Sie sind auf Seite 1von 26

MYANMAR ACADEMY OF MEDICAL SCIENCE

The First Myanmar Academy of Medical Science Oration


12 August 2001

HUMANISM AND ETHICS IN MEDICAL


PRACTICE, HEALTH SERVICES, MEDICAL
EDUCATION AND MEDICAL RESEARCH

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


Formerly Professor of Physiology, Faculty of Medicine, University of Rangoon,
Retired Director-General, Department of Medical Research, Yangon, and
Retired Director, Health Systems Infrastructure, World Health Organization, South-
East Asia Regional Office, New Delhi, India

Myanmar Academy of Medical Science


27, Pyidaungsu Yeik Tha Road,
Dagon Township, Yangon, Myanmar
1

The First M.A.M.S Oration

The Myanmar Academy of Medical Science was founded with the objectives,
inter alia, to contribute knowledge and expertise of medical scientists in building a
peaceful modern developed nation, and to undertake the progressive improvement of
health care of the people. The duties of the Academy of Medical Science include
holding meetings for paper presentations and lecturing and demonstrating in
dissemination of medical education (Medical Science).
The Academy therefore had undertaken various scientific works and activities
to attain these objectives. During the past two years, the Academy has organized four
Symposia on various subjects, a workshop on developing research culture, scientific
meetings, and supported a number of Quick and Simple Research projects and
commissioned writing books.
The first MAMS Oration is being organized as a major scientific activity
aiming at promoting interest and disseminate knowledge. Webster's Encyclopedic
Unabridged Dictionary of the English Language defines Oration as a formal speech,
especially one delivered on a special occasion. According to the Shorter Oxford
English Dictionary, an Oration is a formal speech, or discourse, especially one
delivered in connexion with some particular occasion. Oration is a structured speech
delivered on a formal occasion presented by an orator, who, by invitation is a
distinguished personality.
The title of this present oration is " Humanism, and Ethics in Medical Practice,
Health Services, Medical Education and Medical Research". The subject is a very
topical one. Humanism and Medical Ethics are fundamental and at the core of all
endeavours of the medical profession, be it medical practice, medical education,
health care services or medical research. All members of the medical profession are or
should be governed by these principles.
The orator for the First MAMS Oration is Professor U Mya Tu, a medical
graduate from Yangon and the first Myanmar to obtain Ph.D in Physiology, the
founder Director General of Medical Research Institute and finally retired from WHO
service as Director of Health System Infrastructure in SEARO New Delhi.
2

Biography of Professor U Mya Tu

Professor U Mya Tu was born in Yangon on July 20. 1927. He attended St.
Philips English Middle School and St. Paul's Institute, East Yangon before World War II
broke out in the east. He passed the High School Final Examination in 1943 from the
Government High School at Maubin. During the war, he attended the Licentiate of the
State Medical Board (L.S.M.B) medical course, which was the only medical course open
at that time. After the war, passed the Matriculation Examination of the University of
Rangoon and in 1946, he was admitted to the First M.B.,B.S class at the re-opened
Rangoon Medical College.
During his undergraduate career, he took an active part in student social affairs,
being Secretary of the Medical College Student's Union, member and later Chairman of
the Social Committee of the Medical College Student's Union, and Editor of the Medical
College Students Union Magazine. He graduated M.B.,B.S. in 1951 and was posted to
the Yangon General Hospital as a Civil Assistant Surgeon. After about a year, he was
transferred to the University of Rangoon service as Assistant Lecturer in Physiology at
the faculty of Medicine, Rangoon. He then went on a State Scholarship to the University
of Edinburgh and studied physiology under Professor David Whitteridge, F.R.S. He was
awarded the Ph.D. degree in 1956, for his doctoral thesis on the electrophysiological
properties of cardiac muscle and Purkinje tissue. One of his examiners was Sir Andrew
Huxley, the 1959 Nobel laureate in Physiology and Medicine. Professor U Mya Tu was
the first Myanmar national to obtain the Ph.D degree in Physiology.
On his return to Myanmar, Professor U Mya Tu was promoted Lecturer in 1957,
and in 1959 was appointed Professor of Physiology at the Faculty of Medicine,
University of Rangoon, thus becoming the first Myanmar full-time Professor of
Physiology at the University of Rangoon.
Professor U Mya Tu was instrumental in forming the Burma Medical Research
Society in 1957 and was its first Secretary. In April 1962, Professor U Mya Tu led a
Burma Medical Research Society scientific expedition to the Arumdum valley in the
extreme north of Myanmar to study the pygmy Taron tribe. Other members of the
Expedition Team included Professor U Ko Ko, the present President of the Myanmar
Academy of Medical Science and Professor U Aung Than Batu.
3

In June 1962, the Minister of Health and Education Colonel Hla Han gave the
responsibility of opening a new Medical College in Mingaladon to Professor U Mya Tu
and Major Ko Ko Gyi the Officer on Special Duty at the Ministry of Health and
Education. Detailed plans were drawn up, buildings renovated and converted to the
laboratories, and equipment procured, and the new Medical College was duly opened
with Major Ko Ko Gyi as the Dean. Professor U May Tu was appointed Part-time
Professor of Physiology at the new Medical College on July 1, 1963, in addition to his
duties as full-time Professor of Physiology at the Landamadaw Medical College.
At the same time as preparing to open the Medical College at Mingaladon,
Professor U Mya Tu was entrusted by the Minister of Health and Education Colonel Hla
Han in August 1962 with the responsibility of drafting an Act for establishing a Medical
Research Council in the Country. The Burma Medical Research Council Act was passed
on October 6, 1962 by the Revolutionary Council Government. Professor U Mya Tu was
appointed Member-Secretary of the Burma Medical Research Council with the
immediate task of opening the Burma Medical Research Institute in the premises of the
Harcourt Butler Institute for Public Health on Zafar Shah (now Ziwaka) Road, Yangon.
The Burma Medical Research Institute came into being when the Harcourt Butler
Institute buildings were officially handed over by the Director of the Harcourt Butler
Institute to Professor U Mya Tu on June 10, 1963. Professor U Mya Tu was appointed
part-time Director of the Burma Medical Research Institute. He became the full-time
Director in 1964. In 1972, the Burma Medical Research Institute was renamed the
Department of Medical Research and Professor U Mya Tu became the Director General.
He served as the chief executive of the Department of Medical Research for a period of
over 13 years.
He was also one time Editor of the Burma Medical Journal and Chairman of the
Board of Editors for the Union of Burma Journal of Life Sciences, and was on the
Editorial Board of several international medical journals. He was Chairman of the Burma
Committee for the Olympic Medical Archives of the International Federation of Sports
Medicine, Switzerland, a Correspondent for the Human Adaptability Section of the
International Biological Programme, U.K., a Member of the International Committee for
the Standardization of Physical Fitness Tests, Japan, and a Member of the Committee on
4

