Medical ethics. Professional ethics of a doctor

And colleagues.

Professional ethics- these are the principles of behavior in the process professional activity person. It is believed that the basic principles of medical ethics were formulated by Hippocrates (the Hippocratic Oath).

That part of ethics, the subject of which is the doctrine of a person’s duty to another person and society as a whole, in Russia is called deontology. Medical deontology is the doctrine of the proper behavior of medical workers that contributes to the creation of the most favorable environment for the patient’s recovery. To replace the concept of “medical ethics,” the outstanding surgeon N. N. Petrov, in 1944, introduced the term “medical deontology” into the Russian language (ancient Greek. δέον - due, proper; λόγος - teaching), extending its principles to the activities of nurses.

Thus, the theoretical basis of deontology is medical ethics, and deontology, manifested in the actions of medical personnel, is the practical application of medical ethical principles. The subject of the study of deontology is larger than the subject of ethics, since, along with the study of morality itself, it studies and regulates the relationship of the doctor with society (the state), with patients and their relatives, with other doctors and health workers.

Modern deontology and medical ethics

Throughout various periods of human history, the medical code has remained virtually unchanged. For a long time, doctors were hostages of religious and secular prohibitions.

The basic principles of ethics for health workers were formulated by Hippocrates two and a half thousand years ago. The “Hippocratic Oath” still proclaims that the purpose of medicine is precisely to treat the patient. Its main principle is known to everyone: “Do no harm.” In the modern world, this medical code is not a legal document, but its violation can become the basis for legal liability.

Currently, based on medical ethics, the doctor is obliged to observe the following rules in relation to the patient:

Communicate patient rights;
Report his state of health;
Respect the human dignity of the patient and treat him humanely;
Do not cause moral or physical harm;
Treat a dying person with care;
Maintain medical confidentiality;
Avoid ignorant interference in the patient’s health;
Keep high level knowledge in your profession;
Treat colleagues with respect;
Maintain respect for medicine.

Doctor and patient

Medical ethics states that a doctor should be a highly educated specialist, and deontology helps to see a patient as a person and respect his rights. After all, he takes his own special oath, the “Hippocratic Oath.” The profession of a doctor combines humanism, civic duty, professional knowledge and high morality.

When interacting with patients, the appearance of doctors, as well as their manners, is important. Bright hairstyles or jewelry, or a flashy wardrobe can cause inconvenience to people undergoing treatment or colleagues. The doctor must remain calm even if the patient or his relatives behave inappropriately - these are the requirements of ethics.

If a doctor feels antipathy towards a patient, he should not express it either in words or in gestures. This should in no way affect the treatment; all personal hostility remains outside the hospital.

Compassion for a sick person is based on scientific knowledge, and not on simple universal humanism. A modern doctor always informs the patient about the severity of his illness.

Traditional rules of interaction between doctor and patient may change over time under the influence of new ethical principles, but their essence, the very “do no harm,” always remains the same.

Nurse and patient

The nursing profession originated from women's desire to help a sick or injured person. It is based on the principle of caring for every patient, regardless of his social status, nationality or religion. This principle in work should be placed above all else.

A nurse is called upon to care for patients, relieve or prevent suffering, and help rehabilitate health. According to the code of ethics of nurses, they should respect the rights of everyone to physical and mental health, observe the principles of humanity, perform quality work and maintain moral principles in their relationships with patients and colleagues.

Respecting the human dignity of the patient is a necessary condition of working in this profession. According to ethics, a nurse has no right to show arrogance, neglect or rudeness towards patients, and should not impose her point of view on any issue on them. She must inform the patient about his rights, health status, diagnosis and treatment.

Causing pain to a patient is permissible only in one case - if it is done in his interests. Threats regarding human life are unacceptable. Disclosure of confidential patient information is prohibited.

Doctor and nurse

Teamwork is an important condition for the proper functioning of a medical institution. His team is united by a common hard work, based on responsibility for human life and health. Therefore, the correct climate within the hospital walls is regulated by medical ethics.

Medical work presupposes that medical ethics underlies the correct attitude not only towards patients, but also towards each other, regardless of position. It’s not for nothing that doctors wear white coats - this emphasizes not only cleanliness, but also the high meaning of their profession. Neglect or loose communication in the medical community reduces the patient's trust in all health care workers.

Doctors should treat nursing and junior medical staff with respect. The nurse is currently the doctor’s main assistant, without whom full treatment is impossible. Nurses are required to follow the rules of etiquette towards doctors and everyone around them at work. Nurses must use all their knowledge to help doctors in their work.

Medical workers, without exception, should not speak negatively about their colleagues, especially in the presence of patients or their loved ones.

Myths about medical ethics

Although modern technologies I am penetrating deeper into medicine, it still combines science and art. This duality, as well as the direct connection with human health and life, creates the ground for various myths.

In medicine, there are topics that excite minds, cause heated discussions and are sometimes interpreted incorrectly (organ transplantation). Kidneys, hearts, lungs and other organs are transplanted from people who have already died. An uninitiated person, if he sees the process of organ extraction, will perceive everything as if the necessary material is being extracted from a still living person.

Or euthanasia. Doctors either stop prolonging the patient’s life or use special measures to ensure a painless death. In some civilized countries this procedure is voluntary, in most countries of the world it is prohibited. This topic causes a lot of controversy. And disputes give rise to rumors. Myths about “killer doctors” worry people.

But there are also AIDS and other dangerous diseases. Most people are not well informed about this, and the medical community is unable to agree on what rules to follow. Until public health issues a final verdict on these “slippery” topics, the public consciousness will continue to feed false rumors.

You cannot live pleasantly without living wisely, morally and justly
Eppkur

Every specialist working with healthy and sick people must acquire knowledge and communication skills with them, as well as the skills of a teacher and educator. This provision becomes especially important when it comes to communication between a doctor, educator (teacher) and disabled people. In fact, for these purposes it is quite acceptable to use the basic principles of medical deontology and ethics
The goals of medicine organically include moral assessments, not only because they presuppose ethical norms of the relationship between doctor and patient, but also because compliance with deoptological norms by doctors in itself gives a therapeutic effect.

Virtue and wisdom without knowledge of the rules of behavior are like foreign languages, because in this case they are usually not understood F. Bacon
Deontology (Greek deon, deontos - due, proper + logos - teaching) is a set of ethical standards for health workers performing their professional duties (BME, vol. 7, p. 109, 1977).
The term “deontology” was introduced into ethics at the beginning of the 19th century. English philosopher Bentham. Some authors identify the concepts of medical ethics and deontology. In fact, these concepts are closely related to each other, but are not identical, since deontology is the doctrine of the rules of behavior of a doctor, arising from the principles of medical ethics and built on them.
The subject of medical deontology is mainly the development of ethical norms and rules of conduct for a medical worker when communicating with patients. However, despite the fact that the concepts of “medical deontology” and “medical ethics” are not identical, they should be considered in a dialectical relationship, “... by medical deontology we... should mean the doctrine of the principles of behavior of medical personnel” (N.I. . Pirogov).
The norms and principles of medical deontology and ethics can correctly guide a medical worker in his professional activities only if they are not arbitrary, but scientifically substantiated. Only then will they be theoretically meaningful and find widespread acceptance. The great doctor of the distant past, Hippocrates, wrote: “A doctor is a philosopher, he is equal to God. And indeed, there is little difference between wisdom and medicine, and everything that is available for wisdom is also in medicine, namely: contempt for money, conscientiousness, modesty, simplicity of dress, respect, decisiveness, neatness, abundance of thoughts, knowledge of everything that is useful and necessary for life, aversion to vice, denial of superstitious fear “of the Gods,” divine superiority.”
Compliance with moral standards is one of the necessary aspects in the activities of any specialist working with people. The most important feature of their moral duty is that all their actions and actions are taken for granted. A.P. Chekhov said that “the profession of a doctor is a feat; it requires dedication, purity of soul and purity of thoughts.”
Medical deontology - the science of what should be, develops principles of behavior of medical personnel aimed at achieving maximum therapeutic and health-improving effects through strict adherence by physicians to ethical standards and rules of conduct. The principles of a doctor’s behavior follow from the essence of his humane activity. Therefore, bureaucracy and a formal callous attitude towards a sick person (disabled person) are unacceptable.
The basic principles regulating the moral character of a doctor have been formed over the centuries. Already in the Indian code of laws of Manu, the Vedas, the rules of conduct for a doctor, understood as ethical standards, are listed in detail.
IN ancient world medical views, as a rule, were directly related to philosophical, ethical and social doctrines. An outstanding role in defining the main problems of medicine as spiders and as a moral activity belongs to the founder of scientific medicine, Hippocrates. The sections of the collection of Hippocrates “Oath”, “Law”, “On the Doctor”, “On Favorable Behavior” are directly related to the problems of medical deontology. Here Hippocrates formulated a number of deontological norms. Hippocrates formulated the duties of a doctor in relation to the patient in the famous “Oath”: “I will conduct my life and my art purely and immaculately... Whatever house I enter, I will go there for the benefit of the patient, being far from everything intentional, unfair and harmful... Whatever I see or hear regarding human life that should never be disclosed, I will keep silent about it, considering such things a secret...®.
In medieval medicine, doctors were also not alien to the norms of medical deontology. For example, they were set out in the “Salerno Code of Health” and in the “Canon of Medicine” and “Ethics” by Ibn Sina.
During the Renaissance, the humane precepts of the great ancient physicians received recognition. The famous physician and chemist T. Paracelsus wrote: “The power of a doctor is in his heart, his work must be guided by God and illuminated by natural light and experience; the greatest basis of medicine is love.”
Russian clinicians (M.Ya. Mudrov, S.P. Botkin, A.A. Ostroumov, etc.) strictly adhered to the principles of deontology in their professional activities. Leading public figures, humanists A.I. had a great influence on the formation of domestic medical deontology. Herzen, D.I. Pisarev, N.G. Chernyshevsky and others.
The merit of introducing the term “medical deontology” into the practice of Soviet health care and revealing its content belongs to N.N. Petrov, who defined it as “...the doctrine of the principles of behavior of a doctor not for achieving individual well-being and honors, but for maximizing the amount of social utility and maximizing the elimination of the harmful consequences of inferior medical work.”
Only a doctor who has chosen his profession by vocation can organize his activities in accordance with the requirements of medical deontology. Loving your profession means loving a person, striving to help him, and rejoicing in his recovery.
Responsibility for the patient and his health is the main feature of the doctor’s moral duty. At the same time, the doctor’s task is to provide psychological impact on relatives, when the latter’s intervention may adversely affect the patient’s condition.
Nurses help the doctor in creating an optimal environment in medical institutions and high service and professional discipline. High culture and neatness, cordiality and caring, tact and attentiveness, self-control and selflessness, humanity are the main qualities needed by a nurse. She must have a good command of the art of speech in communicating with patients and their relatives, observe a sense of proportion and tact, and make every effort to create an atmosphere of trust between the patient and the doctor.
Relations between doctors, nurses and junior medical workers must be impeccable and based on absolute mutual trust. In medical institutions, an environment should be created that would spare the psyche of patients as much as possible and generate an atmosphere of trust in the doctor.

11.1. Fundamentals and principles of medical deontology

Ethics is unlimited responsibility for everything that lives.
A. Schweitzer

Ethics (from the Greek cthika - custom, rights, character) is a philosophical science that studies issues of morality and ethics.
Ethics. In a narrower sense, medical ethics is understood as a set of moral standards for the professional activities of medical workers. In the latter sense, medical ethics is closely related to medical deontology.
Ethics studies the relationships between people, their thoughts, feelings and deeds in the light of the categories of good, justice, duty, honor, happiness, dignity. Doctor's ethics is truly human morality and therefore only a good person can be a doctor.
Moral requirements for people involved in healing were formulated back in the slave society, when the division of labor occurred and healing became a profession. Since ancient times, medical practice has been highly revered, because it was based on the desire to save a person from suffering, to help him with illnesses and wounds.
The most ancient source, which formulates the requirements for a doctor and his rights, is considered to date back to the 18th century. BC. "The Laws of Hammurabi" adopted in Babylon. An invaluable role in the history of medicine, including the creation of ethical standards, belongs to Hippocrates.
He owns the axioms: “Where there is love for people, there is love for one’s art,” “Do no harm,” “A physician-philosopher is like God”; he is the creator of the centuries-old “Oath” that bears his name. Hippocrates was the first to pay attention to the relationship between the doctor and the patient’s relatives, the relationship between doctors. The ethical principles formulated by Hippocrates were further developed in the works of ancient doctors A. Celsus, C. Galen and others.
Doctors of the East (Ibn Sipa, Abu Farzja, etc.) had a huge influence on the development of medical ethics. It is noteworthy that even in ancient times, the problem of the doctor’s relationship with the patient was considered in terms of their cooperation and mutual understanding.
In Russia, advanced Russian scientists have done a lot to promote the humane orientation of medical practice: S.G. Zybelin, D.S. Samoilovich, M.Ya. Mudrov, I.E. Dyadkovsky, S.P. Botkin, zemstvo doctors. Particularly noteworthy is the “Sermon on the piety and moral qualities of the Hippocratic physician”, “Sermon on the way to teach and learn practical medicine” by M.Ya. Mudrova and the works of N.I. Pirogov, representing an “alloy” of love for one’s work, high professionalism and care for a sick person. The “holy doctor” F.P. became universally famous. Haaz, whose motto was “Hurry to do good!”
The humanistic orientation of the activities of Russian doctors is described in many ways in the works of writer-doctors A.TT. Chekhova, V.V. Veresaeva and others.
Morality is one of ancient forms social regulation of human behavior and human relationships. A person learns basic moral norms during his upbringing and perceives following them as his duty. Hegel wrote: “When a person commits this or that moral act, then by this he is not yet virtuous; he is virtuous only if this mode of behavior is a permanent feature of his character.”
On this occasion, Mark Twain noted that “we do not use our morality very well on weekdays. It always requires repairs by Sunday.”
A morally developed person has a conscience, i.e. the ability to independently judge whether his actions correspond to the moral standards accepted in society, and is guided by this judgment when choosing his actions. Moral principles are especially necessary for those specialists whose objects of communication are people.
Some authors believe that there is no special medical ethics, that there is ethics in general. However, it is wrong to deny the existence of professional ethics. Indeed, in each specific area social activities people's relationships are specific.
Each type of work (doctor, lawyer, teacher, artist) leaves a professional imprint on the psychology of people, on their moral relationships. Interesting Thoughts About Communication moral education Helvetius also spoke about the professional division of labor. He said that in the process of education one must know “what talents or virtues are characteristic of a person of a particular profession.”
Professional ethics should be considered as a specific manifestation of general ethics in special conditions specific activity Professional ethics is a branch of science about the role of moral principles in the activities of the corresponding specialist, including issues of humanism, problems of duty, honor and conscience. The subject of professional ethics is also the study of the psycho-emotional traits of a particular specialist, manifested in his relationships with sick people (disabled people) and with his colleagues against the background of certain social conditions.
The peculiarities of the professional activity of a doctor determine that in medical ethics, universal human norms of morality and justice are always expressed to a relatively greater extent, in any case, more than in the ethical standards that regulate the activities of people of other professions.
The norms and principles of medical ethics can correctly guide a medical worker in his professional activities only if they are not arbitrary, but scientifically substantiated. This means that various recommendations regarding the behavior of doctors, medical practice, need theoretical (to the point of "impimmy.
Medical ethics must be based on a deep understanding of the laws of natural and social life of man. No connection to science moral standards in medicine they turn into groundless compassion for humans. A doctor's true compassion for a sick (disabled) person must be based on scientific knowledge. In relation to a sick (disabled) patient, doctors should not behave like inconsolable relatives. According to A.I. Herzen, doctors “can cry in their hearts, take part, but to fight the disease you need understanding, not tears.” Being humane towards sick people (disabled people) is a matter not only of the heart, but also of medical science and the medical mind.
Some of the failed doctors so skillfully coordinate their behavior with the needs of medical ethics that it is almost impossible to reproach them for not having a vocation for medicine. We are talking about “that coldly businesslike accounting, indifferent attitude towards the most acute human tragedies,” wrote the famous domestic surgeon S.S. Yudin, “when behind the guise of so-called professional restraint and restrained courage they actually hide selfish insensitivity and moral apathy, moral squalor.”
The most important principles of medical ethics

