CURRICULUM VITAE

NAME: Adewale Opeyemi.

SCHOOL: Federal University of Technology, School of Postgraduate Studies, Minna; Nigeria.

PROGRAM OF STUDY: Architecture

DEGREE IN VIEW: M.tech

E-MAIL: justshonuff@yahoo.com

POSTAL ADDRESS: Dept. of Architecture, FUT PMB 64 Minna, Niger State.

ESSAY TITLE:
INSTITUTIONAL MEDICAL ETHICS: THE
UNEXAMINED IMPACT OF ARCHITECTURE
The short time that building designers spend on formulating a building can have long-term
consequences on the health of all future occupants 1
SCIENCE ASKS "CAN WE?"
LAW ASKS "MAY WE?"
MORALITY ASKS "SHOULD WE?" 2

Bioethics emerged in Greco-Roman times but the current form of this discipline can be said to
have come about in the 1960s. The practice of bioethics is broadly based on the moral issues,
values and virtues as it is applied to the medical discipline. Bioethics has been described using
various names including medical ethics. Medical ethics is principally the study of ethics within
the discipline of medicine and medical care. Medical ethics can further distinguished into clinical
medical ethics and institutional medical ethics. Clinical medical ethics focuses on ethical issues
at the patient-physician interface, such as informed consent or foregoing treatment. Institutional
medical ethics examines the structural or institutional context within which medicine is
practiced, such as issues in healthcare policy or the distribution of resources within a hospital.
There is also healthcare ethics, which focuses primarily on the policy analysis or issues related to
insurance.3

The practice of medicine and the institution of hospitals both have their histories set in
humanitarian ideals. The first hospitals were founded by religious institutions and they served as
homes where the poor and marginalised found care. Examples are Hindu hospitals opened in Sri
Lanka in the 5th century BC and the monastery-based European hospitals of the Middle Ages.
The Hôtel Dieu in Paris, a monastic hospital founded in ad 660, is still in operation today 4.

The first hospital in Nigeria was also established by a missionary organisation. The hospital was
located in the South-western part of the country in present day Ogun State. During the nascent
years of hospitals, especially before the introduction of antiseptic techniques by British surgeon
Joseph Lister in 1865, it was far more dangerous to receive care in a hospital than at home
because of poor sanitation. As many as 25 percent of patients died after surgery because
hospitals of that era were overcrowded, poorly ventilated, and inadequately cleaned. The
hospitals that came after the discovery of the antiseptic are therefore safer. The last statement
seems like a logical conclusion but the premise for determining hospital safety appears to have
been broadened and the environmental design of the modern day hospital plays a pivotal role in
determining this safety.

One of the earliest proponents of the importance of the physical environment was Florence
Nightingale. Her efforts on behalf of the British soldiers during the Crimean War focused on
design engineering to improve lighting (especially with sunlight), ventilation, heating and
cooling, sewerage facilities, and sufficient space for soldiers' personal belongings. The safety
aspects of clean air and water were not inconsequential to Nightingale's patients or to her nurses;
the effects of her improvements on patient outcomes were reflected in the mortality figures for
1855, which fell from 42.7 deaths per 1000 to 2 per 1000 within 3 months of Nightingale's
changes. More recently, environmental factors such as noise, air quality, light, toxic exposures,
temperature humidity, and aesthetics have been scrutinized for their effects on both patients and
workers. The combination of environmental factors with the growing consumer demand for
safety, security, competence, and physical and psychological comfort has engendered the
concept of a "healing environment." 5.

In contemporary times, bad hospital design is a major cause of stress and fatigue amongst staff
and this decreases the effectiveness in care delivery, reduces patient safety, increases patient and
family stress and worsens overall healthcare quality. Richard L. Kobus et al (2008) make a lucid
point in the book “Building Type Basics for Healthcare Facilities” which resonates with
institutional medical ethics and the not so moral compromises that designers make. The book
states:

Architects practicing in the industry today are met by an increasing focus on

limiting the cost of construction and the cost of their services. In an effort to be
responsive to the demands of their clients, some may choose the route that leads
solely to greater efficiency while forgetting their responsibility to the care of the
prime consumer, the patient. The emphasis of healthcare architecture today must
be on improving the quality of the environment for patients and care givers alike.
The best support architects can give to healthcare management is efficient
solutions, but not those that ignore the environment or the quality of patient-
caregiver relations that it supports.