Diabetes, Obesity and Cardiovascular Diseases, International Union of Nutritional


Sciences.
In 1977, Professor U Mya Tu joined the WHO, South East Asia Regional Office
as Regional Adviser in Health Manpower Development on deputation from the
Government. He was then appointed successively as Chief of Health Manpower
Development and as Director of Health System Infrastructure till his retirement from
WHO in 1987. His contributions during his ten years with WHO include, promoting the
reorientation of medical education in the countries of the WHO South-East Asia Region,
initiating and promoting the development of the Health Literature and library Services
(HELLIS) Network in the SEA Region, and the conceptualisation of the comprehensive
health system based on primary health care, and the development of the Primary Health
Care Model.

Professor U Mya Tu's research interests and publications have been wide in the
fields of electrophysiology of the heart, physical fitness and sports physiology,
population genetics, medical education, primary health care and the HELLIS Library
Network. He is also the author of a number of books, which include the WHO 40th
Anniversary Volume entitled "Health Development in South-East Asia", in 1988, and its
Update in 1992, and also the 50th Anniversary Souvenir volume for the World Health
Organization, Regional Office for South-East Asia entitled "Fifty Years of WHO in
South –East Asia-Highlights: 1948-1998"
Professor U Mya Tu has been the recipient of several international honours and
academic awards during his career.
Professor U Mya Tu's hobbies include music. He plays the piano for relaxation.
He is also a keen golfer and he led the Department of Medical Research Team to victory
for three successive years in 1973, 1974 and 1975 in the Inter-Professional/ Trade Golf
Tournament at the Burma Golf Club.
Since his retirement in 1987, Professor U Mya Tu has served as a consultant to
the WHO both at Headquarters in Geneva, and at the Regional Officer for South –East
Asia in New Delhi. He is at present working on the "Who's Who in Health in Medicine in
Myanmar" Project together with his wife Dr. Khin Thet Hta.
5

HUMANISM AND ETHICS IN MEDICAL PRACTICE, HEALTH SERVICES,

MEDICAL EDUCATION AND MEDICAL RESEARCH

(The First Myanmar Academy of Medical Science Oration)

By

Professor Mya Tu∗

Mr. Chairman, the Honourable Deputy Minister of Health, Professor Mya Oo,
His Excellency the Honourable Minister of Health, Major-General Ket Sein,
The Honourable President of the Myanmar Academy of Medical Science,
Professor U Ko Ko,
Distinguished Members of the Myanmar Academy of Medical Science,
Honoured Ladies and Gentlemen,

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

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


Practice, Health Services, Medical Education and Medical Research” because in this
present age and climate of materialism, reductionism and economic rationalism, the
medical profession is in danger of losing sight of its social roots and its high ideals of
altruism and service to humanity.

First, I would like to define what I mean by the terms “Humanism’ and "Ethics".
The meaning of ethics is well understood. Stedman's Medical Dictionary defines medical
ethics as the principles of correct professional conduct with regard to the rights of the
physician himself, his patients, and his fellow practitioners.

The term "humanism" needs a bit more explanation. Originally the term referred
to a philosophical and cultural movement during the 15th century European Renaissance.
But later it came to mean an attitude that was concerned with human interests and
stressing compassion and individual dignity. It is in this latter sense that I use the word
‘humanism’ in my Oration.

What does humanism in medicine imply? It implies respect for the dignity of the
patient as an individual human being; it implies showing feeling of compassion and an


Formerly Professor of Physiology, Institute of Medicine 1, Yangon , Director-General, Department of
Medical Research, Ministry of Health, Yangon, and Director, Health Systems Infrastructure, World Health
Organization, South-East Asia Regional Office, New Delhi, India
6

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


communications with the patient to understand him/her as a whole person and not just as
a disease. Humanism in medicine is more than medical ethics. It is more than refraining
from doing physical and mental harm to the patient through professional misconduct. It is
more than just abiding by the Hippocratic Oath. Humanism is a positive action, just as
compassion is not only a feeling of concern for the suffering of others, but also prompting
action to give help or to promote its alleviation. It is indeed surprising that a definition of
'compassion' is not included in two major Medical Dictionaries – Dorland's and
Stedman's. Yet compassion is as important as scientific knowledge and skills in a
humanistic physician.

What is the present situation with regard to the degree of humanism and ethics
imbued in the medical profession today at the beginning of this 21st century?

In the 1999 Year Book commemorating the Silver Jubilee Reunion of the Class of
1974-75 Medical Graduates of the Institute of Medicine 1, Yangon, there were a number
of Commemorative Messages from retired teachers. Two struck me as resonating with
the theme of this Oration. One was by Professor Dr. Daw Khin Si, who wrote: "Human
Relationship is important....Patient understanding is the secret of all human
relationship....".

Dr. Maung Maung Taik was more explicit. This is what he wrote:
"... I must however add, with malice towards none that the present ethical standard of
our noble profession is much to be desired. We, as doctors, should safeguard ourselves
from human frailty: the lure of lucre. There is much need to uphold the ideals of our
noble profession today and to avoid practices that tarnish its name. We need to abide by
the sacred tenets enshrined in the Oath. Let us go out of our way to be more
compassionate to the suffering of the poor and the needy. Let us be doctors of mercy and
charity: rather than the doctors of money and affluence...."