A humane attitude towards a sick (disabled) person, expressed in the readiness to always come to the aid of everyone in need, in the need to comply with the Hippocratic requirement - not to harm, to spare the psyche of the sick (disabled) person, to try not to cause him pain.
Compliance of the doctor's actions public function, the goals and objectives of medicine, according to which a doctor cannot, under any pretext, participate in actions directed against physical and mental health and life.
The duty of a doctor is to fight for the physical and mental perfection of people. Self-sacrifice and heroism in the name of human health and life should be the rule of medical behavior.
The duty of a doctor is to help everyone, regardless of gender, nationality, race, political and religious beliefs.
The principle of solidarity and mutual assistance between all doctors.
The principle of maintaining medical confidentiality.

Many of the listed principles are universal, i.e. are typical for the activities of any specialists who communicate with people, including the sick and disabled.
The problem of the relationship between doctor and patient (disabled person) has always been important issue medicine at all stages of its development.
Already in the ancient manuscripts of Egypt and India there are instructions about what kind of moral qualities a doctor should be, what rules he should follow in his attitude towards patients and colleagues. An ancient Indian saying says: “To the sick the doctor is a father, to the healthy he is a friend. When the illness has passed and health has been restored, he is a guardian.”
A very curious prayer of a doctor dating back to the 12th century has been preserved. It says: “Give me love for people, deliver me from greed, vanity, so that they do not mislead me and prevent me from benefiting people, preserve me the strength of my body and my soul, so that I can help the poor and the rich, the good and to the evil, enemy and friend, may I always see only a person in every sufferer.”
Issues of medical ethics occupied a prominent place in the history of Russian medicine. For the first time, medical practice in Russia was regulated under Peter I. Already in his first decrees, attention was drawn to what ethical considerations doctors should be guided by when performing their duties. One of Peter’s decrees says: “So that the doctor has a good foundation and practice in his doctorate, so that he behaves sober, moderate and willing, and in necessary cases can perform his rank both night and day... Every doctor has the first duty to be a lover of humanity and in any case be ready to provide help to people affected by illnesses.”
The best representatives of domestic medicine Zybelin, Mudrov, Botkin and others in their works paid a lot of attention to the issues of a doctor’s behavior, the moral qualities that are necessary for him to enjoy authority. The famous Moscow doctor Haaz at the beginning of the 19th century. wrote: “The surest path to happiness is not in the desire to be happy, but in making others happy. To do this, you need to listen to the needs of people, take care of them, not be afraid of work, helping them with advice, in a word, love them, and the more often you show this love, the stronger it will become.”
Every profession requires a calling. This is especially necessary for specialists who work with people. The great Russian clinician Mudrov believed that acquiring the profession of a doctor should not be a matter of chance, but a calling. He wrote: “A mediocre doctor brings more harm“than the benefit: patients left without his medical help can recover, but those who use this doctor die.”
The famous Russian writer K. Paustovsky described the concept of “vocation” as follows: “Healing is not a craft or an occupation, but the fulfillment of a duty. Healing is a calling to fulfill one’s duty.” Let me remind you that the word “calling” comes from the word “call”.
Honesty, truthfulness, spiritual purity, a sense of moral responsibility to one’s conscience, the team, and society are the main things that measure the requirements for any specialist, what determines the measure of their value, their understanding of their duty.
Issues of deontology should be considered in terms of implementing the principles of behavior of certain specialists in their professional activities. In this regard, the general ethics of debt becomes important. “We always have one anchor, from which if you don’t yourself, you will never break free - a sense of duty” (I.S. Turgenev). In the words of L.N. Tolstoy there is a statement about a sense of duty, personal responsibility each person before others: "The purpose of life is good. Living for others seems difficult just as it is difficult to work. The more you serve others (with effort), the more joyful it is; the more you serve yourself (without effort), the harder life is." V. Goethe has these wonderful words: "Duty is love for what you command yourself. How can you know yourself? Not by contemplation, but only by activity. Try to fulfill your duty, and you will find out what is in you."
The duty in general and the duty of any specialist in particular is, first of all, to fulfill his duty honestly and well. The explanatory dictionary states that “honor is the internal moral dignity of a person, valor, honesty, nobility of soul and clear conscience.”
The behavior of any specialist should be based on the requirements of humanism. Hence, his highest moral duty must find its manifestation in selfless service to people. The moral duty must express the need to love a person. At the same time, in the activities of any specialist, it is especially important that the performance of duty is organically combined with inner conviction, which turns into habitual everyday behavior. “The moral qualities of a person must be judged not by his individual efforts, but by his daily life” (Pascal).
Fulfilling your duty as a doctor is not an easy task. Fulfilling one's duty requires certain efforts, because duty and the doctor's personal desires do not always coincide. “Man lives on earth not in order to become rich, but in order to become happy” (Stendhal). High moral character is the highest goal of human aspirations.
Fulfilling a medical duty presupposes the conviction of the need to subordinate one's personal desires to the demands of duty. It also happens in life that a doctor has to sacrifice personal interests if it is necessary to save the lives of others. ON THE. Dobrolyubov said: “It is not the one who should be called truly moral who only endures the dictates of duty over himself, like some kind of heavy yoke, like moral chains, but precisely the one who cares to merge the demands of duty with the needs of his being, who tries to process his own flesh and blood by an internal process of self-awareness and self-education so that they not only become truly necessary, but also provide inner pleasure.”
Some wise sayings:
“Only he lives freely who finds joy in fulfilling his duty” (Cicero);
"Duty! You are a sublime great word. This is the great thing that elevates a person above himself” (E. Kant);
“There is no other greatness than the greatness of a fulfilled duty, there is no other joy” (E. Renan).
Modern development of medical technology, laboratory and instrumental research methods leads to the replacement of direct “doctor-patient” contacts with “doctor-device-patient” relationships. There is a concern that the doctor, trusting technology, ceases to improve his knowledge, that technology can affect the relationship between the doctor and the patient and lead to a disruption in the optimal psychological contact between them. Therefore, the high culture of a doctor, the combination of developed clinical thinking and modern scientific knowledge acquire an emphasized deontological significance. The device should not obscure the patient’s identity.
“The crisis of man...is not rooted in human nature itself; it is not some inherent property of it...; no, it is rather a crisis of civilization or culture, which is the cause of a deep discrepancy between human thinking and behavior, on the one hand, and the changing real world- with another. And this crisis - with all its depth and danger - can still be overcome” (A. Peccei).

11.3. Personality (doctor's authority)

A person who thinks only about himself and seeks his own benefit in everything can be happy. If you want to live for yourself, live for others
Seneca

The authority of the doctor plays a big role in establishing optimal psychological contact with the patient, and therefore largely determines the effectiveness of treatment. At all stages of healing, good contact established between the patient and the doctor is extremely important. The lack of such contact may be one of the main reasons for incorrect diagnosis and unsuccessful treatment. You have to trust the doctor completely. It is very difficult to treat a doubtful patient. V.V. Veresaev pointed out that “a doctor may have a remarkable recognition talent, be able to grasp the most subtle details of his prescriptions, and all this will remain fruitless if he does not have the ability to subjugate the soul of the patient.” Thus, there is no doubt that the psychological compatibility of the doctor and the patient plays a leading role in the healing process.
In this regard, the need to gain the patient’s trust is of great importance. The prerequisites for the emergence of a positive psychological relationship between doctor and patient are, undoubtedly, the qualifications, experience and skill of the doctor. However, qualification serves only as a tool, the use of which, with greater or lesser effect, depends on other aspects of the doctor’s personality. This stems from trust in the doctor. After all, “the doctor is the only person to whom we, without embarrassment, dare to tell everything about ourselves” (Moore).
Trust in a doctor is a dynamic, positive attitude of a patient towards a doctor, when the patient sees that the doctor has not only the ability, but also the desire to help him the best way. During the treatment process, the patient must become an ally of the doctor. M.Ya. Mudrov in his work “A Word on the Way to Teach and Learn Medicine” wrote: “Now you have experienced the disease and know the patient, know that the patient has also experienced you and knows what you are like. From this you can conclude what kind of patience, prudence and mental tension are needed at the bedside of a patient in order to win all his trust and love for himself, and this is most important for a doctor.”
The authority of a doctor is the result of high medical professionalism, high moral qualities and high culture.
Of course, any specialist must have good knowledge and extensive professional experience. High professionalism requires a lot of systematic work. The entire life of any specialist is a constant improvement of his knowledge. However, development and education cannot be given or communicated to any person. Therefore, anyone who wants to join them must achieve this through his own activity, on our own, own voltage. Polish physician Kslanovich writes that a doctor who does not look into books should be more wary of illness. An important task in the learning process is to teach a person to think. A.M. Gorky said: “Knowledge is necessary not only in order to know, but to act meaningfully.”
Only in work, in overcoming obstacles, are professional knowledge and skills, true character formed, and high morality is cultivated throughout life. A person must engage in self-education. Only then is a constant, meaningful psychological readiness to act as one’s conscience dictates and a sense of duty dictates. Of course, a solid layer of professional knowledge and experience is required. “Intelligence consists not only in knowledge, but also in the ability to apply knowledge in practice” (Aristotle).
A medical worker gains the trust of patients if he, as a person, is harmonious, calm and confident, but not arrogant, and if his behavior is persistent and decisive, accompanied by human participation and delicacy. The need to be patient and control oneself places special demands on him.
The balanced personality of a doctor is for the patient a complex of harmonious external stimuli, the influence of which takes part in his recovery. In general, we can say that the patient loses confidence, and the doctor loses his authority, if the patient gets the impression that the doctor is what is called " bad person" Isn’t it about such doctors that Voltaire said: “Doctors prescribe medicines about which they know little, for diseases about which they understand even less, and feed them to people about whom they know nothing at all.”
The circumstances of the work force the doctor to be a kind of actor. No matter the patient, for the doctor it is not only a new disease, unique in its details, but also a special personality. What a range of temperaments and characters; everyone has their own way of thinking. And the doctor must have a special approach to everyone. In this regard, the words of K.S. are very consonant. Stanislavsky: “...Playing in front of a full and sympathetic audience is the same as singing in a room with good acoustics. The viewer creates, so to speak, spiritual acoustics. He receives from us and, like a resonator, returns to us his living human feelings.”
It is very important for a doctor to know the patient’s personality reactions that are formed during illness. Therefore, doctors must be good psychologists and psychotherapists. There is no doubt that the disease affects the psyche of patients to a certain extent. Each patient has his own psychology, his own attitude towards others, himself and his illness. It is no coincidence that Academician Mirotvortsev once said that “there are no greater egoists than the sick...”. Consequently, if mental factors are of such great importance in therapeutic activities, then it is necessary to study methods of their knowledge. As G.A. said Zakharyin: “...the doctor must paint a psychological portrait of the patient.”
Attaching great importance to the state of the nervous system and psyche in resisting pathogenic influences, we must treat patients with care. It is recommended not to injure or frighten patients, to calm the excited nervous system and to subordinate the patient to your psychotherapeutic influence.
A sick person expects affection and consolation, and sometimes even tenderness. At the same time, being humane to people and to the sick is a matter not only of the heart, but also of the mind. Zweig's discussions about different types of compassion are interesting. He writes: “...there are 2 types of compassion. One is cowardly and sentimental, it is, in essence, nothing more than the impatience of the heart, rushing to get rid of the painful sensation at the sight of someone else’s misfortune; this is not compassion, but only an instinctive desire to protect one’s peace from the suffering of the patient. But there is another compassion - true, which requires action, and not sentimental experiences, it knows what it wants and is determined, through suffering and compassion, to do everything that is humanly possible and even beyond it.”

