so than in the United States, and even the newlyindependent ex-colonial countries after World War II tried to emulate this model ofmedical education. This emphasis on academic and technological medicine taught in

large university hospitals extended right into the twentieth century. As a consequence,

students graduating from these medical schools, being trained in a university hospitalsetting with excellent facilities were reluctant to work in less well-endowed hospitals or

to go to the small towns and rural areas. In any case, their training was such that they

were ill-prepared to work in a community setting. The result was that these areasremained unserved or underserved.

Reform in medical education

This state of affairs in medical education existed till the 1950s. The emergence of

the concept of Social Medicine and the introduction of the teaching of social and

preventive medicine in the curricula in place of Public Health, gave the required impetusfor medical schools to bring about certain changes in the hope of preparing doctors to be

able to deal with this problem of the large underserved and underprivileged population in

the nation (Ko Ko, 1987). A little later the concept of Community Medicine wasintroduced in the medical schools and was particularly promoted by the World Health


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Organization in the 1960s and the 1970s. By that time the need for reform in medical

education had become apparent. Many medical schools made serious efforts at reform,

concentrating:

Firstly on where medicine should be learned (in the community, including home

visits and clinical teaching in hospitals, as against solely and exclusively in the Universityteaching hospital setting).

Secondly on how medicine should be learned by (changing the curriculum or what

has been called 'curriculum shuffling', for example, introduction of behavioural sciences,and medical ethics, and a change in emphasis from public health to preventive and social

medicine, and latterly to community health, and by changing the methodology of

teaching such as small group learning and Problem Based Learning). All sorts ofintegrated teaching were experimented with the horizontal, and the vertical, and also as

one wag put it spiral integration when everyone got screwed up! and finally gave up. It

should be mentioned that integrated teaching requires leadership, and a lot of

coordination and cooperation. It also requires a constant input of energy to keep thesystem running.

Thirdly, medical education reform has tried to concentrate with what should belearned during medical school and this has been more intractable. With such a rapid rate

of increase in knowledge and new disciplines, medical educators face a daunting task in

determining what to leave out and what new things to include. All Professors jealouslyguard their subjects resisting any attempt at reducing their curriculum time. Of course, it

is some other Professor's subject that should be reduced. And most often than not, the

opinion of the politically powerful Professors prevail! Here also there is excellentopportunity for good group dynamics and for cooperation and coordination to arrive at

the most suitable curriculum mix relevant and appropriate to the local situation.

Recently WHO has introduced the concept of social accountability of medical

schools, advocating that medical schools review their activities in the three main

domains of Institute responsibility, namely Education, Service, and Research in

relation to the fundamental values of social accountability of relevance to priority

health problems in the country, quality, and cost-effectiveness of health care provided,

and equity in the provision of health care services, i.e. provision of care for the

underserved and the underprivileged (Fig. 1)

al Accountability Grid for Medical Schools


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Fig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLSFig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLSFig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLSFig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLS

Medical educators agree that the purpose of these reforms is to redirect medical

education towards a community-based experiential, learner-centred model that willenable doctors to be both life-long learners and practitioners with the knowledge and

skills available to equate the psychosocial and biological aspects of medical care (Bloom,

1989). In the WHO South-East Asia Region, medical educators meeting in 1987 agreed

that the goal for the Reorientation of Medical Education (ROME) was that "... all medical schools in the region will be producing, according to the needs and resources of thecountry, graduate or specialist doctors, who are responsive to the social and societal

needs, and who possess the appropriate ethical, social, technical, scientific, and

management abilities so as to enable them to work effectively in the comprehensive

health system based on primary health care ...". (World Health Organisation, 1988)

It should be noted that both the objectives include ethical, social or psychosocial

aspects of medical care.