What is it that has made these two respected teachers to voice their apprehensions
of the state of our profession?

When we take stock, we will realize how far we have strayed from the ideal. This
phenomenon is a world wide one and unfortunately it has also spread to our country. Not
only has medical practice and the care of patients deviated from the original social ideal,
the concept of humanism is almost alien in medical education and medical research
endeavours. True, medical ethics is part of the curriculum in a number of medical schools,
but it has been alleged that medical faculties insert the teaching of medical ethics in the
curriculum to salve their consciences. As will be described a little later, much more than
inclusion of the subject of medical ethics in the curriculum is required for medical
graduates to imbibe humanism and ethical behaviour as their second nature.
7

Humanism and ethics in medical practice

Caring for the sick at its most fundamental level is rooted in the human spirit and
humanism. Take for example the young mother caring for her young sick infant or child;
or her kith and kin rallying round her offering advice, helping wherever needed; or an
older woman friend in the community who have experience in looking after the sick
responding to the call of the young mother for help. All of them have no pecuniary
motive save compassion for the sick child.

At a different level are the priests, priest-doctors, and witch doctors who since
time immemorial have taken to treating sick people because of the belief of ancient
people that disease is a manifestation of evil influence exercised by a god or supernatural
being or another human being. Their motive for curing sick people may not wholly be
altruistic for certainly they benefited from the offertories, in addition to the power and
authority it gave them over the community.

When it comes to the medical profession, we are made to believe that its social
origins are rooted in its attitude of humanism, a compassion for our suffering fellow
people, and a desire of being of service to them. Present day medical practitioners and
specialists have a one-to-one doctor-patient relationship. It is a unique relationship, and a
very private one, involving a complete submission, dependence, and trust of the patient to
the authority, knowledge and skills of the doctor. And with that authority comes the
social obligation to treat with compassion those who trust us and are dependent upon us.

In spite of this relationship and the authority the doctor has over the patient, the
prestige and status of the medical profession in society was not always as high as we have
seen it in the 20th century. For example, in ancient India, the status of physicians, was
not high, except for the King's physician who was highly honoured especially during
times of war and had his tent next to the King's with a flag of his own. According to
Manu, the first law-giver in India, the physician was considered to be always impure and
was never invited to sacrifices offered to the gods. A Brahman was not supposed to eat
the food given by a physician because it was considered vile (Rao & Radhalaxmi, 1960).
In the Roman Empire, physicians were slaves, freedmen and foreigners, and medicine
was considered a lowly occupation. In 18th century England, surgeons and apothecaries
were considered as tradesmen, and physicians were at the margins of the gentry class.
Even as late as the 19th century, doctors in France were extremely poor and lacked status
(Starr, 1949).

However, with the growth and advances in medical science and the ability of
doctors to radically influence the course of disease, beginning in the latter part of the 19th
century, medicine gradually changed from a trade to a profession and the power and
prestige of the medical profession have correspondingly increased reaching an all time
high in the 20th century.
8

When medicine gained the status of a profession from that of being a trade, it
acquired all the characteristics of a profession, namely autonomy, controlling the entry
into the profession, maintaining the standards of competency through training which
included theory, as compared to just skills training for tradesmen. The medical profession
thus organized the structural institutions of professions, such as associations, publications
and medical schools that they controlled, and had as its aim the altruistic or humanistic
service to society. It also constituted bodies to develop and apply a code of professional
conduct and ethics.

Ethics has been a fundamental part of medicine since early times and dealt with
the obligations and responsibilities of the physician. The principal concern of the doctor
for the welfare of his patient and the clear admonition to do no harm were embodied in
the Hippocratic Oath. It should be noted however that all the statements of ethics were
professionally oriented. There were none concerning the humanistic aspects.

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


history. The earliest known code is that of Hammurabi, the Babylonian King who lived
about 2000 B.C. It prescribed rewards for successful treatment and punishments for
failure. In the code of medical ethics of ancient Egypt also, punishments were meted out
for malpractice that were even more severe than those of the Babylonian Code of
Hammurabi, even to the extent of forfeiting the physician's own life. These codes were
imposed on the medical practitioners by kings and rulers. Hence their harsh nature.

The next well-known Code is that of the physician Hippocrates (460 – 355 B.C.) ,
exemplified in the Oath which is familiar to all medical graduates. In this code of ethics,
the graduate is reminded of the dignity and responsibility of his calling, and among other
things, urged to seek above all the benefit of the patient, and taking no mean advantage of
the position of the medical adviser. In his Aphorisms he mentions the idea of focusing full
attention on the patient, rather than on theories of the disease. No more are the extreme
penalties for failing to cure. (Sigerist, 1961)

The pattern of medical practice in the early eighteenth century was the “Solo Fee-
for-Service” type of practice where the individual doctor renders medical services for a
fee, the fees being either money or some farm produce as still occurs in developing
countries in some very poor communities and villages. This was the age of the country or
'horse and buggy' doctor or the family doctor who knew the families in the villages or
community well, went on house rounds, and often acted as 'guide philosopher and trusted
friend', in addition to treating all the illnesses in the family.

The development of major cities and hospitals during the 18th and 19th centuries
saw the country doctor slowly disappear as more and more doctors settled in the urban
areas to practice medicine. Some authors have commented that the disappearance of the
country 'horse and buggy' or family doctor has contributed to the beginning of what has
been called 'dehumanized care' in the hospitals.
9

Within the last few decades of the 20th century, the pattern of medical practice
radically changed in industrialized countries with market-oriented economies. From the
solo individual practice type of organization, there are now more of group practices,
where the medical services are provided by a group of three or more doctors under a
formal agreement for the joint use of facilities and equipment and allied health personnel,
the incomes being distributed according to a previously agreed upon plan.