A sick person is, to a much greater extent than a healthy person, susceptible to various kinds of suggestive influences. Even a careless gesture by a doctor can give a patient a distorted idea of the severity of the disease, while an encouraging word can instill faith in recovery. “If after talking with a doctor the patient does not feel better, then this is not a doctor” (Bekhterev).
Unfortunately, there are still doctors who are unworthy of the humane medical profession. A.P. Chekhov paid a lot of attention to issues of medical deontology. However, in defending medicine and doctors, did this mean that all doctors were some kind of living embodiment of the commandments of Hippocrates? Such serene goodness would not be at all in the Chekhov spirit. Everyone will immediately remember Ionych, Doctor Chebutylka and Na from “Three Sisters”, a whole gallery of other characters from his stories. Chekhov is far from striving to defend the honor of his uniform at all costs and does not share the views of dissector Pyotr Ignatievich from “A Boring Story,” according to whose deep conviction “the best science is medicine, the best people are doctors, the best traditions are medical.” . He saw plenty of ignoramuses and boors among doctors, as well as among people of other professions. If a doctor is not only a knowledgeable person, but also a decisive, sincere person who takes the grief and suffering of his patient to heart, then personal charm is added to his professional skill. The authority of such a doctor and faith in him have a beneficial effect on the patient’s health and strengthens his will. Yu. German in his work “The Cause You Serve” wrote: “A doctor should not be boiled beef, but an energetic, strong person who is pleasant to obey. You are obliged to be a moral hero, a legend, a fairy tale, and not oatmeal jelly... You are also obliged to act with your personality, and not just with sweat or potions.”
Character traits that contribute to a doctor's authority
Nobility of soul. “Those of the people are glorified among the people because they are noble by nature” (Ibn Sipa).
The ability not only to teach others, but also to encourage them. “Encouragement after reprimand is like the sun after rain” (W. Goethe).
Before you give advice to others, know yourself. “First of all, teach yourself, then you will learn something from others” (W. Goethe).
Commitment. “When a person commits this or that moral act, then by this he is not yet virtuous; he is virtuous only if this mode of behavior is a permanent feature of his character” (Hegel).
Appearance, the doctor’s behavior, his manner of talking to the patient. Good behavior and a calm, confident voice of a doctor are important conditions for his authority. Remember that “behavior is a mirror in which everyone shows his own image” (W. Goethe). You should not rush or rush when communicating with a patient. “Be wise: those who hasten are in danger of falling” (W. Shakespeare).
Ease of communication. “Simplicity is not only the best, but also the noblest” (Fontane).
Purposefulness, conviction. “We recognize a person who changes his views to please the first person he meets as trashy, vile, and without any convictions” (N. Dobrolyubov).
Integrity. “Whoever does not understand the principles in all their logical completeness and consistency, not only has confusion in his head, but also nonsense in his affairs” (N. Chernyshevsky).
Conscience, honor. Developing a sense of conscience always helps to fulfill one’s duty, warns one against wrong, immoral actions, and prompts honest, worthy and just actions. “The law that lives in us is called conscience; conscience is, in fact, the application of our actions to this law” (E. Kant).
Be true, truthful! * Wisdom is only in truth” (W. Goethe).
Sympathy. “Compassion breeds trust, and trust is the key to the heart” (Wodenstedt).
Strength of character. “The greatest firmness is the greatest mercy” (W. Goethe).
Shyness. “Shame sometimes prohibits what the laws do not prohibit” (Seneca).
Generosity, self-control, patience. “Patience is the art of hoping” (Schleiermacher).
Honesty. “An honest man, sitting in the judge’s chair, forgets about personal sympathies” (Cicero).
Justice. “There are two principles of justice: to harm no one and to benefit society” (Cicero).
Strict adherence to the principles of deontology and medical ethics. “Do to the patient only what you would do in this case to yourself or to your loved one” (N. Petrov).
Clear statement of the task and monitoring its implementation. Remember that “advice is like castor oil: it’s quite easy to give, but damn unpleasant to take” (B. Shaw).
Wisdom, which is the daughter of experience. “If you want to be smart, learn to ask intelligently, listen carefully, answer calmly and stop talking when there is nothing more to say” (Lavater).
Compassion, mercy, kindness. “Kindness is a quality, the excess of which does not harm” (D. Galsworthy).
Truthfulness, humanity, kindness. “Kindness is the most necessary seasoning for everything. The best qualities are worthless without kindness” (L.N. Tolstoy).
Modesty, selflessness. “Be modest - this is the kind of pride that least irritates others” (Cervantes).
Some character traits that negatively affect the authority of a doctor
Ignorance, low professional and moral qualities.
Cowardice. “Cowardice is the lot of the insignificant. He whose heart is strong, whose actions are in accordance with his conscience, will defend his principles to the end of his life" (Paine).
Unscrupulousness, dishonesty, deception. “The father of lies is undoubtedly the devil, through negligence he did not patent his idea, and now his enterprise suffers greatly from competition” (B. Shaw).
Unscrupulousness, arrogance, stubbornness. “Only fools and dead people never change their minds” (Lowell).
Rudeness, tactlessness. “Anger is momentary madness” (Horace).
Impoliteness. “Impoliteness between equals is unsightly, but on the part of superiors it is tyranny” (Lope de Vega).
Ambition, vanity. “Ambition is the immodesty of the mind” (Devenanath). “Pride that dines on vanity, suppers with contempt” (Franklin).
Cynicism. “The cynic is the human owl, awake in the dark and blind in the light, preying on carrion and disdaining noble game” (Beecher).
Hypocrisy. “Flattery is a counterfeit coin that circulates only thanks to our vanity” (Larashefouq).
Inattention, indifference.
Arrogance, stubbornness. “The arrogant and stubborn person does everything in his own way, does not listen to anyone’s advice and soon becomes a victim of his own delusions” (Aesop).
Injustice, dishonesty, cowardice, immodesty. “A lack of modesty is a lack of intelligence” (A. Paul).
Selfishness. “Personal egoism is the father of meanness” (M. Gorky).
Inhumanity, immodesty, meanness, boasting. “Do you want people to believe in your virtues? Do not boast about them” (B. Pascal).
Verbosity, talkativeness. “Those who do not know how to think are talkative” (R. Sheridan).
Intemperance, deceit, laziness, weak character, boastfulness.
Anger, pessimism, envy, haste in conclusions, haste in judgments and actions, frivolity, cowardice, selfishness, rudeness, arrogance.
Ambition. “Insatiable ambition darkens a person’s mind, and he does not notice the dangers that threaten him” (Aesop).
Narcissism. “A narcissistic person is something between a fool and an impudent person, he has something of both” (J. La Bruyère).
Stubbornness.
The lack of optimal contact between doctor and patient has a negative impact on the psychological and somatic state of the patient and can be a source of conflict situations. Let us remember the illness of Kitty Shcherbatskaya, brilliantly described in the novel by L.N. Tolstoy's Anna Karenina. The visit of the famous professor, who violated all the principles of deontology and medical ethics, led not only to a lack of contact with Kitty, but also to complete hostility towards him. As a result, after the examination, “Kitty stood in the middle of the room. When the doctor came out, she flushed and her eyes filled with tears. Her whole illness and her treatment seemed to be such a stupid, even funny thing; her treatment seemed to her as funny as putting pieces together broken vase. Her heart was broken. Why do they want to treat her with pills and powders?”
The destiny of every person is often found in his character. The character of each person influences the happiness of other people, depending on whether it has the property of causing harm or benefit.
The famous domestic therapist Kassirsky wrote: “A person who has entered the path of a doctor must be a bearer of high moral and ethical qualities. A young doctor has to pass two tests in life: the test of success and the test of failure. The first threatens self-delusion, the second - capitulation of the spirit: perseverance in the face of these trials depends on the personality of the doctor, his ideological principles, beliefs and moral ideals.”
The authority of any specialist greatly benefits if he is not afraid of responsibility. Anyone who is afraid of responsibility cannot decide the fate of people. A person achieves his greatest success when he sets a good example. No one should give others advice that he himself does not follow. A doctor's personal example always has a stronger impact than a sermon. “Follow my deeds, not my words” (Titus Livius). In this regard, it is quite true to say that the teacher is not the one who teaches, but from whom one learns.
The ability to eliminate your mistakes and shortcomings is of great importance. Authority benefits greatly if mistakes are recognized, corrected, and not repeated in a timely manner. It should be remembered that it is easy to move from small mistakes to major vices. Awareness of your mistake is one of the main means of self-education and a lesson for others. A thinking person draws no less knowledge from his mistakes than from his successes. Stubbornness is the unwillingness to correct your mistakes and listen to the opinions of other people.

11.4. Physician culture

Art has a moral effect not only because it provides pleasure through moral means, but also because the pleasure provided by art itself serves as the path to morality I.F. Schiller
Representatives of professions who have constant contact with healthy and sick people (disabled people) must be carriers of high culture, remembering that “culture and external gloss are completely different things” (Emerson).
It should be natural for all specialists to strive for knowledge of all that is beautiful and sublime. “The decisive and determining quality of clinical work is not the research methodology, but the culture of the doctor’s own personality” (Bilibin). All this is necessary as one of the conditions for effective professional activity.
Empathy, excitement when touching the world of art (painting, music, theater, works of classical literature) is a comprehensive development of the individual, the formation of high morality, effective contact with the sick (disabled). Art brings harmony to the personality of a particular specialist, accelerates the search for the right solutions in seemingly hopeless situations, calms, and resolves spiritual conflicts. The sense of beauty protects a specialist from extremes and rationalism, revives his creative powers, activates thought, and humanizes professional activity. It is mental culture that provides refined feelings. “An enlightened mind ennobles moral feelings: the head must educate the heart” (Schiller).
If a doctor ceases to be interested in poetry, music, and the humanities, then there is no doubt that his interest in the world around him, in particular in the sick person, is fading. Indifference to works of art weakens the feeling of empathy, contributes to the emergence of such negative moral qualities as rudeness; he will perceive the patient’s suffering only with his mind. In this regard, the words of the famous Russian artist Levitan that “a diseased heart can only be treated with the heart” are very consonant.
Sidenagam, this English Hippocrates, was once approached by a young physician with a request for advice on what books to read in order to become a good doctor. “Read, my friend, Don Quixote by Cervantes - it’s a wonderful, good book, which I myself often re-read,” answered the famous doctor.
A doctor, when communicating with patients (disabled people) who are representatives of various segments of the population, must be fully prepared in order to always find general theme for a conversation that could become a prerequisite for successful treatment.
In shaping the moral character of doctors, the cultivation of a culture of feelings, and in particular, familiarization with the world of beauty, is important. As Aristotle pointed out, “...music is capable of exerting a certain influence on the ethical side of the soul.” V.F. Odoevsky said that “music has a greater connection with the moral actions of a person than is usually thought.”
For a doctor, the ability to perceive artistic phenomena is important as one of the means of developing clinical thinking. D. Diderot wrote: “Imagination! Without this, one cannot be either a poet, or a philosopher, or an intelligent person, or a thinking being, or just a person. Imagination is the ability to conjure up images. A person completely lacking this ability would be a stupid person.” By developing imagination, intuition, fantasy, active artistic perception develops the skills to think associatively. A doctor, as the famous Russian surgeon N. Burdenko noted, with a vivid imagination makes fewer mistakes than an honest pedant and only a hardworking researcher. Passion for one-sided practical or scientific activity, as a rule, leads to one-sided personal development and is condemned even by those specialists who themselves did not avoid such one-sidedness in their intellectual development, although they were able to achieve outstanding success in the beer of science. Charles Darwin recalls, not without regret, that he “almost lost the artistic taste for paintings and music and therefore, if he could start his life all over again, he would make it a rule to read some poetic work at least once a week or listen to good music." He believed that “the loss of sensitivity to such things is a loss of happiness, it is possible that it has a harmful effect on the intellect, and, in any case, it causes irreparable damage to the development of human morality, weakening its emotional side.”
Prominent domestic surgeon S. Yudin emphasized that “Monotonous work without the life-giving shocks of poetry, art and travel creates tranquility, a habit of dilapidated antiques, reconciliation with vulgarity and petty goals, that in such conditions one gradually develops not an interest in life, but an interest in her ghosts: material wealth, money, ranks, orders and gossip. We have seen so many times how promising and even bright talents faded away and died out, how they died not from alcohol - this most terrible scourge of the former Russian reality, but from boredom and monotony.”
There are people who judge medicine no worse than patients, because they themselves have been visited by illness more than once, and at the same time they understand no less than doctors, because they personally listened to patients and sat at the bedside of the suffering. They strive to tell others about all this, and the more accessible, the better. These people are writers and doctors. As Andre Maurois rightly said at the International Congress of Doctors in Paris: “There is a deep kinship between writers and doctors, since both treat human beings with passionate attention, and both forget about themselves for the sake of people.” Therefore, it is no coincidence that such great writers as Rabelais, Schiller, Maurois, Copan Doyle, Chekhov, Veresaev, Bulgakov and others were physicians. In one of his essays, Andre Maurois wrote: “A great writer must cover all aspects of human existence.”
Look how the classics of Russian literature, being not doctors, so fully, vividly, deeply, but at the same time simply and naturally presented a description of a number of painful conditions. Let us remember the novel by I.S. Turgenev “Fathers and Sons” or the story of D.V. Grigorovich "Karenin's Dream". In the story by L.N. Tolstoy’s “The Death of Ivan Ilyich” describes the inner world of a patient suffering from cancer. A.I. Kuprin, in his story “In the Circus,” perfectly described the clinical picture of an attack of angina pectoris in a circus athlete.

P. Chekhov said that “a real writer is the same as an ancient prophet: he sees more clearly than ordinary people.”
V. Veresaev studied at St. Petersburg University at the Faculty of History and Philology. In 1888 he entered the Faculty of Medicine at the University of Dorpat. In his Autobiography, he later explained his desire to become a doctor: “My dream was to become a writer, and for this it seemed necessary to know the biological side of man, his physiology and pathology; In addition, the specialty of a doctor made it possible to get close to people of various strata and ways.” He further said: “Since then, for more than two centuries: medicine has taken a gigantic step forward, it has become a science, and yet what a huge area of osmosis there is in it, where even today the best teachers are found Cervantes, Shakespeare, Tolstoy, who have nothing to do with medicine.”