The training of medical students is one of the areas in which ethical and

humanistic considerations can be focused, because this is where the attitudes andperceptions of tomorrow's medical profession are formed. But classes in medical ethics

and humanism alone may not lead to greater sympathy for changes in doctor-patientrelations. Medical students are very discerning, and have no difficulty in determining

which subjects are taken seriously by the senior faculty. Do they show concern about

ethics and humanism in their lectures, their ward rounds, their other discussions and atthe bedside? In other words are ethical and humanistic considerations part of their second

nature, as much as a systematic history taking, observation and clinical examination?

DOMAINS OF

INSTITU-

TIONALRESPONSI-BILITY

FUNDAMENTAL VALUES OF SOCIAL ACCOUNTABILITY

Relevance To

Priority Hlth

Problems

High

Quality Of

HealthCare

Cost-

Effectiveness

of Health care

Equity in

Health Care

Services

Education

Service

Research


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The social and moral environment of society in general is also very important in

influencing the humanistic and ethical behaviour in medical students. One medical

educator has opined that "If we are to train humane physicians, we must begin to addressourselves as a society to the basic general education towards ethical and moral values

from infancy onwards".

Humanism and ethics in Medical Research and Development

Social consciousness, social responsibility and social accountability have been thehallmark of the medical profession, and these characteristics apply equally to the medical

researcher. Ethics and humanism can apply to the whole spectrum of research activity,

from the selection of research topics, through the mode of conducting research, and to theapplication of results of research and development.

In selecting research topics, while on the one hand researchers have the right to

academic freedom of research on any subject however esoteric, it should be rememberedthat the researcher also has a social responsibility to try to find solutions to problems

causing much of illness and suffering in the community. In other words, the researcher

should have one foot in the ivory tower, but the other foot should be firmly planted on theground.

In conducting clinical trails on patients or experiments involving humanvolunteers, researchers are now, or should be, under strict ethical control. Although ethics

has been a fundamental part of medicine since ancient times, a heightened interest in the

subject in relation to medical practice and medical research is a phenomenon of postWorld War II. This was a reaction against medical experiments on prisoners-of-war

during that war. The Helsinki Declaration issued at the 1975 World Medical Association

Meeting established standards not only for experiments on volunteers but also for clinicaltrials on patients undergoing treatment. The Tokyo Amendment set forth more explicitly

the conditions that should govern the experiment, and adds that the results of research

that do not meet these requirements should not be accepted for publication in scientific

journals. Most medical research and academic institutes, including the DMR have nowEthics Committees to approve research projects involving human subjects. But the

relation between the researcher and the patient or volunteer does not end once the project

has been approved by the Ethics Committee. In fact, it is just the beginning. And just asthe clinician should have a good 'bed-side manner' and humanistic relationship with

his/her patients, so should the researcher likewise.

Social responsibility and social accountability in research means that the research

is not done for its own sake. It is incumbent upon the researcher to see to the utilization

of his/her research results. This means that his work on this particular aspect does not end

with a paper appearing in a scientific journal. The results, in a digestible form, have toreach the policy-makers, the health care decision-makers, the health professionals and the

consumers.


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When it comes to development of research results it is usually taken over by

business. But business it has its own objectives, profit being their main aim. So when

commercial firms get into the business of developing medical products, be they drugs orappliances, it is with a profit motive notwithstanding their oft-repeated claims to the

contrary. For no commercial venture will take into consideration the ethical aspects and

refrain from developing a product simply because it is too expensive for the consumerwho need it. And no matter how humanitarian it is, the company is unlikely to donate it

to society. Just consider the recent court case in which the multinational pharmaceutical

firms objected to the intention of the South African Government to purchase the much

cheaper generic forms of AIDS-HIV drugs to combat the AIDS epidemic in the country.

A word here about the ethics of authorship of scientific articles. There is a

tendency nowadays of multiple authorship. It is of course true that a lot of research worknow is teamwork. But when the list of 'authors' stretch to ten or even fifteen, it makes a

mockery of the term authorship. An author, according to the Oxford Dictionary, is an

originator, a writer of a book, treatise or article. Authorship implies intellectual

responsibility. Too often, authorship is given or is expected for giving permission toconduct the research in one's department or hospital ward. Providing the facilities alone

does not merit authorship. Similarly, providing technical assistance alone does not

deserve authorship. If acknowledgement should be given to technicians, it could be provided after the names of the author/s with the note " With the technical assistanceof .............." as had been suggested by some journals such as Circulation andCirculation Research. This is intellectually more honest and ethical.