During the 1970s and the early 1980s, business in the developed countries
particularly in the United States, saw a big market in the health care field, resulting in an
increasing commercialization of medical care, and the growth of the medical industrial
complex. Large for-profit corporations were formed offering to government and business
purchasers on a pre-payment basis a variety of packages of services, including a range of
products from “wellness” programmes through organ transplantation to hospice services.
With doctors forming into groupings, and the practice of medicine becoming big business
with health care corporations reaping revenues in billions of dollars, medicine is no
longer a cottage industry as the traditional fee-for service solo practice was termed. This
meant that it is the managers of these corporations – the economists and the Chief
Executive Officers, rather than doctors who are deciding more and more on the type of
health care practice and organization. With emphasis on cost-containment and efficiency,
these managers of the for-profit corporations are placing restrictions and applying
pressure on the physicians or their staff to follow prescribed patient care protocols,
reduce admissions and patient length of stay in the hospital, and the number of diagnostic
tests, resulting in an overall loss of control over aspects of patient management by the
doctor.

The reverse situation applies when the doctor has financial interests in the
company operating a private hospital and is encouraged to employ high-tech diagnostic
tests and procedures. In both cases, it is the patients who come worse off.

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


cost of drugs and medical care consequent upon the application of highly sophisticated
medical equipment in diagnosis and treatment. While the rational and systematic use of
high technology procedures is definitely of benefit to the patients, indiscriminate use with
a profit motive is to be deplored. It has been said that the more physicians come to
depend solely on technology, the more they lose their humanism, continuing the slide
towards 'dehumanized care'. This is compounded by the fear of being sued for
malpractice, doctors paying a high insurance premium, which is of course passed on to
the patients, driving the cost of medical care still higher.

This situation in developed industrialized countries with market-oriented


economies is also being reflected in the developing countries. Fortunately litigation for
malpractice has not yet reached our shores.

These changes have coloured the behaviour and attitudes of the profession, with
increasing emphasis on the financial and technological aspects of treatment to the
detriment of the altruistic and humanitarian calling of the profession.
10

In this context, the following words of that great humanitarian and physician of
the late 19th and early 20th centuries, Sir William Osler, came to mind:

"If I can ease one life its suffering and brush away one pain.
If I can stop one heart from breaking ---
I will not have lived in vain.
"If I can help one ailing brother regain his strength again.
If I can calm one weeping mother ---
I will not have lived in vain".

"If I can ease one life its suffering and brush away one pain".
He did not say "I will wait for the admission forms to be filled and all the bureaucratic
procedures to be completed, and then I will try to ease the suffering and the pain of the
patient".

"If I can stop one heart from breaking –"


He realised the anguish and suffering that illness can cause, not only to the patient, but
also to the family members.

"If I can help one ailing brother regain his strength again".
He talks of a 'brother', not a patient or a case.

"If I can calm one weeping mother – "


He did not say he would stop a mother from weeping by curing or healing all illnesses. A
physician's role does not end when the patient dies, but to provide a calming, reassuring,
soothing influence even in tragedy.

In the March 2000 issue of the Myanmar Medical Journal the editorial
dwelt on the same subject of medical ethics. You might remember that the title of the
editorial was "Of Patch Adams and Goose Eggs". (Nyunt Wai, 2000) The thrust of the
editorial was on financial aspects, on altruism, the observance of professional ethics, and
on practicing what 'Patch' Adams called "a little bit of excessive happiness ". Dr. Hunter
D. "Patch" Adams to give his full name, is an American doctor, a social revolutionary
who believes that care of the sick should not be a business transaction; that the doctor-
patient relationship has deteriorated from the time when doctors gave time to listen and
communicate with patients, to the aloofness of doctors nowadays, because of undue
dependence on technology. A video version of the film on Patch Adams is available and
is worth watching for a number of telling commentaries Patch Adams makes. For
instance, he criticizes the Medical Superintendent telling him: "You don't even look at
people when you're talking to them.... You don't connect to people". And again when he
argues his defence before the Medical Board: "Death is not the enemy, gentlemen. It is
indifference. You treat a disease, you win or lose. You treat a patient, you will win,
whatever the outcome".
11

Some of you who have seen the satirical popular British TV series "Yes Minister",
might remember that in one episode, it is the bureaucracy that is against the patient.
When the Minister asked why the new hospital was still not admitting patients but had
employed the full complement of non-medical administrative and other staff, the Health
Secretary replied: "They have great experience at the Department of Health and Social
Services in getting hospitals going. The first step is to sort out the smooth running of the
place. Having patients would be of no help at all – they'd just get in the way".

Even during the medieval period, physicians and surgeons recognized the
importance of treating the patient in addition to the disease. It has been reported that one
Henri de Mandeville (1260-1320) suggested a method 'to solace (the patient) by playing
on a ten-stringed psaltery". He even suggested some dubious means such as writing false
letters telling him of the death of his enemies, or if he is a canon of the church he should
be told that the bishop is dead and that he is elected. I am not suggesting that present day
doctors should follow explicitly the advice of Henri de Mandeville and start to learn how
to play a musical instrument to entertain patients or to employ such unethical methods as
he advocated. However it goes to show that even in those days, doctors tried what they
called "sustaining the spirits of the patient" in addition to treating the disease.

In passing, it should be noted that it is not only the practicing clinicians who
forgot the humanitarian roots of their profession in their drive for technological
excellence. In the field of public health also, where the dictum is "the greatest good for
the greatest number", there are instances where the individual patients suffered. Consider
the treatment of lepers in ancient and until relatively recent times when they were treated
as social outcasts. Some years back I occasion to visit the Molokoi Island, once a leper
colony in the Hawaii Islands and associated with the name of Father Damein. I was told
of how lepers were rounded up in the main Hawaii Islands and taken by ship to Molokoi
Island where they were told to jump from the ship and swim ashore, or those who were
hesitant, were pushed into the bay. Consider also the imposition of quarantine for plague
and cholera in the early days. Where was humanism then?