A deep knowledge of life in all its manifestations, combined with the greatest and inquisitive observation, allowed writers who did not know medicine to quite clearly and clearly describe the clinical picture of a number of painful conditions.
9 years before Veresaev began his “Notes of a Doctor,” in 1886, a cast iron sign “Doctor Chekhov” appeared on the doors of a two-story mansion in Moscow. The future writer considered medicine to be the main thing in his life. He valued and was proud of the title of doctor. When the Russian Academy of Sciences elected him an honorary member, he wrote to his wife Olga Leonardovna Knipper, an actress of the Moscow Art Theater: “... I first wanted to make you the wife of an honorary academician, but then I decided that being the wife of a doctor was much more pleasant.”
A.P. Chekhov created exceptionally accurate and vivid prose, in which artistic and scientific medical elements merged. French doctor Henri Bernard Duclos devoted his doctoral dissertation to the topic “Anton Chekhov - doctor and writer.”
“In Chekhov’s works,” Duclos wrote, “there are many patients; there are descriptions of individual cases and clinical observations. But we are not interested in pathological and epidemiological details, but in the ability with which Chekhov, with a few strokes, a few words, without even resorting to scientific terms, allows the medical reader to recognize the symptoms of the disease and make a diagnosis... It is not enough for a writer to see people, he must be able to observe and grasp their most important features.”
At the end of this chapter, it is appropriate to quote the words of N.G. Chernyshevsky: “Scholarly literature saves people from ignorance, and elegant literature saves people from rudeness and vulgarity.”

11.5. Conditions promoting optimal psychological contact between a doctor and a patient (disabled person)

When a person does not know which pier he is heading towards, not a single wind will be favorable for him.
Seneca

These conditions include:
1. The authority of a specialist who must be trusted undividedly. The specialist must not only dispel the doubts and fears of the patient (disabled person), reassure him, but also be able to hide his grief and dissatisfaction, show calmness and self-control. In relation to each patient (disabled person), the specialist’s reaction must be quick, sometimes almost instantaneous, and the solution to the issue must be extremely accurate. The authority of a specialist is the result not only of high professional and moral qualities, but also of great culture.
“An enlightened mind ennobles moral feelings: the head must educate the heart” (Schiller). A specialist, when communicating with sick (disabled) people who are representatives of different segments of the population, must be fully prepared in order to always find a common topic for conversation, which could become a prerequisite for successful contact.
Cases of conflict situations in the relationship between a specialist and a patient (disabled person), unfortunately, still occur. The conflict process is usually two-way. Sometimes sick (disabled) people can also be guilty. If a specialist is a well-mannered and educated person, if he is a good psychologist, then he should have enough prudence and tact in communicating with the so-called conflict patients (disabled people). And vice versa, if he does not find a common language with the sick (disabled) person, conflicts, if they complain about him, then this is direct evidence that there are serious problems in his education or upbringing.

Finding a common language with a sick (disabled) person is sometimes difficult: sometimes only kindness and cordiality, courtesy and attention do not help. In these cases, the specialist must draw the patient’s (disabled person’s) attention to some unusual aspect of his knowledge, unobtrusively show the patient (disabled person) such a good knowledge of non-medical issues that he, considering himself an expert on them, did not expect to find them in a specialist.

Some advice in the form of statements from wise people for the purpose of a full conversation with sick (disabled) patients:
“Let me speak freely if you want to hear the truth!” (Public Sir);
"WITH ordinary people talk less about theories, and act more according to them” (Epictetus);
“Live with people so that your friends do not become enemies, and your enemies become friends” (Pythagoras);
“Whoever is so deaf that he does not even want to hear the truth from a friend is hopeless” (Cicero);
“There is only one way to become a good conversationalist - to be able to listen” (K. Marley);
“Having silenced a person, you have not yet convinced him” (K. Marley).

Trust in a specialist is a dynamic, positive attitude of the patient (disabled person) towards him, due to the expectation that the specialist has the ability, means and desire to help the patient (disabled person) in the best possible way. As Bedengitedt said, “empathy breeds trust, and trust is the key to the heart.”

A medical worker gains trust from patients (disabled people and other cases) if he, as a person, is harmonious, calm and confident but not arrogant, and if his behavior is persistent, quick and decisive, accompanied by human participation and sharing The doctor is obliged to subjugate the soul of the patient.

Non-standard, individual approach (conversation) to patients (disabled people). No matter how sick (disabled), for a specialist it is not only a new disease (disability) that is unique in detail, but also a special personality. Everyone has their own way of thinking. People are different in age, education, upbringing, profession. And the specialist must have a special approach to each of them.

Each person has his own character, And the healer will be right, If, studying these and these properties, He will keep any in mind.
Ibn Sima

The need to take into account the uniqueness of the patient’s (disabled) psyche. It is no coincidence that Academician Mirotvortsev said: “There are no greater egoists than the sick.” There is no doubt that illness (disability) affects to a certain extent the psyche of the patient (disabled person). Hence the different psychological reactions to illness (disability). Attaching great importance to the state of the nervous system, we must take care of the sick (disabled). It is recommended not to injure or frighten patients (disabled people), calm their excited nervous system and subordinate the patient (disabled person) to your psychotherapeutic influence,

There are people who judge medicine well - writers. A.P. Chekhov could look at medicine from three points of view - the writer, the doctor and the patient. In his works, he paid a lot of attention to mental suffering, the “mental” pain of a person. Practical medical activity helped him in a number of novels and stories to describe the inner world and psychology of a sick person. A.P. Chekhov describes two aspects: the influence of bodily pain on the patient’s psyche (stories “A Boring Story”, “Compensation Disorder”, “Case from Practice”, etc.) and the influence of the psyche on the development of physical illness (stories “Gusev”, “Wife”, etc. .).
Each patient (disabled person) has his own psychology, his own attitude towards the environment, towards himself and his illness (disability). Therefore, every specialist who works with people must be a good psychologist. Failure to comply with these principles may result in medical errors and conflict situations. An example is the medical history of Natasha Rostova, the heroine of the novel War and Peace. L.N. Tolstoy brilliantly described Natasha's mental illness, caused by a quarrel with Prince Bolkonsky, which doctors mistakenly regarded as a physical illness.

A sick person is much more susceptible than a healthy person to suggestive influences of various kinds, both positive and negative. A careless gesture by a doctor can give the patient a distorted idea of the severity of the disease, but an approving word, on the contrary, can instill faith in healing.

The doctor's word acts as a material means. “For a person, a word is the same real irritant as all the others, and therefore can cause all those reactions of the body, as well as to any real irritant” (I.P. Pavlov). The word heals and the more effective it is, the more significant the doctor’s personality. Bernard Shaw said that “there are 50 ways to say the word “yes” and 50 ways to say the word “no”. However, it should also be remembered that “words hurt faster than they heal” (Goethe). Violations of the principle of an individual approach to patients (disabled people) without taking into account their psychological portrait, especially a careless word, tone, etc., can be a source of so-called iatrogenic diseases, i.e. diseases “born by a doctor”. Words can hurt a person and cause illness, and words can heal someone who is sick. This idea is expressed especially well in Chekhov’s story “The Wolf”.
Panaev in his literary memoirs cites the following historical incident. The famous doctor Spassky was returning from the dying Pushkin. The patient he then visited was in very serious condition. He asked the doctor: “Tell me, is there any hope, doctor? Can I get better? “None,” Spassky replied. - “What is it!” - “Everyone dies, father. So Pushkin dies. Do you hear? Pushkin! So now you and I can die,” the patient groaned and lowered his head onto the pillow and died almost at the same hour as Pushkin.
Another example. “Z goes to the doctor,” Chekhov describes a case taken from medical practice, “he listens, finds a heart defect. Z dramatically changes his lifestyle, talks only about his illness, the whole city knows that he has a heart defect... he does not marry, refuses amateur performances, does not drink, walks quietly, barely breathing. Eleven years later he goes to Moscow and goes to see a professor. This one finds a completely healthy heart. Z is happy, but he can no longer return to normal life, because he is used to lying down with the chickens and walking quietly, and he is already bored not talking about his illness. I just hated doctors, and nothing more.”
The success of conscious implementation of recommendations and advice is due to the unity of views and actions of the specialist and the patient (disabled person). Unity of spirit, views, will, action - only this is true unity, although unity does not always mean complete uniformity. Where there is no community of interests, there can be no action. “The individual is weak, like the abandoned Robinson; only in society with others can he do much” (Schopenhauer).

Test tasks

Principles of medical deontology.
Principles of medical ethics.
Personality traits of a doctor that determine his authority.
The importance of culture for the professional activity of a doctor.
Conditions that promote optimal contact between the doctor and patients (disabled people).

Medical ethics and medical deontology. Bioethics

The term "ethics" comes from the Greek "ethos", i.e. custom, manners. Another term has almost the same meaning - “morality” (from the Latin “morbus”). Therefore, "ethics" and "morality" are usually used together. Ethics is more often qualified as a science, theory, doctrine of morality and ethics, i.e. as a science about the forms of social consciousness. Prof. A.A. Grando in textbook for students of medical institutes he rightly writes: “Ethics is the science that deals with determining the moral value of human aspirations and actions.” You can give hundreds of definitions of ethics (as well as morality, morality). There are even more discrepancies in the understanding of the term “deontology”. At the First All-Union Conference on Problems of Medical Deontology (1969), organized on the initiative of the Minister of Health of those years, Academician. B.V.Petrovsky and academician USSR Academy of Medical Sciences A.F. Bilibin, who devoted a lot of effort and attention to the problems of ethics and deontology, in opening remarks B.V. Petrovsky defined deontology as “the doctrine of the doctor’s duty not only to the patient, but also to society.” This term came into use and, above all, in scientific works and speeches as a teaching about what should be done, about duty. In fact, the author of the term, the English jurist I. Bentham, in his well-known book “Deontology or the Science of Morality” (early 19th century), considered deontology as a doctrine of what is proper (hence the origin of the term itself) in human behavior. He contrasted deontology with ethics as the science of morality or socially proper behavior of people. Such an understanding of deontology opened up scope for all kinds of individualistic and not always humane activities, and could justify egoistic morality. The author of the term gave it an inhumane orientation, but it became the embodiment of behavior that corresponds to the high purpose and humane activity of a physician. I. Bentham gave his teaching certain normative features, i.e. considered deontology not so much as a theory or doctrine, but as a justification for certain (including pragmatic, egocentric) activities, human behavior as the achievement of a personal, personal goal.

There are still debates about, for example, which concept is more comprehensive - ethics or deontology, and many are inclined to believe that deontology is broader than ethics, since it includes the doctrine, the theory of proper behavior, and the implementation of moral rules, norms, i.e. behavior itself, and ethics is limited only to theory, the development of scientific moral standards, rules, concepts, etc.

Ethics reflects the attitude of people not only towards each other, but also towards facts, events, phenomena in the life of mankind, including science and the application of its achievements in practice. The ethical component arises immediately as soon as the question is raised about the goals of this or that action, action, action, about the interests of a person or group of people. In this regard, it is possible and necessary to talk about the ethical aspect of every sphere of activity and knowledge, including the ethical value of science. Progressive scientists are concerned about the possibility of using the greatest achievements of science to the detriment of themselves and people’s health. The most striking example is the use for military purposes of discoveries in the field of nuclear physics and the creation of thermonuclear weapons. Equally justified are concerns about the use of genetic engineering achievements for inhumane purposes. The same can be said about robotics, bacteriology, immunology, etc.

What has been said about ethics and deontology applies entirely to medicine. It is impossible not to note the blood connection of medicine with the general properties of ethics and deontology, primarily with universal human norms of morality and ethics, which are valid for all political, class and other categories and for various socio-political and economic structures. These are the so-called simple norms of morality and ethics - goodness, love, compassion, respect, mercy, resistance to evil, violence, malice and other phenomena and features of human relations that separate people and destroy the human community. They are often associated with Christian virtues.

Medical ethics and medical deontology, as they are most often referred to, are an expression of high duty, universal humanity in the specific conditions of professional activity.

Unlike all other professions, a doctor or other medical professional deals with a sick person. It should be added - either with a practically healthy person, whom we must protect from diseases, and also with a healthy person, whom we must not only protect from diseases, but also maintain his health, strengthen and improve this health.

There are other specific points. In medicine, unlike other specialties, human affairs and knowledge, only an ethical maximum is permissible, from the standpoint of which one must be both a good doctor and a good person. There are bad doctors, but the very concept of “bad doctor” and “bad person” are excluded from medical ethics and deontology, although public consciousness fully allows such a situation in other professions.

A physician deals not just with the object of his activity - a sick person; health and life are in his hands.

A doctor (of course, a good, real one) must be ready for self-sacrifice, forget the personal in the interests of another person, his condition, his health. Everyone who has written about medical ethics has emphasized this. A.P. Chekhov said that the profession of a doctor is a feat, and not everyone is capable of it.

One of the most important principles of Hippocrates - “do no harm” calls not for self-withdrawal in difficult situations, not for passivity, but obliges one to use all knowledge and experience to save the patient, for his benefit, but always in such a way that his actions do not worsen his condition. This is prudence based on high professionalism, caution and at the same time activity.

Universal human moral categories of honor, dignity, duty, guilt, duty, responsibility and others, passing through the crucible of medical practice, acquire peculiar qualities that are characteristic only of this specialty and give rise to problems inherent only to medicine, for example, the problem of medical confidentiality, intervention without patient consent, euthanasia, experimentation on oneself and on other people, etc.

The connection between professional medical ethics and general ethics is reflected in its definitions. Of the hundreds of definitions, we present the one proposed by A.M. Izutkin back in 1968: “Medical ethics is a branch of science about the role of moral principles in the work of a doctor, about his highly humane attitude towards the patient as a necessary condition for successful treatment and promotion of human health.” 1 . A broader and, so to speak, socially oriented definition is in the collective monograph by Yu.P. Lisitsyna, A.M. Izutkin and I.F. Matyushin (1984), which states that medical ethics considers “... the entire set of moral factors that guide health care workers in all spheres of material and spiritual activity aimed at meeting the needs of society and individuals in preserving and promoting health” 2 .