Conclusion

Ever since man practiced medicine, there must have been those who misused the

trust placed on them by patients, and had an undue interest in pecuniary rewards of theprofession. For example, one Isaac Judaeus (A.D. 845-940) an Egyptian Jew who became

physician to the ruler of Tunisia gave this advice to physicians: "Ask thy reward when thesickness is at its height, for being cured, the patients will surely forget what thou didst for

him". What would patients and society in general think of the medical profession if theystrictly followed this advice? Yet is the practice of depositing the consultation fee on

making an appointment with the doctor, as occurs in some private hospitals, very much

different?

The above review has shown that humanism and ethics permeates through the

whole fabric of the medical profession - medical practice, the organization of healthservices, medical research and development, and medical education. It is the very

foundation on which the moral authority of the profession rests. Yet there are several

influences as described previously, which shape the ethos of humanism and ethics in the

medical profession in a negative or positive way. These are summarized in the next figure:(see Fig. 2)


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NEGATIVE

INFLUENCES

POSITIVE

INFLUENCES

FIG. 2 Positive and Negative Influences on Humanism and Ethics in the Medical

Profession

The factors which have a negative influence on the ethos of humanism and ethics in themedical profession are:

- Medicine becoming a business, and- Present day ethos of materialism.

I have put two other factors,

- Technological advances, and

- Hospital based practice

between the negative and positive influences because both of these factors should have

beneficial effects for patient care, but as discussed previously they have unfortunately

turned out to contributing to 'dehumanised' medical care.

These negative influences have shaped the present day behaviour of the

medical profession. And it is into this professional milieu that the young medical

graduate enters. In this context, I would like to relate to you the story about a magical

Humanism EthicsTechnological

advances

Hospital-

based Practice

Medicine as

a business

Present

day ethos

Control &

Regulation

Societal

moral mores Role

Model Teaching of

Medical ethics

& medical

education

reform


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dragon who lived in a cave and which ate humans. The king sent in many a brave man

into the cave to kill the dragon, but the moment the dragon was killed, blood spurting

out would drench the man and he himself would become a dragon. And so the dragon

lived on. In a similar vein, are we sending our young graduates, who have passed

through a reoriented medical education system, into the cave of the current

professional milieu, to become tainted with the blood of professional power,privileges, and pelf, turning them yet into young dragons and dragonesses?

What can be done to counter the present trend? Some positive influences have

already been identified and discussed already. They are:

- Control and regulation by Medical Councils or analogous bodies.

- Societal moral mores,

- Role models,- Teaching of medical ethics and medical education reforms.

One can view the recent reforms in medical education as attempts to influence the practice of the medical profession that has to a large extent, become insular and

indifferent to the health care needs of the population, and to the values of social justice

and equity.

Can the present reforms in medical education bring about the desired change in

pattern of medical practice and the behaviour and ethos of the medical profession?

Several medical educators have commented on this issue and have pin-pointed a

few leads.

Professor Bloom remains skeptical of the present reform efforts in medicaleducation concentrating only on change in the curriculum and on the pedagogic methods.

He argues that: ... the structure of modern medical education was established 75 years

ago for the purpose of incorporating the revolution of biomedical science, and successful

in that purpose, it added high-technology specialization as the main outcome goal forclinical medicine. To prepare doctors to serve the changing needs of society is repeatedly

asserted as the objective of medical education, but this manifest ideology of humanistic

medicine is little more than a screen for the research mission that is the major thrust ofthe institutions social structure. He goes on to add: ...The choice is clearly trending

away from people-centred practice and toward the role of technical-specialist. If this

observation is accurate, the explanation is not to be found in the motivation or the

selection of recruits to the profession. It is in the structure of the situation of modernmedicine and in the structure of its major institutions. That is where change must occur if

we are not content with the way things are.