Humanism and ethics in the health services

Since ancient times, kings and rulers have taken the responsibility of looking after
the health of its people. There are records that in ancient India, the Kings established
places where the sick and disabled were cared for. The ancient Ayurvedic literature
mentions specifications of different types of hospitals like obstetrics and surgical
hospitals. Asoka's Rock Edict II (4th century B.C.) described curative arrangements and
hospitals or dispensaries for men and animals. (Rao & Radhalaxmi, 1960)

In the Roman Empire, medical services for the poor and for their legions were
organized. Public physicians were appointed to attend the poor and to supervise medical
practice within their area. The first hospital in Rome was built on the island of St.
Bartholomew in 293 B.C. Later various writers mentioned the existence of private
hospitals and nursing homes (Guthrie, 1958).
12

During the Dark Ages in Europe, when intellectualism and experimentation were
discouraged, it was in the monasteries that the light of medicine was maintained. Many
monasteries had herbal gardens and hospices. During this period, medicine in the Arab
countries flourished. There were magnificent hospitals in Damascus, Cordova and Cairo,
which catered to all aspects of patient care, including the humanistic aspects: such as the
spiritual side (where speakers recited the Koran day and night without ceasing); the
aesthetic aspects (such as playing soft music at night to lull the sleepless); and aspects
for lifting the spirits (such as having storytellers to amuse the patients). The rehabilitative
aspects were not overlooked. Each patient, on departure was given a sum of money,
sufficient to tide him over convalescence, until he should be fit to resume work (Guthrie,
1958). It was a very humanitarian approach to patient care indeed!

In Europe, particularly England, heath services for the population as we know it


and sponsored by the State, is a relatively late phenomenon, although from medieval
times the State has taken emergency measures and ad hoc legislation to deal with
epidemic diseases. In the early 19th century, as a result of the industrial revolution, there
were growing health and social problems while there was no legislation to deal with these
problems and no central or local authority specifically concerned with the health of the
population. It took a cholera epidemic in 1831 for England to form an emergency Board
of Health which later became the General Board of Health. A Ministry of Health was not
formed till 1919. Nowadays all countries regard the preservation of the nation's health as
one of their moral duties and have formed Ministries of Health or similar Agencies.
Hospitals have sprung up but mainly concentrated in large cities and urban areas.

During the first part of the 20th century, the health care system in industrial
countries developed around hospitals. After World War II, developing countries on
gaining independence followed the health care delivery system of the industrialized
countries, and built huge hospitals or as Dr. Halfdan Mahler the former Director General
of WHO called them, "disease palaces". By the late 1950s and 1960s societal pressure
on the medical profession for change in the manner of medical and health care became
more pronounced. The spectacular advances in medical care using highly sophisticated
technology was acknowledged. But it was costly and was available only to those few
who had access to and could afford it. The plight of the vast multitude of the poor as well
as the rural population went unserved or underserved. Doctors whose training was
hospital-based, using sophisticated technology, and instructed by academic research-
oriented professors were ill-equipped to deal with the health problems in the community
and with the new developments in health care. These trends were disturbing to society.
At this time, a new philosophy of health development based on equity and social justice
was evolving in WHO which ultimately resulted in the Primary Health Care and the
Health for All movements. (World Health Organisation, 1981)

The voices of two eminent people eloquently expressed the situation of the health
care system in the 1980s. The situation is not much better today. Jimmy Carter, the ex-
President of the United States, said: "...Although American medical skills is among the
best in the world, we have an abominable system in this country for the delivery of health
13

care with gross inequities towards the poor – particularly the working poor – and
profiteering by many hospitals and some medical doctors who prey on the vulnerability
of the ill"

Dr. Halfdan Mahler, the ex-Director-General of WHO describes the global view:
" ...The general picture in the world today is of an incredibly expensive health industry
catering not to the promotion of health, but to the unlimited application of disease
technology. This perversion of health work is self-perpetuating. There is a vast
professional establishment concentrating on the problems of the few. The whole
"unhealth" system finds its most grandiose expression in buildings, in "disease palaces'
with their ever growing staff needs and sophistication."

As stated previously, in relatively recent times under market economy, medicine


has become big business even in developing countries. Large corporations have moved
into what has been called the medical industrial complex. And when medicine is run as a
business for profit, there is a rise in the cost of medical care, thereby further denying
medical care to the poor. The relationship and attention given to the poor patients also do
not match that given to the more well-to-do. It is true that the State subsidized hospitals
are there to cater to the needs of poor patients, but the reality is there are costs involved in
attending any hospital and it has been known that many poor patients have foregone
treatment in hospital rather than have the family face financial ruin.

Humanism and ethics in medical education

What is it then that makes a doctor technically proficient and also develop an
humanistic attitude, to cultivate 'bedside manners'? Is it part of the training and education
of medical students and the role model of the Professors and other teachers? So let us
now turn our attention to humanism and ethics in medical education.

Both in the western world and in the eastern traditional cultures, the training of
future medical practitioners originated with the apprenticeship system. In the west, up
until the eighteenth century, the majority of practitioners received their training through
this system. This was a highly decentralized system of training in which the apprentice
and the master were bound in a personal relationship. In India, this traditional method of
teaching through a close personal relationship between the pupil and the teacher of
Ayurvedic medicine dates back to a few thousand years B.C. The pupil stayed in the
house of the teacher and in fact became a member of the household also doing household
chores, the teacher being actually regarded as a father. (Bhatia 1977) In ancient Greece,
the apprentice paid the master a fee, and spends a number of years with him, assisting
him, and learning and observing, until the day came when he was a master himself.
(Sigerist 1941).

Though an uneconomical method of production of physicians, nevertheless, there


is much to be said for this traditional apprenticeship system. With such a close
association and relationship with the teacher for several years, the student not only learns
from the teacher, but also imbibes his philosophy, his moral behaviour, his attitudes,
values and methods from his daily life and his work and the way he deals with his
patients – in fact his 'bedside manner'. This is very similar to the present day one-to-one
14

relationship between a Ph.D. student and his Professor supervisor, where the student
working on a research problem together with his/her supervisor, imbibes the Professor's
approach, his methods, his way of thinking and the way he attempts to solve problems.