Before we talk about specific problems, the structure of ethics and deontology, it is proposed not to separate these concepts, but to consider them as one direction, one doctrine - medical ethics and deontology. Medical ethics and deontology, as organically related concepts, deal with moral and moral norms and the principles and rules of conduct of medical workers based on them when fulfilling their civic and professional duty.

These concepts are close, but not identical. From this perspective, ethics (as a science) is a more methodological concept, and deontology (as principles and rules of behavior) is a more methodological concept.

The importance of medical ethics and medical deontology is increasing at the present time, during the period of changes in socio-economic relations, the introduction of market and marketing processes that directly affected healthcare. Proud statements about free medicine for the entire population at the expense of public funds and the right of every citizen to free medical care are becoming a thing of the past. At the expense of the state and the currently introduced compulsory health insurance, only part of the medical services under the so-called state guarantee program is provided (most of the outpatient and part of inpatient medical care, and not even all types of preventive care). Due to government budget cuts, this mandatory program is increasingly limited. At the same time, medical institutions received the legal right to paid services; moreover, they became the financial basis of the so-called voluntary health insurance. Already today, the majority of the population, whose material capabilities have sharply fallen, are not able to receive all the necessary medical care, including medications, due to the extremely increasing cost of drugs.

In such a situation, the postulates about the doctor’s freedom from commercial relations with patients, about the absence of soil for business in medicine, about free ethical, uncontaminated by commercial interests, have lost their basis. moral relations with patients. In fact, the position of a physician in our country at present is not fundamentally different (except for the still much lower salary) from that in other (capitalist) countries. “Communist”, “socialist” medical ethics have sunk into oblivion. This circumstance has brought the general problems of medical ethics and deontology closer to our society, to our healthcare and, in a broader sense, to social policy in the field of public health.

In connection with health care reform, state regulation of paid services and the tariff for medical care in general, the creation of public organizations (associations, unions), the definition of the rights of patients, doctors, insurance bodies and trade union representations to monitor the work of insurers, doctors, and medical organizations are becoming practically important. . The so-called ethical commissions provided for by law (Fundamentals of Legislation on the Protection of the Health of Citizens of the Russian Federation) are of particular importance.

Such organizations operate abroad, and their experience is useful for us. Codes of medical ethics, which will be discussed below, are especially important.

Now about the most important problems of medical ethics and deontology, one of which - payment for medical care - has just been mentioned. The main problem remains relationship between doctor and patient, doctor and patient. This pillar of medical ethics and deontology revolves around the problems of relationships between the doctor (physician) and those surrounding the patient (relatives, loved ones, acquaintances, etc.); doctors with each other and other medical and paramedical personnel (i.e. relationships within the medical environment); physicians (doctors and other medical personnel) with different strata and groups of society, in essence, the problem of the position of the doctor (medical worker) in society. Medical ethics and deontology also include the problems of medical confidentiality, medical error, euthanasia, the right to experiment on oneself (doctor, physician), medical intervention without the consent of the patient, experimentation on humans, organ and tissue transplantation, genetic engineering, witchcraft, paramedicine, etc., which today are usually classified as bioethics.

The annals of the history of medicine have accumulated numerous statements on the main issue of medical ethics and deontology - the requirements of a highly moral, sincere, careful, merciful, sympathetic, of course, highly professional, masterful attitude of the doctor (medic) to the patient. Perhaps there is not a single scientist or practitioner who would not emphasize the necessity of such an attitude. From such judgments and orders, edifications, instructions and advice, entire volumes can be compiled, the content of which comes from the origins of medicine. The appearance of the doctor in them appears morally, mentally and physically clean, modest, restrained, confident, courteous, a friend, adviser and mentor to the sufferer. In the ancient manuscripts of Ayurveda ("Knowledge of Life", India), the outstanding physician of antiquity Sushruta wrote: “A doctor must have a pure compassionate heart, a calm temperament, a truthful character, be distinguished by the greatest confidence and chastity, and a constant desire to do good. One can be afraid of father, mother, friends ", teachers, but should not feel fear of the doctor. The latter should be kinder, more attentive to the patient than father, mother, friends and mentor." 25 centuries ago, the famous treatise of Tibetan medicine “Zhud-shi” said: “The basis of a good doctor is 6 qualities, according to which he must be completely wise, straightforward, full of vows, skillful in external manifestations, diligent in his activities and wise in human sciences ".

Undoubtedly, the well-known Hippocratic Oath, as an example of subsequent oaths, oaths, professional ethical medical promises, etc., has become the quintessence of highly humane moral requirements for a doctor since ancient times. In different translations and interpretations, its individual elements sound differently, but the essence is the same. Its main provisions:

Serve the celebration of life.

Direct the regimen of patients to their benefit in accordance with available strength and understanding.

Maintain medical confidentiality.

Live and work blamelessly.

Consult with teachers and mentors, read them.

Stay true to your oath.

Excerpt from the original text translated by Prof. V.P. Rudneva: “I will direct the regime of the sick to their benefit in accordance with my strengths and my understanding, refraining from causing any harm and injustice... Whatever house I enter, I will enter there for the benefit of the patient, being far from everything intentional, unrighteous, righteous and harmful... I will conduct my life and my art purely and immaculately... Whatever, during treatment, as well as without treatment, I see or hear about human life that should never be disclosed, I I will keep silent about it, considering such things a secret."

One of the founders of epidemiology, the famous Danila Samoilovich, in a speech to students of hospital schools (1782), said: those who are preparing to become doctors must be “merciful, sympathetic, helpful, love their neighbor as themselves, not be stingy... in a word “To become a doctor, you have to be an impeccable person.”

All the authors who brightly, figuratively, sincerely, strongly urge the doctor to be noble, skillful, decisive, calm and compassionate, like the father of medicine Hippocrates (M.Ya. Mudrov, I.E. Dyadkovsky, N.I. Pirogov, M.Ya. Mukhin and others), emphasized one fundamental quality in the relationship between doctor and patient - humanism in its fullest expression. Humanism, in the words of the famous French surgeon L. Leriche, takes as its object the whole person “in the creativity of his mind, in the movement of his intellect, his heart, his anxiety, in his hopes, in his despair. This current of thought must permeate all medicine. This that humanism that a doctor must awaken in himself when he comes into contact with human grief."

Recalling the high requirements in the spirit of medical ethics and deontology for the doctor in his relationship with the patient is especially useful at the present time, when, in the context of the transition to market relations, it is necessary to reconsider the requirements of medical ethics and deontology.

The decrease in the level of ethical and deontological requirements is also confirmed by sociological research. Thus, only 30% of sixth-year students at the evening department of the Russian State Medical University answered that they have a clear understanding of medical ethics and deontology, 35% have a vague, vague idea, and 15% could not answer the question of what it is.

According to R.V. Korotkikh, who defended her doctoral dissertation on medical ethics and medical deontology in 1990, 61% of doctors violate the moral norms of relationships with patients and colleagues, 30% do not respect medical confidentiality, and constantly talk about patients, regardless of the situation, mentioning their names . Among the moral reasons causing dissatisfaction with medical care, 37% of respondents complained about the inattention of doctors, 6% - about rudeness. Patients react very sensitively to the psychological climate in the team of a medical institution, to the relationships of medical staff; a significant part of patients evaluate these relationships negatively. In total, according to R.V. Korotkikh, 60% of the population are not satisfied with their relationships with doctors and other medical personnel. Insufficient attention to the problems of medical ethics and deontology in educational institutions and the indifferent attitude towards them of many senior colleagues in the team lead to difficulties when communicating with patients, especially among novice doctors. It turned out that 11% of the surveyed doctors experience difficulties in collecting anamnesis and contacting patients, 14% in determining prescriptions, 52% in monitoring and fulfilling prescriptions. As rightly noted by R.V. Korotkikh, this indicates insufficient psychological and moral preparation for communication with the patient, which constitutes the most important content of a doctor’s activity.

The rules of medical ethics and deontology in the relationship between doctor and patient arise from centuries of professional experience and universal human qualities.

Violations of these or similar ethical and moral rules often lead to iatrogenicity, self-inflicted illnesses, exacerbation of diseases, mental breakdowns, depression, and sometimes tragic cases. The influence of words on a person, especially on a patient, is generally recognized. The word heals, but it can also kill. V.M. Bekhterev said that if after a conversation or communication with a doctor the patient does not feel better, then this is a bad doctor.

Among other problems of medical ethics and deontology, let us name the relationship between moral and legal, legal, those. included in the legislation, making a number of rules of conduct for physicians law.

There is no insurmountable wall between the moral, ethical rules and norms that are developed and regulated by society, and legal, legal, regulated by laws, the state, for violation of which the perpetrators are subject not only to public censure, but also to various punishments specified by law, up to imprisonment and etc. Moreover, rules and norms that arise and spread as ethical, moral and ethical, often become legal, legal categories, enshrined in law.

The most demonstrative example is the requirement of medical confidentiality. This rule has existed since ancient times as one of the important provisions of the Hippocratic oath and was included in all ethical codes and other documents on the principles and rules of conduct for physicians. Many centuries later, the observance of medical confidentiality began to be included in legislative acts. In 1969, the Supreme Soviet of the USSR adopted a law, or rather, a set of legal provisions “Fundamentals of the legislation of the USSR and Union republics on health care,” which included the observance of medical confidentiality (Article 16 “Obligation to maintain medical confidentiality”). The provision on medical confidentiality is included in the “Fundamentals of Legislation on the Protection of the Health of Citizens of the Russian Federation” (1993). Art. 61 of this law states: “Information about the fact of seeking medical help, the state of health of a citizen, the diagnosis of his disease and other information obtained during his examination and treatment constitute a medical secret. The citizen must be guaranteed a guarantee of confidentiality of the information transmitted to him.” The legislation also included other rules that were considered ethical, moral and ethical, for example, performing surgical interventions without the patient’s consent (Article 34). Art. 43 on biomedical research involving humans as an object, i.e. on experiments on humans, subject to obtaining the written consent of the citizen.

However, perhaps the most striking example of the legislative consolidation of moral and ethical principles was the inclusion in it of the so-called Doctor’s Oath (Article 60), which for many centuries was accepted as a moral obligation. The tradition of such promises, oaths, oaths was resumed in the 60s in a number of medical institutes of the USSR upon receipt of a diploma. In 1971, by Decree of the Presidium of the Supreme Soviet of the USSR, the text of the doctor’s oath was approved, and subsequently a new text of the oath was approved.

An important moral and at the same time legal issue is represented by medical errors, although medical errors were not mentioned in the Criminal Code. However, their

the consequences are often close to criminal acts. Medical errors are usually understood as the consequences of errors without elements of negligence, negligence, dishonesty, or professional ignorance. A number of errors depend on the imperfection of research methods and equipment, atypicality, unusualness of the clinical case, i.e. features of the course of the disease that the doctor did not know or did not recognize, and most often due to the doctor’s little experience and insufficient competence. Iatrogenesis often becomes the cause of medical errors and unprofessional behavior of a physician. To overcome and prevent errors, a self-critical, open analysis of their causes and circumstances is necessary at clinical, clinico-pathological conferences, and in a professional environment. Self-criticism, public recognition of one’s mistakes is an important criterion for the moral qualities of a physician; sometimes it requires personal courage.

N.I. was especially strict about his mistakes. Pirogov. There are even cases of him making his mistakes public. Unfortunately, there are frequent examples of concealing mistakes, moreover, covering up and protecting doctors who have committed such mistakes, sometimes criminal acts prosecuted by law. There is even a special type of insurance - payment for claims for errors that lead to adverse consequences for the health of patients, or for unjustified medical (most often surgical) interventions.

In the US, for example, more than 98% of doctors have malpractice insurance. A detailed register of conditions and examples of errors and an insurance premium rate have been developed. The highest fees are for surgeons and especially for neurosurgeons (from several thousand to tens of thousands of dollars). But insurance policies are issued up to 300 thousand dollars, and sometimes up to 1 million dollars.

The growing social (and economic) importance of medicine, the undiminished number of medical errors and other violations of medical ethics and deontology, including crimes, the high responsibility of doctors and other representatives of our profession to people and society, led to the development of a special type (section) of law - medical law, which included legal aspects of the rights and obligations of physicians. Such a proposal was considered in 1977 at the IV International Medical and Legal Conference in Prague. Today, medical law, the 16th in a row, is recognized along with other types of law (criminal, administrative, civil, labor, etc.).

From the standpoint of medical law, moral and ethical norms and regulations are carefully considered. The problem is especially difficult in practical terms (execution) and complex in theoretical and legal terms (i.e. from the standpoint of medical law). euthanasia, i.e. voluntary death of a patient (usually doomed) at his request and demand. In 1952, an appeal with more than 2.5 thousand signatures was sent to the UN, among which were the names of famous doctors, scientists, and cultural figures from the USA and Great Britain. The appeal spoke of the need to supplement the Universal Declaration of Human Rights with the right of a terminally ill person to demand an easy death for himself. The appeal was rejected by the UN, which declared it inhumane. In response, associations began to be created to push for the adoption of the right to euthanasia. One of these organizations (New York) even drew up a sample will of a patient asking for an easy death: “If there is no reasonable hope that I will be able to recover from a physical or mental illness, then I will that I be allowed to die and not any artificial or other measures were used to save my life."

Naturally, the right to a voluntary, easy death has caused and still causes discussion due to a complex set of legal and moral problems. A number of US states have passed legislation allowing euthanasia. Its implementation under this law requires compliance with many formalities: a statement signed by the patient, certified by three doctors, the right to refuse this request, the exclusion of the use of the law by relatives or medical personnel for mercantile purposes, etc. Although such laws have been adopted, there is practically no information in the press about their application on practice. Our legislation excludes the decision on euthanasia, considering this, like the UN, to be contrary to the requirements of humanity (Article 45 of the Legislation on the protection of the health of citizens of the Russian Federation prohibits euthanasia).

No less controversial and controversial are decisions about transplanting unpaired organs (heart, liver) from a donor who is considered dead. The complexity and severity of the problem are associated with determining the biological death of the donor. The law allows the removal of human organs or tissues for transplantation (Article 47) and national and international criteria for death have been developed, which boil down mainly to the statement of brain death. However, these provisions are not always and not for all specialists convincing. For example, the heart should be taken as early as possible, when it shows signs of functioning, in the belief that the brain has already died irrevocably.