Giving this statement further impetus Guenther and Vittori (2007) opined about the ethical
challenge before designers in the book “Sustainable Healthcare Architecture”: Ultimately, the
built environment is the product of intentional design decisions and waste signifies failure.
Designers today stand on the brink of being seen by society as essential contributors to its health,
safety and welfare. If design professionals decide to examine materials and processes endemic to
their work, as well as demand that materials and processes become environmentally safe, they
will be the heros of the 21st century. The larger challenge is to transform a wasteful society into
one that meets human needs with elegant simplicity. The ethical challenge is also broad in scope.
It is not simply about designing environmentally benign hospital buildings for an ever-expanding
industrial complex, but about formulating a system of healthcare that supports vital communities
that nurtures health and whole people "who do not confuse what they have with who they are ".
This broader vision of design can be termed ecological design.
Ecological design requires a revolution in our thinking, they suggest changing the kinds of
questions we ask about design from, How can we do the same old things more efficiently? to
ones such as:

 Do we need it?
 Is it ethical?
 What impact does it have on the economy?
 Is it safe to make or use?
 Is it fair?
 Can it be repaired or reused?
 What is the full cost over its expected lifetime?
 Is there a better way to do it?

Advancements in medical sciences including those in molecular biology, pharmaceuticals,

diagnostic and therapeutic modalities have changed management of diseases and influenced
changes in healthcare provisioning including hospital architecture. A correct design can
transform healthcare facilities into extraordinary places to get well and stay well and the patient
is to be kept as the focus 6.

The infinite connection between architecture and medicine is not summed up better than Richard
Miller and Earl Swensson. In their book Hospital and Healthcare Facility Design, they state:

Learning the language of business is invaluable for planning and communicating

design strategies in the field of healthcare. But, in speaking this language, we
must never forget that hospitals are more than businesses. They reach to the very
core of society and civilization as expressions and instruments of our deepest
humanity and compassion. The architect’s role in shaping these expressions and
instruments is a socially crucial one. Indeed, the practice of medicine and the
practice of architecture are more intimately related than may be superficially
apparent...Synergenial buildings (new design approach for hospitals) are
functional environments that evoke positive responses from their users on
physical, intellectual, and emotional levels. The synergism comes from combining
state-of-the-art technology and sound economics with the scientific and functional
information at the contemporary architect’s disposal to produce an effective
design inspired by the people who are going to use it. The hope is that a design so
inspired will appeal to all the human senses all the time, making its attraction
subtle, sophisticated, even subconsciously genial rather than critical.
Improved design can make hospitals significantly less risky and stressful for patients, their
families, and for staff. Relying on evidence based research, the following recommendations have
been made: eliminate

 double occupancy rooms in favour of single occupancy rooms that can be adjusted to
meet patients' changing medical needs:
 improve indoor air quality with ventilation systems and air filters to prevent nosocomial
infection;
 use sound absorbing ceiling tiles and carpeting to reduce noise and lower stress;
 provide better lighting and access to natural light;
 create pleasing, comfortable and informative environments;
 make hospitals safer and less stressful for patients and families to navigate
 and design hospitals that help staff do their jobs.

These recommendations may seem far-flung for some African communities based on the cost of
construction but this is the challenge architects have before them and it can be achieved with a
proper application of locally-obtainable inert materials and better circulation planning of
hospitals.
ENDNOTES

[1] Lee, T G, Health And The Built Environment: Indoor Air Quality retrieved from
http://arch.ced.berkeley.edu/vitalsigns/res/downloads/rp/iaq/iaq.pdf on August 10, 2008.

[2] Ethics and the Built Environment. A Theory of General Ethics Human Relationships, Nature,
and the Built Environment Warwick Fox

[3] Shannon, T 1996, An Introduction to Bioethics (Third Edition) Paulist Press

[4] Karen, S "Hospital." Microsoft® Student 2008 [DVD]. Redmond, WA: Microsoft
Corporation, 2007.

[5] Seifert, P C. and Hickman, D S, 2005- Enhancing Patient Safety in a Healing Environment
retrieved from http://journal.medscape.com/ on August 10, 2008.

[6] Gupta, S and Kant, S 2005, Trends and Dimensions in Hospital Architecture A Hospital
Administrator’s Perspective JK SCIENCE Vol. 7 No. 2, April-June 2005

REFERENCES

Kobus R. L. et al 2008, Building Type Basics for Healthcare Facilities Wiley; 2 edition

Miller, R L and Swensson, E S, 2002 Hospital and Healthcare Facility Design

Yee, R 2006, Healthcare Spaces No.3 (Healthcare Spaces) Visual Reference Publications