The next change in the system of training physicians occurred under the Roman
Empire. Because of the great need for physicians and surgeons for their armies, the State
took responsibility for the training of physicians and surgeons by appointing teachers.
(Sigerist 1941).During the ensuring centuries, a number of countries followed suit. In the
Islamic countries, the education of physicians was already well established by the eighth
century A.D. The Islamic rulers founded hospitals with schools for teaching medicine
attached to them. Well-to-do citizens also set up private hospitals employing reputed
physicians who had the dual responsibility of treating patients in the hospital as well as to
teach the medical students.

The famous medical schools in Europe in the ninth to the thirteenth century A.D.
- Salerno, Montpellier, Bologna and Padua - put medical education on a sound basis and
medical degrees were granted after a definite course of study and examinations. The
faculty of the medical schools during this period not only trained physicians but also
controlled their actions, thus gradually assuming the same functions as the craftsmens’
guilds of the period. During the Renaissance, medical faculties gradually lost their power
to control the practice, which in many countries were taken over by the State, and State
Medical Boards were formed. (Sigerist 1941).In England, the General Council of Medical
Education and Registration – more commonly known as the General Medical Council,
was established by the Medical Act of 1858 specifically to regulate the profession on
behalf of the State, to oversee medical education, to control the professional conduct and
ethical behaviour of the profession, and to maintain a register of qualified practitioners.
Since the Council membership was primarily of doctors, this in effect gave the profession
the task of regulating itself.

In Europe, with the development of more hospitals in the nineteenth century, the
traditional apprenticeship system gradually gave way to a more centralized system of
medical education, firstly in the hospital medical schools and later in the universities.

As more and more students were being trained in hospitals, the plight of the
hospital patients seems to have been overlooked. Clinical teaching of a large number of
students had its effect on patients. As early as Roman times, under the apprentice system,
one Latin poet by the name of Martial, who lived in the 1st century AD complained:

"I'm ill. I send for Symmachus; he's here,


A hundred students following in the rear;
All paw my chest, with hands as cold as snow:
I had no fever; I have it now."

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


15

The nineteenth century saw dramatic scientific advances which was to have
profound effect both on medical practice and on medical education. Medical practice in
the early nineteenth century had been more or less of an empirical nature. But with
medical advances and discoveries, vaccination against smallpox, the establishment of the
bacterial origin of many diseases, and the introduction of anti-rabies vaccine and of
diphtheria antitoxin, and with some preparations such as digitalis, cinchona bark,
morphine and aspirin, physicians now had some effective preparations at their disposal.
They could therefore afford to give up the time-honoured heroic but ineffectual measures
such as blood-letting, purging and blistering. All these developments strengthened the
armamentarium of the medical profession and contrasted sharply with the “therapeutic
impotence” of the practitioners prevailing during the early part of the nineteenth century.
The result was an increased faith of the public in the application of science for the
alleviation of human suffering, at the same time enhancing the prestige and status of the
profession.

The effect of these developments on medical education was also far-reaching. The
teaching of the basic sciences that had hitherto been neglected or haphazard was now
regarded as the foundation of medicine. The training of medical students became more
systematized during the twentieth century particularly after the 1910 Flexner Report
which analysed the state of medical schools in the USA and gave recommendations to
place them on a sound scientific footing. The teaching of the basic preclinical sciences
accompanied by dissection and experiments in the laboratory in the first few years of the
medical course became the standard model. The Flexner Report had far reaching effects
beyond the borders of the USA. And to this day the basic structure of the organization of
medical education in many countries is largely based on the three segments of premedical,
preclinical and clinical areas. With this increased emphasis on basic science teaching,
medical education became closely wedded to academic medicine and research.(Starr
1949). Nowhere was this more so than in the United States, and even the newly
independent ex-colonial countries after World War II tried to emulate this model of
medical education. This emphasis on academic and technological medicine taught in
large university hospitals extended right into the twentieth century. As a consequence,
students graduating from these medical schools, being trained in a university hospital
setting with excellent facilities were reluctant to work in less well-endowed hospitals or
to go to the small towns and rural areas. In any case, their training was such that they
were ill-prepared to work in a community setting. The result was that these areas
remained unserved or underserved.

Reform in medical education

This state of affairs in medical education existed till the 1950s. The emergence of
the concept of Social Medicine and the introduction of the teaching of social and
preventive medicine in the curricula in place of Public Health, gave the required impetus
for medical schools to bring about certain changes in the hope of preparing doctors to be
able to deal with this problem of the large underserved and underprivileged population in
the nation (Ko Ko, 1987). A little later the concept of Community Medicine was
introduced in the medical schools and was particularly promoted by the World Health
16

Organization in the 1960s and the 1970s. By that time the need for reform in medical
education had become apparent. Many medical schools made serious efforts at reform,
concentrating:

Firstly on where medicine should be learned (in the community, including home
visits and clinical teaching in hospitals, as against solely and exclusively in the University
teaching hospital setting).

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


has been called 'curriculum shuffling', for example, introduction of behavioural sciences,
and medical ethics, and a change in emphasis from public health to preventive and social
medicine, and latterly to community health, and by changing the methodology of
teaching such as small group learning and Problem Based Learning). All sorts of
integrated teaching were experimented with – the horizontal, and the vertical, and also as
one wag put it spiral integration when everyone got screwed up! and finally gave up. It
should be mentioned that integrated teaching requires leadership, and a lot of
coordination and cooperation. It also requires a constant input of energy to keep the
system running.

Thirdly, medical education reform has tried to concentrate with what should be
learned during medical school and this has been more intractable. With such a rapid rate
of increase in knowledge and new disciplines, medical educators face a daunting task in
determining what to leave out and what new things to include. All Professors jealously
guard their subjects resisting any attempt at reducing their curriculum time. Of course, it
is some other Professor's subject that should be reduced. And most often than not, the
opinion of the politically powerful Professors prevail! Here also there is excellent
opportunity for good group dynamics and for cooperation and coordination to arrive at
the most suitable curriculum mix relevant and appropriate to the local situation.