Solving problems of medical ethics and deontology is not always indisputable and is often extremely difficult. For practical use, summaries of rules of conduct for physicians, codes of medical ethics and deontology are compiled. Adherence to these codes is considered mandatory for medical professionals and their corporations. Essentially, the Hippocratic Oath can already be considered a set of rules of conduct for a doctor, i.e. a kind of code of medical ethics and deontology. Since the creation of the UN and the adoption of the Universal Declaration of Human Rights (1948), international medical ethical codes have become more actively and systematically developed. Among them: the “Declaration of Geneva” (1948), supplemented by the World Medical Association in 1968 and 1983; Ten Rules of Nuremberg (1947); Declaration of Helsinki-Tokyo (1964, 1975), International Code of Medical Ethics, adopted in 1949 and amended in 1968 and 1983; 12 principles for the provision of medical care in any health care system, adopted in 1963 and supplemented in 1983, and a number of subsequent additions and revisions of these and other documents. The International (World) Medical Association has taken on a kind of role as coordinator of such codes. The Declaration of Geneva, for example, states that the doctor solemnly promises to “devote himself to the service of humanity” and swears “to maintain throughout his life gratitude and respect for his teachers; to perform professional duties with conscience and dignity, the health of the patient will be the first reward; to respect trusted secrets even after the death of the patient; do everything to maintain the honor and noble traditions of the medical community; colleagues will be my brothers; do not allow considerations of a religious, national, racial, party-political and social nature to come between me and my patients."

Introduction

Medicine and society

The path of any science is difficult, and medicine is especially difficult. After all, it, like no other field of knowledge, does not affect the very lives of people. Often, medical discoveries not only successfully cure specific patients, but also influence the worldview of society as a whole.

There are two opposing points of view on the relationship between medicine and society. Supporters of the first believe that inert public opinion slows down the progress of medicine. Advocates of the second are convinced that the development of medicine violates the harmonious unity of nature and man, is the main reason for the weakening of humanity as a whole and can even lead it to degeneration. In fact, on the one hand, people have become healthier - life expectancy has increased, modern man is larger and stronger compared to his ancient ancestors. On the other hand, medications and vaccines have “weaned” the body from fighting diseases on its own.

However, medicine and society do not oppose each other, being in a complex interaction. Medicine, wittingly or unwittingly, influences society, changing it. From compliance with medical standards in different areas the activities of people depend on the life and health of everyone, and society is interested in taking them into account.

It is necessary to say about the humanizing influence of medicine. Suffice it to remember how much effort doctors had to make to explain to society seemingly obvious things: HIV-infected people should not be outcasts; mental disorders are diseases, not vices, and they require treatment, not punishment.

However, society also dictates its own requirements to medicine. They slow down its development, but within reasonable limits - after all, the result of any process, if it proceeds uncontrollably, is unpredictable and sometimes tragic. The development of gynecology posed the task of limiting abortion. The successes of resuscitation have raised the question for society and doctors as to how long it is necessary to continue reviving an organism that is no longer capable of life. Advances in genetic medicine have sparked debate about the line that scientists should not cross in cloning experiments. Under public pressure, doctors already in the 20th century. began to approach the introduction of new drugs into medical practice with particular rigor. As a result, the laws of “medicine of evidence” emerged, which are now followed by doctors all over the world. The increased value of human life has influenced modern medical ethics and led to the legislative recognition of patient rights.

Hippocratic Oath.

“I swear by Apollo the physician, Asclepius, Hygieia and Panacea and all the gods and goddesses, taking them as witnesses, to fulfill honestly, according to my strength and my understanding, the following oath and written obligation: to honor the one who taught me the art of medicine on an equal basis with my parents, shares with him with his wealth and, if necessary, help him with his needs; ...instructions, oral lessons and everything else in the teaching to communicate to your sons, the sons of your teacher and students bound by obligation, 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 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... Whatever house I enter, I will enter there for the benefit of the patient, being far from everything intentional, unrighteous and harmful.

Whatever, during treatment, as well as without treatment, I see or hear regarding human life that should never be disclosed, I will keep 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 takes a false oath, let the opposite be done to this.”

For two and a half millennia, this document remains the quintessence of physician ethics. Its authority is based on the name of the ancient Greek physician Hippocrates, the “father” of medicine and medical ethics. Hippocrates proclaimed the eternal principles of the art of medicine: the goal of medicine is to treat the patient; healing can only be learned at the patient's bedside; experience is the true teacher of a doctor. He justified an individual approach to each patient. However, if Hippocrates himself saw healing primarily as an art, then later one of Hippocrates’ followers, the ancient Roman physician Galen, approached medicine as a science and as hard work. In the Middle Ages, Avicenna gave an excellent poetic description of the personality of a doctor. He said that a doctor should have the eyes of a falcon, the hands of a girl, the wisdom of a serpent and the heart of a lion.

However, whether Hippocrates had anything to do with medical oaths is not known for certain. During his era, medicine in Greece ceased to be a purely family affair, with the profession being passed on from father to son. Doctors also took students from outside. Doctors have already formed a corporation with its own internal code. (Hence the prohibition on communicating medical knowledge to strangers and the requirement to behave in such a way as not to cast a shadow on colleagues).

There is a widespread belief in society that after graduating from college and taking the canonical Hippocratic Oath, young doctors are legally considered doctors. In fact, it was no longer possible to swear by pagan gods in the Middle Ages. The texts spoken by medical graduates of that time were very different from the traditional Hippocratic Oath. In the 19th century The era of scientific medicine has arrived, the text has been completely replaced. Nevertheless, the basic principles (non-disclosure of medical confidentiality, “do no harm”, respect for teachers) were preserved.

In Russia until the revolution of 1917. doctors gave a “Faculty Promise”, which they signed. It briefly and clearly outlined the concept of a doctor’s duty to the patient, the medical world and society. The “Promise” introduced some new principles of medical ethics, different from both the Hippocratic Oath and subsequent official oaths of the Soviet and Russian oaths. Corporate spirit was not put above all else. In the “Promises” there were, in particular, the following words: “I promise to be fair to my fellow doctors and not to insult their personalities; however, if the benefit of the patient required it, tell the truth directly and without partiality.”

During the Soviet period, graduates of medical universities gave the “Solemn promise of a doctor of the Soviet Union.” The main emphasis in this document was on the responsibilities of a physician - a builder of communism. Oath of a doctor of the Soviet Union: “Receiving the high title of doctor for medical practice, I solemnly swear: to devote all knowledge and strength to the protection and improvement of human health, treatment and prevention of diseases, to work conscientiously where the interests of society require it; be always ready to provide medical assistance, treat the patient with care and attention, and maintain medical confidentiality; constantly improve your medical knowledge and medical skills, contribute through your work to the development of medical science and practice; turn, if the interests of the patient require it, for advice from fellow professionals and never refuse them advice and help; protect and develop the noble traditions of domestic medicine, be guided in all your actions by the princes of communist morality; aware of the danger posed by nuclear weapon for humanity, to tirelessly fight for peace, to prevent nuclear war; always remember the high calling of the Soviet doctor, his responsibility to the people and the Soviet state. I swear to carry allegiance to this oath throughout my life.” After the collapse of the USSR, this ceremony was abolished for several years. Since 1999 Graduates of higher medical educational institutions of Russia take the following oath:

“Fulfill your medical duty honestly, devote your knowledge and skills to the prevention and treatment of diseases, preserving and strengthening human health; be always ready to provide medical care, maintain medical confidentiality, treat the patient with care and attention, act exclusively in his interests, regardless of gender, race, nationality, language, origin, property and official position, place of residence, attitude to religion, beliefs, membership in public associations, as well as other circumstances; show the highest respect for human life, never resort to euthanasia; remain grateful and respectful to your teachers, be demanding and fair to your students, and promote their professional growth; treats colleagues kindly, turns to them for help and advice if the interests of the patient require it, and never refuses help and advice to colleagues; constantly improve your professional skills, protect and develop the noble traditions of medicine.”

The Hippocratic Oath and similar oaths and promises are a tribute to the traditions of a particular country or educational institution. For example, in the United States, graduates of 27 of 98 medical faculties do not take any oath at all, and in Canada, not a single medical school requires any pledge from its graduates. Where it is customary to take a doctor's oath, it is not a legal document. But if it is violated, the relevant state laws and departmental instructions are triggered.

Etiquette in medicine.

The fundamental requirement of medical etiquette is this: the appearance of the doctor must convince the patient that this is a professional who is not afraid to entrust health and life. No one wants to become the patient of a person who is frivolous, careless, and has an indifference, or even hostility, towards patients. Appearance sometimes reveals adherence to bad habits. The doctor must be collected, reserved, friendly and, of course, a healthy and fit person (or at least give such an impression).

According to medical etiquette, the appearance of a doctor is very important. It is preferable to wear a suit and tie to work rather than a T-shirt and jeans. It is not appropriate for a doctor to shine with ultra-fashionable outfits and expensive jewelry, or to amaze colleagues and patients with unusual hairstyles. Good manners, politeness, and goodwill are required for doctors. Raising your voice or being rude to patients and their relatives is unacceptable; even when faced with their inadequate reaction, the doctor should behave firmly but correctly. If the patient and his relatives cause obvious antipathy in the medical worker (which happens not so rarely), negative feelings should not be manifested in words or gestures and, naturally, should not affect the treatment - this is not a requirement of etiquette, but of deontology .

Medical etiquette also requires correctness in relations between all members of the team, regardless of rank and title. Respectful address to colleagues, as well as the white color of the medical gown, emphasizes the purity and high meaning of the profession. This principle should be adhered to especially strictly if communication occurs in the presence of the patient. Familiarity, neglect from superiors and ingratiation from subordinates harm the authority of doctors. A situation where a doctor questions the professionalism of a colleague in the eyes of a patient is considered extremely unethical.

Another important element of ethics is mentoring, the transfer of experience and knowledge to novice doctors. Every good doctor and scientist had his own Teacher at the beginning of his journey, to whom great respect and gratitude remains for the rest of his life. In medicine, like in no other profession, it is customary to show respect to honored doctors, professors, and academicians. Behind these people, the main asset of a physician is experience, which cannot be replaced by any ability or education.

If the facts prove a medical error (for example, the results of the examination were incorrectly interpreted, an incorrect diagnosis was made, the treatment was carried out incorrectly), the doctor should think first of all about how to help the patient, and not blame his predecessor for everything. However, corporate solidarity does not mean turning a blind eye to mistakes. First of all, you need to discuss the situation with a colleague – in person and in private.

Criticism must be justified, correct and to the point, not transferring to the personal qualities of a colleague. IN difficult cases When it is impossible to immediately clearly determine whether a mistake has been made and how to proceed further, you can jointly contact a more experienced colleague or a council of several doctors.

Doctors treat nursing and junior medical staff with emphatic respect. A modern nurse is a highly qualified worker who knows and can do a lot. She is the doctor's first assistant, without whom the treatment process is impossible. The most important requirement Nurse ethics - respect for the doctor - must be strictly observed. Unfortunately, nurses are often impolite and undutiful (especially if the instructions come from a young doctor). Nurses are also prevented from perceiving doctors as workers with a higher status by the small difference in pay between doctors and nurses (although these categories of medical personnel are incomparable in terms of training and complexity of the work performed). At the same time, an experienced, qualified nurse sometimes actually knows much more about the course of a particular disease than a novice doctor, and his mistakes are obvious to her. For this reason alone, manifestations of snobbery and the desire to “indicate a place” are unacceptable for a doctor. Respectful, friendly relationships with nurses allow a young specialist to learn a lot and avoid a lot of mistakes.

Development of medical ethics.

The principles of professional ethics were proclaimed and supported by the best doctors of the past. From the history of medicine it is known that back in the 3rd century BC. In the composition of the Indian folk epic “Ayurveda” (“Book of Life”), issues of the doctor’s attitude to the patient and the relationship between doctors were reflected. Philip Aureolus Theophrastus Bombastus von Hohenheim (1493-1541) was an outstanding medical reformer, better known as Paracelsus. He strongly spoke out for the return of surgery to the fold of medicine (at that time, surgeons were not considered doctors, but were equated with artisans). Paracelsus also contributed to the development of medical ethics. He contrasted the mutual responsibility that then reigned in the medical world with other principles: “a doctor should think about his patient day and night”; “a doctor does not dare to be a hypocrite, a tormentor, a liar, or a frivolous person, but must be a righteous person”; “the strength of a doctor is in his heart, his work must be guided by God and illuminated by natural light and experience”; “The greatest foundation of medicine is love.” Written sources of the Russian state of the 9th – 11th centuries also contain information defining the norms of behavior for a doctor. Peter I issued detailed regulations on medical activities and physician behavior. The remarkable Moscow doctor of the past, F. P. Haaz, proclaimed that medicine is the queen of sciences, because health is necessary for everything great and beautiful in the world. F. P. Haaz spoke about the need to listen to the needs of people, take care of them, not be afraid of work, helping them with advice and deed, in a word, to love them, and the more often this love is shown, the stronger it will become. And it’s not for nothing that the words that he loved to repeat during his life are carved on his grave: “Hurry to do good.”

Anatoly Fedorovich Koni (born January 25, 1844 in St. Petersburg) is an outstanding judicial figure in Russia at the end of the 19th and beginning of the 20th centuries, a legal scholar who made a huge contribution to the development of Russian and world legal science. He developed as a scientist in the 60s of the 19th century. It was a difficult time. The Russian intelligentsia, brought up on the lofty but abstract ideals of the 1940s, felt insecure. Crash revolutionary populism showed how little she was prepared for direct work, how idealistic and detached from real life her romantic ideology.

A.F. Koni had encyclopedic knowledge in the field of Russian and foreign law, history, philosophy, medicine, and psychology. One of the aspects of his activity was the development of moral and ethical principles of medical practice, in particular the issue of medical confidentiality. The existing legislation did not address this issue at all. Even in the Statutes of the Medical Police and Forensic Medicine there was not a word about medical confidentiality.