This means a major overhaul in the whole system.


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The present situation however, is not new. Human nature being such, it has

occurred throughout history, as articles bemoaning the situation and exhortations to the

profession appear in medical journals regularly at intervals every few years. Is it thereforecause for pessimism? Not necessarily. History has also shown that human nature can rise

from the lowest ebb to heights of self-sacrifice, compassion and service. That is our hope.

So where do we start?

How do we slay and put to rest the magical human eating dragon?

In other words, how can we influence the working environment and the working

system?Can the profession be "regulated" for its humanistic behaviour as it is

controlled for its professional conduct and ethical behaviour?

Is it a personal behaviour based on socio-religious beliefs and conduct andmoral upbriging?

Can these traits be identified during student selection?

Can this behaviour be inculcated during training particularly with community

oriented teaching? and finally,Does the profession really want to change?

Perhaps these questions might get the attention of the Myanmar Academy ofMedical Science.

Perhaps the Academy will apply its collective wisdom as to how to injecthumanism and ethics in our young medical students and graduates and thus provide

yeoman's service to our people, our patients and our profession.

Perhaps the outcome would be a more compassionate humanistic and ethical

medicine in our country where the patient, as a suffering human being, will once again

become the main focus of our medical care system.Before I conclude may I state that my views expressed in this Oration is in no

way a sweeping indictment of the whole medical profession in our country. There are,

and I personally know of a large number of doctors who are still practicing the art of

curing with cetana, compassion, caring and humanism embodied in the altruistic spirit ofour profession.

Finally, may I express, once again, my heartfelt thanks to the Myanmar Academyof Medical Science for this high honour conferred on me by giving me the opportunity to

deliver this Oration to the Academy.

Thank you.


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REFERENCES

Bhatia S.L. (1977). A History of Medicine with special reference to the Orient. New

Delhi: Medical Council of India.

Guthrie, D. (1958). A History of Medicine, New and revised edition, with supplement.

London, Thomas Nelson and Sons Ltd.

Ko Ko, U (1987). Preventive and Social Medicine at the Crossroads. Presentation at theNational Conference of the Indian Association of Preventive and Social Medicine,

Cuttack. India, 26-28 November 1987. Published as a booklet WHO/SEARO

Nyunt Wai (2000). Of Patch Adams and Goose Eggs. Myanmar Medical Journal

(Editorial); 44 Page 1., 2000.

Rao, M.N. and Radhalaxmi K.K. (1960). History of Public Health in India. Calcutta, M.S.Rao, Manthripragada House, Kakinada, Andra Pradesh (Navana Printing Works

Private Ltd., 47 Ganesh Chunder Avenue, Calcutta.

Sigerist, H.E. (1941). Medicine and Human welfare, Yale University Press, 1941

Sigerist H.E. (1961). A History of Medicine. Vol 2 Early Greek, Hindu and PersianMedicine. New York, Oxford University Press, 1961.

Starr Paul. (1949). The Social Transformation of American Medicine. Nwe York: BasicBooks Inc. Publishers.

World Health Organisation (1981)Global Strategy for Health for All by the year 2000-H.F.A. Series No 3. WHO Geneva 1981.

World Health Organisation (1988). Reorientation of Medical Education: Goal, Strategies

and Targets-2 SEARO; Regional Publications No. 18. Regional Office for South-East Asia, New Delhi.


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Professor U Mya Tu, M.B.,B.S, Ph.D

In appreciation of the First MAMS Oration

delivered in Yangon, 12 August 2001

Plaque of Honour presented to Professor U Mya Tu after theOration by His Excellency the Honourable Minister of Health

Major- General Ket Sein


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Page

The First M.A.M.S Oration 1

Biography of Professor U Mya Tu 2

Oration

Humanism and Ethics in Medical Practice, Health

Services,

Medical Education and Medical Research

5

Plaque of Honour presented to Professor U Mya Tu 24

Documents

Mmr Humanism and Ethics