Recently WHO has introduced the concept of social accountability of medical


schools, advocating that medical schools review their activities in the three main
domains of Institute responsibility, namely Education, Service, and Research in
relation to the fundamental values of social accountability of relevance to priority
health problems in the country, quality, and cost-effectiveness of health care provided,
and equity in the provision of health care services, i.e. provision of care for the
underserved and the underprivileged (Fig. 1)

al Accountability Grid for Medical Schools


17

Fig. 1 SOCIAL ACCOUNTABILITY GRID FOR MEDICAL SCHOOLS

DOMAINS OF FUNDAMENTAL VALUES OF SOCIAL ACCOUNTABILITY


INSTITU-
TIONAL
RESPONSI- Relevance To High Cost- Equity in
BILITY Priority Hlth Quality Of Effectiveness Health Care
Problems Health Care of Health care Services

Education

Service

Research

Medical educators agree that the purpose of these reforms is to redirect medical
education towards a community-based experiential, learner-centred model that will
enable doctors to be both life-long learners and practitioners with the knowledge and
skills available to equate the psychosocial and biological aspects of medical care (Bloom,
1989). In the WHO South-East Asia Region, medical educators meeting in 1987 agreed
that the goal for the Reorientation of Medical Education (ROME) was that "... all medical
schools in the region will be producing, according to the needs and resources of the
country, graduate or specialist doctors, who are responsive to the social and societal
needs, and who possess the appropriate ethical, social, technical, scientific, and
management abilities so as to enable them to work effectively in the comprehensive
health system based on primary health care ...". (World Health Organisation, 1988)

It should be noted that both the objectives include ethical, social or psychosocial
aspects of medical care.

The training of medical students is one of the areas in which ethical and
humanistic considerations can be focused, because this is where the attitudes and
perceptions of tomorrow's medical profession are formed. But classes in medical ethics
and humanism alone may not lead to greater sympathy for changes in doctor-patient
relations. Medical students are very discerning, and have no difficulty in determining
which subjects are taken seriously by the senior faculty. Do they show concern about
ethics and humanism in their lectures, their ward rounds, their other discussions and at
the bedside? In other words are ethical and humanistic considerations part of their second
nature, as much as a systematic history taking, observation and clinical examination?
18

The social and moral environment of society in general is also very important in
influencing the humanistic and ethical behaviour in medical students. One medical
educator has opined that "If we are to train humane physicians, we must begin to address
ourselves as a society to the basic general education towards ethical and moral values
from infancy onwards".

Humanism and ethics in Medical Research and Development

Social consciousness, social responsibility and social accountability have been the
hallmark of the medical profession, and these characteristics apply equally to the medical
researcher. Ethics and humanism can apply to the whole spectrum of research activity,
from the selection of research topics, through the mode of conducting research, and to the
application of results of research and development.

In selecting research topics, while on the one hand researchers have the right to
academic freedom of research on any subject however esoteric, it should be remembered
that the researcher also has a social responsibility to try to find solutions to problems
causing much of illness and suffering in the community. In other words, the researcher
should have one foot in the ivory tower, but the other foot should be firmly planted on the
ground.

In conducting clinical trails on patients or experiments involving human


volunteers, researchers are now, or should be, under strict ethical control. Although ethics
has been a fundamental part of medicine since ancient times, a heightened interest in the
subject in relation to medical practice and medical research is a phenomenon of post
World War II. This was a reaction against medical experiments on prisoners-of-war
during that war. The Helsinki Declaration issued at the 1975 World Medical Association
Meeting established standards not only for experiments on volunteers but also for clinical
trials on patients undergoing treatment. The Tokyo Amendment set forth more explicitly
the conditions that should govern the experiment, and adds that the results of research
that do not meet these requirements should not be accepted for publication in scientific
journals. Most medical research and academic institutes, including the DMR have now
Ethics Committees to approve research projects involving human subjects. But the
relation between the researcher and the patient or volunteer does not end once the project
has been approved by the Ethics Committee. In fact, it is just the beginning. And just as
the clinician should have a good 'bed-side manner' and humanistic relationship with
his/her patients, so should the researcher likewise.

Social responsibility and social accountability in research means that the research
is not done for its own sake. It is incumbent upon the researcher to see to the utilization
of his/her research results. This means that his work on this particular aspect does not end
with a paper appearing in a scientific journal. The results, in a digestible form, have to
reach the policy-makers, the health care decision-makers, the health professionals and the
consumers.
19

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


business. But business it has its own objectives, profit being their main aim. So when
commercial firms get into the business of developing medical products, be they drugs or
appliances, it is with a profit motive notwithstanding their oft-repeated claims to the
contrary. For no commercial venture will take into consideration the ethical aspects and
refrain from developing a product simply because it is too expensive for the consumer
who need it. And no matter how humanitarian it is, the company is unlikely to donate it
to society. Just consider the recent court case in which the multinational pharmaceutical
firms objected to the intention of the South African Government to purchase the much
cheaper generic forms of AIDS-HIV drugs to combat the AIDS epidemic in the country.

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


tendency nowadays of multiple authorship. It is of course true that a lot of research work
now is teamwork. But when the list of 'authors' stretch to ten or even fifteen, it makes a
mockery of the term authorship. An author, according to the Oxford Dictionary, is an
originator, a writer of a book, treatise or article. Authorship implies intellectual
responsibility. Too often, authorship is given or is expected for giving permission to
conduct the research in one's department or hospital ward. Providing the facilities alone
does not merit authorship. Similarly, providing technical assistance alone does not
deserve authorship. If acknowledgement should be given to technicians, it could be
provided after the names of the author/s with the note " With the technical assistance
of .............." as had been suggested by some journals such as Circulation and
Circulation Research. This is intellectually more honest and ethical.

Conclusion

Ever since man practiced medicine, there must have been those who misused the
trust placed on them by patients, and had an undue interest in pecuniary rewards of the
profession. For example, one Isaac Judaeus (A.D. 845-940) an Egyptian Jew who became
physician to the ruler of Tunisia gave this advice to physicians: "Ask thy reward when the
sickness is at its height, for being cured, the patients will surely forget what thou didst for
him". What would patients and society in general think of the medical profession if they
strictly followed this advice? Yet is the practice of depositing the consultation fee on
making an appointment with the doctor, as occurs in some private hospitals, very much
different?