In his fundamental work “On Materials on Medical Ethics,” A. F. Koni analyzes a number of issues of medical deontology - the moral duties of a doctor towards the patient and his relatives, “the possibilities of hastening death in hopeless cases,” etc. He believed that moral The doctor’s duties include “respect for true science, avoidance of any unacceptable methods that give a short-lived effect, non-application of conclusions from insufficiently and inconclusively verified discoveries, steady patience in relation to people, selfless in some cases fulfillment of one’s duty to society and consistent behavior.” “The doctor lives constantly with a sense of responsibility to the suffering, witnesses the suffering of the sick, and sometimes exposes himself to the danger of infection, showing everyday heroism.”

Since the end of the 19th century, the attention of physicians, lawyers and philosophers has been drawn to the moral problems associated with organ transplantation. In particular, the question was discussed whether a doctor has the moral right to cause physical harm healthy person to heal a patient or alleviate his suffering. This problem could be solved taking into account the balance of interests of the donor and recipient. A.F. Koni was the first to provide legal justification for the transplantation of endocrine glands. He argued that an agreement between the donor and recipients can contradict the rules of law and morality only in cases where the “seller” is a minor or weak-minded. It is prohibited to induce a donor to consent through mental stimulation, deception, seduction or authoritative suggestion. If these requirements are met, the doctor has the legal and moral right to perform a transplant in which the damage to the donor's body will be classified as lung. The motives for the donor’s consent (sympathy, humanity, goodwill or the ability to solve financial problems), according to A.F. Koni, should not interest the doctor. Based on the listed legal conditions, A.F. Koni formulated the basic requirements for transplantations:

Only a physically and mentally healthy person can be a donor.

The doctor must be firmly convinced that the damage caused to the donor is minor and temporary.

The donor and recipient must be fully informed about all possible consequences operations.

Written documented consent of the donor and recipient for the operation is required.

The moral aspect of organ transplants is still one of the most important in medical deontology.

Of great interest are the views of A.F. Koni on medical ethics, expressed by him in books dedicated to doctors. One of them is “Fedor Petrovich Gaaz”. F. P. Haaz lived during the reign of Nicholas I, in the harsh era of serfdom and senseless cruelty. The chief physician of Moscow prison hospitals, F.P. Gaaz was a model of selfless service to the people, truly a people's doctor. Koni's talented book revived the memory of this wonderful man. This is how he wrote about Gaza: “By satisfying the physical and spiritual suffering of those who need his help, while avoiding the routine coldness and cruelty in his methods, he supports people in moments of despair and, with his participation, advice and help, can compare suffering people with those who have befallen their illnesses and misfortunes."

A. F. Koni considered the activities of ophthalmologist professor L. L. Girshman, famous forensic doctors D. F. Lambl and V. F. Grubbe, and prominent psychiatrists I. M. Balinsky, I. P. Merzhevsky to be an example of philanthropy. These include the words of A.F. Koni: “A doctor who understands his calling and is aware of his responsibilities is a worker in science and his special art, a bearer of compassion for suffering humanity and very often a prominent public figure.”

The speech delivered by A.F. Koni in the hall of the City Duma on November 21, 1910 sounded like a hymn to medicine. on the occasion of the centenary of the birth of N.I. Pirogov. He focused on the ethical views of N. I. Pirogov and his pedagogical views. Associated with the name of N. I. Pirogov important stage in the development of medical ethics. His views on the main issues of medical deontology, including the relationship between doctors and medical administration, and the recognition of one’s own mistakes, are of lasting importance.

Ethics of medicine.

At all times, doctors were treated with respect. After all, people of this profession come to the rescue at the most critical moments of a person’s life, from birth to the hour before death. But not only respect surrounds a man in a white coat - misunderstanding, skepticism, ridicule and even curses have accompanied doctors from ancient times to the present day.

A wary attitude towards doctors appeared from the very first steps of medicine. In ancient times, people laughed at the modest and even dubious capabilities of the then medicine against the backdrop of the exorbitant self-importance of doctors. In the Middle Ages, a proverb appeared: “A doctor has three faces - the face of a decent person in everyday life, the face of an angel at the patient’s bedside, and the face of the devil when he demands a fee.”

Even today, despite amazing achievements in the fight against the most complex diseases, medicine is reproached for its inability to cope with AIDS, for the return of almost forgotten diseases - tuberculosis, diphtheria and much more. The source of most reproaches is the sharply increased expectations of people, which modern practical medicine cannot justify. Why does this profession evoke so many passions, often opposing ones? Firstly, it is connected with human life itself. And secondly, every doctor - conscientious or not - deals with different patients, different characters. Some people are grateful for any attention and help. Others perceive even the most selfless actions of doctors with indifference or hostility. But it is a good person - a person who really relieves suffering, and not rarely saves a life - that evokes a sincere feeling of deep gratitude in patients.

Doctors often have to make decisions related to the life, health, dignity and rights of people. Therefore, ethics - the principles of morality and the rules of behavior based on them - occupy a special place in medicine.

Over the long history of medicine, many ethical principles have taken shape in clearly formulated rules and norms of physician behavior. The set of these norms is called medical deontology. The term “deontology” (derived from the Greek word “deon” - due) was introduced in the 18th century. English philosopher Bentham. With this term he designated the rules of professional behavior of a person. Medical deontology includes the doctrine of medical ethics and aesthetics, medical duty and medical confidentiality, etc. She studies the principles of behavior of medical personnel, the system of their relationships with patients, their relatives and among themselves. Its tasks also include eliminating “the harmful consequences of inadequate medical work.”

Over thousands of years of medical practice, many norms of deontology have become a kind of rituals, like rules of good manners, the deep meaning of which a person does not always understand, but tries to observe them. These rules form medical etiquette - a set of “good manners” that every self-respecting doctor follows almost without hesitation.

Ethics, deontology and etiquette are closely related. Although the requirements of etiquette sometimes seem formal, one can detect their deep ethical basis. For example, it is not decent to wear bright clothes and provocative makeup in a hospital, among people who are ill. The rules of deontology, even the most ancient and sanctified by tradition, can change with the formation of new ethical principles. Thus, the deontology of Soviet medicine required concealing the true diagnosis from a terminally ill patient. Behind this position stood a certain attitude towards a person - not as the master of his fate, his life and death, but as an “object of care” who was obviously weak in spirit. According to the rules of modern deontology, the doctor must tactfully but honestly inform the patient about the severity of his condition. Treating a person, even a seriously ill person, as a free and rational being is an ethical requirement.

Information about the disease, as well as personal life of the patient, which have become known to medical workers and are a medical secret and in no case can be transferred to third parties without the consent of the patient. Hippocrates insisted on this rule, and modern Russian legislation provides for criminal liability for disclosing medical confidentiality. Indeed, violation of medical confidentiality can have very serious consequences, literally destroying a person’s life. This problem has become most acute due to the spread of AIDS. There are dozens of cases where the leak of information that a person is a carrier of the immunodeficiency virus led to his expulsion from society. There are medical specialties (gynecologist, andrologist, venereologist, psychiatrist) that deal with the most intimate side of a person’s life, and any careless word can cause gossip, destroy a family, and provoke a severe crisis of self-esteem in a person.

The requirement to maintain secrecy is not only ethical, but also practical. A doctor will not be able to treat effectively if he does not have enough information about the symptoms of the disease and the circumstances of the patient’s life. And the patient will not be completely frank with him without confidence that the information will remain between them. However, there are situations where keeping a secret can cause harm to the patient himself or other people. For example, information about their child's health should generally not be a secret to parents.

However, life is complex, and often it poses problems for doctors and society for which there are no ready-made answers, and deontology is unable to help. Then the only way out is to directly turn to your own ethical sense, think for yourself and decide how to do the right thing.

Deontology in neuropathology.

A patient with deviations in the neuropsychic sphere requires exceptional care for herself. The success of therapeutic and educational measures largely depends on the attitude of speech pathologists and doctors towards a sick child. These specialists must conduct their work in accordance with the principles of deontology.

A sick child in the family requires a lot of attention from parents and other close relatives. Parents, as a rule, are deeply traumatized by the illness of their children. Because of this, they are often excluded from active social activities. Their entire inner life is concentrated on the child’s illness. Misconceptions about the mechanisms of development of diseases, often existing ignorant prejudices, can give rise to a feeling of guilt and mutual reproaches in parents for the fact that the child was born sick. Parents of a sick child make increased and sometimes inadequate claims to doctors and speech pathologists. In such situations, health workers and educators need to show great tact and patience. You should refrain from indignation, insults, and especially from insufficiently thought-out words. We need to understand the psychology of parents, delve into their misfortune, and sympathize with their experiences. However, this does not mean following their lead or agreeing with them in everything. When talking with the patient’s relatives, one must always remember the ancient commandment: “Remember what to say, who to say and how you will be understood.”

Particularly important is the care of children with neurological and mental illnesses, in conditions of their isolation from their parents (in a hospital, in a sanatorium, in a boarding school). It must be remembered that children react very sharply to the absence of their parents: they cry, are capricious, and often refuse to eat. Therefore, they need a particularly sensitive, attentive, affectionate approach. Under no circumstances are rudeness, shouting, or punishment acceptable. Medical personnel and teachers should replace parents for children. This is a difficult and yet noble task. It is important for a child to feel a loving attitude towards him; in this case, he will be disposed towards a teacher, doctor, nurse, nanny. Well-established contact with a sick child significantly increases the effectiveness of the therapeutic and pedagogical work carried out with him.

An important condition for medical deontology is the correct relationship between doctors, speech pathologist and other personnel. It is well said in Ayurveda about the personality of a doctor, about what he should be like in life: be modest in life and behavior, do not flaunt your knowledge and do not emphasize that others know less than you - let your speech be pure , truthful and restrained. A certain relationship is established between the teacher-defectologist and the doctor in the process of their joint work. They are based on general positions in the examination, treatment and medical and pedagogical correction of certain developmental disorders. These relationships should be business-like and based on the interests of the patient. It is important that the doctor and the speech pathologist understand each other and act in complete harmony, the same applies to middle and junior staff.

It must be remembered that the ultimate goal of the work of doctors, defectologists and all staff is the social adaptation of the patient. The patient should feel like a person needed by society. The child must be able to convince that he is not an “extra person” and, along with others, can bring all possible help to society.

"Holy Lies"

The ethics of human relations requires people to be truthful. Lying is condemned, liars are despised. A person’s health and life depend on doctors, so they are required to special requirements. It is one thing for a worker or employee to somewhat embellish before his superiors the true state of affairs regarding the performance of the assigned work. And it’s quite another thing for a doctor who, in order to improve his performance, will “embellish” the patient’s test results or lower his temperature. It’s one thing for a secretary who didn’t send a fax on time, but insists that she did, and another thing for a nurse who forgot to give a vital injection to a patient, but says that she did.

But, paradoxically, it is for doctors that strict ethics makes the only exception to the “don’t lie” rule. This exception is a “holy lie”, or a “white lie”. Doctors are obliged to tell the truth to colleagues, bosses, representatives of regulatory and law enforcement agencies. At the same time, the traditions of medicine have long prescribed to mislead hopeless patients, to hide from them that the disease is incurable.

For many hundreds of years, this rule seemed obviously reasonable and humane: one must not take away a person’s hope or condemn him to difficult experiences associated with the proximity of death. An Indian treatise of the 3rd century BC included “holy lies” in the duties of a physician. Ayurveda. The need to lie was justified as follows: what is useful to the patient is true, even if it is a lie. There are, of course, real reasons for such a belief. For some time, the doctor's reassuring speeches can really inspire strength in the patient. Faith in the possibility of recovery sometimes brings even hopeless patients back to life, while despair and a sense of doom only worsens the condition. It’s also hard for the patient’s relatives, who are painfully experiencing the impending separation from a loved one. And it is psychologically easier for a doctor to tell a lie to a patient than to reveal the true state of affairs and face grief and despair, and sometimes even anger at the doctor for his own powerlessness.

“Holy lies” was the rule of Soviet deontology. Some people have been treated for cancer and recovered without knowing the true diagnosis. It was considered unethical to inform a patient that death was near, even if the person was morally ready to accept such information. However, such a careful approach has a downside. Usually the patient still felt that something bad was happening and he was not being told the whole truth. And if the deception was revealed, he experienced deep despair; he perceived the “holy lie” as a betrayal, a conspiracy of his relatives and doctors behind his back. With this approach, a person was deprived of the right to consciously prepare for his own death, say goodbye to loved ones, complete important matters for himself, and dispose of property.

At the end of the 20th century, the attitude towards the “holy lie” changed. Doctors and society have established the opinion that the patient has the right to know the truth about the state of his health. A conversation with a seriously ill or dying person requires special tact and skill, true compassion and great warmth from the doctor. Doctors are specially trained in how and at what point to inform the patient about his situation. Some clinics employ psychologists who help patients and their relatives accept the inevitable and find peace of mind. A priest or simply a wise man that the patient trusts. Even special medical institutions have appeared - hospices, the purpose of which is not to treat, but to alleviate last days hopeless patients. In Russian medicine, the turn in attitude towards the “holy lie” cannot yet be called complete. It requires a change in the perception of death not only on the part of doctors, but also on the part of the entire society. Even at the beginning of the twentieth century, the famous Russian lawyer A.F. Koni insisted that the doctor must inform the patient about his impending death so that he could fulfill his legal and spiritual obligations. Today this right is enshrined in law. Article 31 of the Fundamentals of Legislation for the Protection of the Health of Citizens of the Russian Federation states: every citizen has the right to complete, truthful information about his health.

Ethical problems in medicine.

Since the time of Hippocrates, unified ethical principles have developed in medicine. Here are the main ones:

· All actions of the doctor should be aimed only at the benefit of the patient, and not to harm (if the doctor can foresee it in advance).

· Actions that could cause suffering to the patient and his relatives should be avoided.

· Actions taken by a doctor should not cause harm to other people, including patients.

· The doctor's decisions are based on the principles of modern science.

· The doctor has no right to look at the patient as a source of enrichment.

· The doctor is obliged to keep confidential information concerning the patient’s health and the circumstances of his life that become known during the course of treatment.