The above review has shown that humanism and ethics permeates through the
whole fabric of the medical profession - medical practice, the organization of health
services, medical research and development, and medical education. It is the very
foundation on which the moral authority of the profession rests. Yet there are several
influences as described previously, which shape the ethos of humanism and ethics in the
medical profession in a negative or positive way. These are summarized in the next figure:
(see Fig. 2)
20

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

Societal
moral mores
Role
Control & Model Teaching of
Regulation Medical ethics
& medical
education
POSITIVE reform
INFLUENCES

Technological Humanism Ethics Hospital-


advances based Practice

NEGATIVE
INFLUENCES

Medicine as Present
a business day ethos

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

- Medicine becoming a business, and


- Present day ethos of materialism.

I have put two other factors,

- Technological advances, and


- Hospital based practice

between the negative and positive influences because both of these factors should have
beneficial effects for patient care, but as discussed previously they have unfortunately
turned out to contributing to 'dehumanised' medical care.

These negative influences have shaped the present day behaviour of the
medical profession. And it is into this professional milieu that the young medical
graduate enters. In this context, I would like to relate to you the story about a magical
21

dragon who lived in a cave and which ate humans. The king sent in many a brave man
into the cave to kill the dragon, but the moment the dragon was killed, blood spurting
out would drench the man and he himself would become a dragon. And so the dragon
lived on. In a similar vein, are we sending our young graduates, who have passed
through a reoriented medical education system, into the cave of the current
professional milieu, to become tainted with the ‘blood’ of professional power,
privileges, and pelf, turning them yet into young dragons and dragonesses?

What can be done to counter the present trend? Some positive influences have
already been identified and discussed already. They are:

- Control and regulation by Medical Councils or analogous bodies.


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

One can view the recent reforms in medical education as attempts to influence the
practice of the medical profession that has to a large extent, become insular and
indifferent to the health care needs of the population, and to the values of social justice
and equity.

Can the present reforms in medical education bring about the desired change in
pattern of medical practice and the behaviour and ethos of the medical profession?

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

Professor Bloom remains skeptical of the present reform efforts in medical


education concentrating only on change in the curriculum and on the pedagogic methods.
He argues that: “... the structure of modern medical education was established 75 years
ago for the purpose of incorporating the revolution of biomedical science, and successful
in that purpose, it added high-technology specialization as the main outcome goal for
clinical medicine. To prepare doctors to serve the changing needs of society is repeatedly
asserted as the objective of medical education, but this manifest ideology of humanistic
medicine is little more than a screen for the research mission that is the major thrust of
the institution’s social structure”. He goes on to add: “...The choice is clearly trending
away from people-centred practice and toward the role of technical-specialist. If this
observation is accurate, the explanation is not to be found in the motivation or the
selection of recruits to the profession. It is in the structure of the situation of modern
medicine and in the structure of its major institutions. That is where change must occur if
we are not content with the way things are”.

This means a major overhaul in the whole system.


22

The present situation however, is not new. Human nature being such, it has
occurred throughout history, as articles bemoaning the situation and exhortations to the
profession appear in medical journals regularly at intervals every few years. Is it therefore
cause for pessimism? Not necessarily. History has also shown that human nature can rise
from the lowest ebb to heights of self-sacrifice, compassion and service. That is our hope.

So where do we start?
How do we slay and put to rest the magical human eating dragon?
In other words, how can we influence the working environment and the working
system?
Can the profession be "regulated" for its humanistic behaviour as it is
controlled for its professional conduct and ethical behaviour?
Is it a personal behaviour based on socio-religious beliefs and conduct and
moral upbriging?
Can these traits be identified during student selection?
Can this behaviour be inculcated during training particularly with community
oriented teaching? and finally,
Does the profession really want to change?

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

Perhaps the Academy will apply its collective wisdom as to how to inject
humanism and ethics in our young medical students and graduates and thus provide
yeoman's service to our people, our patients and our profession.

Perhaps the outcome would be a more compassionate humanistic and ethical


medicine in our country where the patient, as a suffering human being, will once again
become the main focus of our medical care system.
Before I conclude may I state that my views expressed in this Oration is in no
way a sweeping indictment of the whole medical profession in our country. There are,
and I personally know of a large number of doctors who are still practicing the art of
curing with cetana, compassion, caring and humanism embodied in the altruistic spirit of
our profession.

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

Thank you.
23

REFERENCES

Bhatia S.L. (1977). A History of Medicine with special reference to the Orient. New
Delhi: Medical Council of India.

Guthrie, D. (1958). A History of Medicine, New and revised edition, with supplement.
London, Thomas Nelson and Sons Ltd.

Ko Ko, U (1987). Preventive and Social Medicine at the Crossroads. Presentation at the
National Conference of the Indian Association of Preventive and Social Medicine,
Cuttack. India, 26-28 November 1987. Published as a booklet WHO/SEARO

Nyunt Wai (2000). Of Patch Adams and Goose Eggs. Myanmar Medical Journal
(Editorial); 44 Page 1., 2000.

Rao, M.N. and Radhalaxmi K.K. (1960). History of Public Health in India. Calcutta, M.S.
Rao, Manthripragada House, Kakinada, Andra Pradesh (Navana Printing Works
Private Ltd., 47 Ganesh Chunder Avenue, Calcutta.

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

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

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

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

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


and Targets-2 SEARO; Regional Publications No. 18. Regional Office for South-
East Asia, New Delhi.
24

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

In appreciation of the First MAMS Oration

delivered in Yangon, 12 August 2001

Plaque of Honour presented to Professor U Mya Tu after the


Oration by His Excellency the Honourable Minister of Health
Major- General Ket Sein
25

Page

The First M.A.M.S Oration 1

Biography of Professor U Mya Tu 2

Oration 5
Humanism and Ethics in Medical Practice, Health
Services,
Medical Education and Medical Research

Plaque of Honour presented to Professor U Mya Tu 24