These principles are aimed at protecting the interests of the patient, and their humanity would seem obvious. But in real life there are situations in which it is impossible to fulfill one postulate without violating others. And then the doctor, making a decision, is forced to take the rather slippery path of causing the “lesser evil.”

There are many examples of such situations. So, important point in military field surgery and emergency medicine is the triage of the wounded. They are divided into three groups: the lightly wounded are bandaged and they try to send them to the rear as quickly as possible, the seriously wounded are given the maximum possible assistance on the spot and then evacuated, the hopeless are relieved by medics of suffering, but are not transferred to the rear. In fact, some “hopeless” people can be saved if such patients are treated by a team of highly qualified doctors equipped with the most modern equipment, or if they are urgently sent with all precautions and accompanied by doctors to a high-class hospital. But then the seriously wounded will be left without the necessary help, whose condition will worsen and their lives will be in danger, as well as the lightly wounded, they may develop complications. It is impossible to leave a person virtually without hope of salvation - this is contrary to ethics. It is also impossible to save one, forgetting about the others. There is no ethically impeccable solution here, and therefore the practical task is set: to preserve the life and health of as many people as possible.

In fact, the practice of teaching students at the bedside is also contrary to ethics. This method of teaching, proclaimed by Hippocrates, has been repeatedly approved by the most prominent humanist doctors over the past centuries. But isn’t it causing harm to the patient when a student examines him unskillfully, and therefore sometimes causing pain, without extreme necessity? However, it is impossible to abandon this practice, since it is simply impossible to train future doctors in any other way. No amount of dummies or practice of working on corpses will prepare young specialist completely to operations on a living, quivering, breathing body. The identified problem is also, in a certain sense, unsolvable. It is clear to everyone that a surgeon must once cut out his first appendix, and a dentist must fill his first tooth, but few will agree to expose their own body to the “experience.”

Another example of an ethically ambiguous situation. According to surveys conducted in the United States, 68% of donors and 87% of volunteers who agreed to a clinical experiment were at that time in constrained financial circumstances. Is it ethical to take advantage of people's difficulties? In addition, frequent blood donation and experiments are not always so harmless for health, but without them they would not have been found modern methods treatment.

However, volunteers themselves decide to participate in the experiment. But laboratory animals have no such choice. The successes of traditional medicine are paid for by many lives: the suffering and death of thousands of dogs, monkeys, millions of mice, rats, rabbits and other animals. In an effort to find a cure, for example, for cancer, a doctor-researcher, in the course of his work, inoculates completely healthy mice and monkeys with cancer. Without such experiments, no one will allow you to try new technique in public. The torture and death of laboratory animals is also a serious ethical problem in medicine.

Clinical experiment is the most important source of new knowledge. Currently, its implementation is regulated by numerous legal and ethical standards that protect the life, health and rights of volunteers. Forced clinical experiments are widely recognized as illegal and immoral (see chapter “Resolution of the UN General Assembly”). However, this has not always been the case in history.

The Ptolemaic laws and medical ethics of two thousand years ago allowed doctors of ancient Alexandria to use criminals sentenced to death for experiments. The most striking and terrible example of medical crimes is the experiments of Nazi doctors. The material for their experiments were concentration camp prisoners and patients in German hospitals. These examples show what crimes a doctor can commit if he rejects the principles of medical ethics for the sake of another “high goal.”

It is not always possible to comply with the requirement of strict science in prescribing treatment. Sometimes a doctor, having tried all means and not achieving improvement, is forced to carry out exjuvantibus therapy (Latin for “at random”, “at random”) - to treat based on intuition, but not on knowledge. Such therapy may not help, but, on the contrary, hasten the patient’s death. However, to refuse exjuvantibus means to completely deprive the patient of hope for recovery. Meanwhile, there are many cases where an intuitive decision turns out to be life-saving.

Many ethical conflicts are associated with the remuneration of doctors, and with the preservation of medical confidentiality, and with organ transplantation, and with many other aspects of medical practice.

Resolution of the UN General Assembly.

"Principles of Medical Ethics 1982" *

Extraction

The General Assembly invited the World Health Organization to prepare a draft code of medical ethics relating to the protection of persons subjected to any form of detention or imprisonment from torture and other cruel, inhuman or degrading treatment or punishment.

Alarmed that members of the medical profession and other health professionals often engage in activities that are difficult to reconcile with medical ethics. Recognizing that there is an increasingly widespread practice throughout the world of essential medical activities being performed by health care workers who are not licensed or trained as physicians, such as physician assistants, physician assistants, physical therapists, and nursing assistants, declares:

Principles of medical ethics relevant to the role of health care professionals, particularly physicians, in protecting prisoners or detainees from torture and other cruel, inhuman or degrading treatment or punishment.

Principle 1

Health care professionals providing health care to prisoners or detainees have a responsibility to protect their physical and mental health and to provide medical treatment of the same quality and standard as provided to non-prisoners or detainees.

Principle 2

Health care workers commit a gross violation of medical ethics, as well as a crime... if they actively or passively engage in acts that constitute participation or complicity in torture... instigating or attempting to commit it.

Principle 3

Health care professionals commit a violation of medical ethics if they:

Use their knowledge and experience to facilitate the interrogation of prisoners or detainees in a manner that may adversely affect mental and physical health.

Certify or participate in certifying that the state of health of prisoners or detainees allows them to be subjected to any form of treatment or punishment that may have an adverse effect on their mental and physical health.

Principle 4

The participation of health care workers, especially doctors, in any procedure of a restraining nature in relation to a prisoner or detainee is a violation of medical ethics, unless it is dictated by purely medical criteria as necessary to protect the physical or mental health or safety of the prisoner or detainee himself or other prisoners or detained persons or personnel are protected and does not pose a threat to his physical or mental health.

Ethics: challenges of the time.

Typically, ideas about what is good and what is bad change very slowly in human society. A new vision develops gradually, and completely opposite points of view coexist for a long time. However, the development of medicine in recent decades has progressed at such a pace that new ethical problems arose before society had time to thoroughly comprehend and discuss them. Today, many moral dilemmas in medicine cause fierce debate, in which not only doctors, but also the press, parliament, church, and public organizations participate.

One such topic is organ transplantation. Modern medical technologies make it possible to transplant various organs into patients: kidney, liver, heart, lung, bone marrow. They are removed from the corpses of people who have received fatal injuries. However, such organs very quickly become unsuitable for transplantation. Therefore, in practice, the work of a transplantologist looks like this: after receiving a fatal injury, a “suitable” donor is taken to the hospital, pronounced dead, and the necessary material for transplantation is immediately taken away. This gives rise to an essentially insoluble ethical problem - the need for the death of one to save the other. The doctor and the patient unwittingly find themselves interested in a “suitable” accident.

However, the ethical conflict does not end there. If the desired donor is taken to the hospital, the problem arises: should he be resuscitated or not? Such a formulation of the question in itself contradicts the ethics of medicine, however, long-term artificial maintenance of the donor’s life can lead to irreversible changes in the desired organ, making it unsuitable for transplantation. Another question: what are the criteria for declaring the death of a donor? Most often, cardiac arrest is considered the main cause. However, by this time the organ of interest to transplantologists is sometimes no longer suitable for transplantation. In accordance with the instructions of the Ministry of Health, organ removal should be carried out after declaring brain death - regardless of the presence or absence of a heartbeat. But in reality, this sometimes looks like taking away an organ from a person who is not yet completely dead, since his heart is beating.

No less painful is the problem of permission to transplant organs. In Soviet times, transplantology was not limited by any legislative rules. The decision to “harvest” an organ (as doctors say) in each specific case was made by doctors; the consent of relatives was not required. However, now in many states such practices are considered a violation of human rights. In Russia, an intermediate policy is being pursued: the collection of organs or tissues does not require the consent of the relatives of the deceased, but cannot be carried out in the event of their active disagreement. Many people (especially in the West) express in advance their willingness to become organ donors in the event of untimely death (information is stored in a special database). Recently, a more tolerant attitude of people towards donation has become generally accepted abroad. After all, after death loved one his organ will continue to live, giving life to another, and, therefore, his death (which was inevitable anyway) was no longer in vain.

Transplanting tissue from a living person also poses ethical challenges. For example, when treating leukemia in children, transplantation of fetal blood cells taken from a sibling is sometimes used. Therefore, parents of a child with leukemia have to give birth to another baby. In a sense, it turns out that he was born for purely utilitarian reasons. But only in 25% of cases, a newborn’s umbilical cord blood is suitable for transplantation. The question of the ethics of cell therapy is extremely pressing. There are degenerative diseases of the nervous system, when an adult patient can be helped by the introduction of nerve cells of a human fetus, which are isolated from abortive materials. There is a great danger that the development of cell therapy will lead to an increase in the number of medically unjustified abortions. However, cell therapy may become a thing of the past due to advances in genetic engineering and improved organ cloning. However, these technologies raise even deeper ethical issues.

Euthanasia is another ethical issue in medicine. Translated from Greek, “euthanasia” means “ good death", this is what the ancient Greeks called honorable death for the fatherland. Nowadays, euthanasia is understood differently: in order to relieve the suffering of a hopeless, dying patient, doctors help him pass painlessly into another world. Euthanasia can be passive, when the patient’s death occurs as a result of the cessation of medical measures to prolong life, and active, when special means are used that lead to death. There are also voluntary euthanasia - at the request of the patient himself and compulsory, which is carried out at the insistence of relatives, society or government agencies. There is no point in even discussing the immorality of the latter - neither doctors, nor society, nor the law accept it. And the permissibility of voluntary euthanasia is the subject of fierce debate.

The problem of euthanasia became especially acute in the twentieth century due to the progress of medicine. Opportunities have emerged to support the lives of incurable patients with the help of artificial respiration and circulatory apparatus, artificial kidneys, and medications. However, by prolonging life, these technologies also prolong suffering. Often such patients have neither the strength nor the desire to live further, and sometimes even remain in an irreversible state of unconsciousness. In addition, most people continue to die in pain, like past eras, although modern science knows ways to die painlessly.

Doctors, like all modern society, are divided into supporters and opponents of euthanasia. The first are confident that an easy, painless death should crown the life of every person, that death throes are completely unnecessary and modern science should save people from them. They propose to use euthanasia for adults who are of sound mind and memory, incurable patients whose death is inevitable in the near future. An indispensable condition is the repeated persistent (confirmed by observing legal formalities) demand of the patient himself. Opponents of euthanasia believe that it contradicts the instinct of self-preservation, religious dogmas prohibiting murder and suicide, and medical ethics. Many doctors oppose euthanasia on the grounds that their profession is to fight for human life, not to shorten it. They say they will refuse to perform euthanasia even if it is legal and they are forced to do so. Another argument against: the patient will want to change the decision, but it will be too late. In addition, the disease may be mistakenly considered incurable, and a request for euthanasia may be accepted under pressure or as a result of deception hidden from others. Finally, starting with voluntary euthanasia of the dying, society is able to reach the forced killing of non-viable infants, disabled people, seriously ill people and the elderly. Abuses in this area cannot be ruled out - for example, there is a danger of contract killings being spread under the guise of euthanasia.

The legislation of most countries, including Russia, clearly interprets euthanasia as murder. Doctors and citizens generally share this belief. But there are countries where it is permitted by law under certain conditions. These are the Netherlands and Australia. The experience of doctors in these countries has not yet been comprehended, and debates about the ethics of euthanasia continue.

Conclusion

Breaking taboos

For a long time, religious and secular prohibitions were imposed on a number of important types of medical activities. Such prohibitions primarily related to the study internal structure human body - anatomy. For many centuries, doctors were not allowed to perform autopsies on corpses. Herophilus (Ancient Greece, late 4th - first half of the 3rd century BC), who violated this taboo, was despised by his fellow citizens, dubbed a “butcher” and more than once wanted to be expelled from the city. But it was Heraphilus who made serious discoveries in the field of anatomy; he invented many methods surgical treatment diseases. Many scientists have suffered while trying to overcome society's misunderstanding. The ban on autopsy of a human body remains in the medieval past.

But there are many other examples when doctors had (and still have to) deal with a fear of the new and a lack of understanding of their ideas. The first attempts to give blood transfusions, organ transplants, preventive vaccinations and brain surgeries, and perform artificial insemination came under fire from public opinion. Medicine will continue to develop, and, like hundreds of years ago, each new step will give skeptics reason to doubt the correctness of the chosen path.

However, the strategy of reasonable containment is in many ways useful for any science, and especially for medicine. In the modern world, such a brake is served by laws that establish the rules for the use of scientific achievements.

State laws today help resolve many disputes between society and the Church, on the one hand, and medicine, on the other. Society doubts the moral acceptability of abortion. A law is being created that says to whom and when abortion is allowed, and when it is absolutely forbidden to do it. People are concerned about the issue of euthanasia. Dutch law specifies the conditions under which euthanasia is possible. In Russia and many other countries, “voluntary death” is prohibited by law.

Society is divided again: it is unable to unambiguously solve these and many other ethical problems. And doctors themselves often do not know exactly “what is good and what is bad.” The development of medical technologies poses new ethical problems for medicine that are not easy to resolve. Finding the right solutions, developing new criteria for ethics is a lot of constant work, and it needs to be done, because otherwise scientific progress can, unnoticed by us, turn into a regression of humanity.

USED BOOKS:

1. Badalyan L. O.

Neuropathology: A textbook for students of defectology faculties of pedagogy. institutions. – 2nd ed., revised. – M.: Education, 1987. – 317 p.

2. L.E. Gorelova, S.I. Molchanova.

The contribution of the outstanding Russian lawyer A.F. Koni to the development of medical ethics./ Nurse.// M.: Medicine - 1989 - No. 1 - pp. 20-21

3. Humanitarian sphere and human rights: Collection of documents: Book for teachers / Comp. V.A. Kornilov and others - M.: Education, 1992. - 159 p.

4. Career in medicine / Ed. A.Eliovich, chief editor M. Shirokova. – M.: Avanta+, 2003. – 320 p.

5. Matveykov G.P. Handbook on the organization of therapeutic care. – Mn.: Belarus, 1988. – 287 p.

Medical ethics. Professional ethics of a doctor

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